Key-words: Hotline - quality initiative - readmission - telephonic triage
Introduction
Transitioning of care from hospital to home can at times be a challenging task for
patients and caregivers. The often-hasty transition process may lead to quality and
safety problems contributing to unnecessary emergency department visits and hospital
readmissions. Patients often do not have a good understanding of their medication
instructions, self-care techniques, how to identify symptoms to report, or the importance
of timely follow-up with their health-care provider. Postdischarge nurse triage facility
and follow-up calls by health-care providers allow patients and families to verbalize
their concerns and issues over the phone. By connecting with patients, the organization
may reduce costly readmissions, intercept possible unfavorable incidents, and increase
patient satisfaction.[[1 ]]
Methods
The project was implemented after a tedious process involving needs assessment, defining
and allocating resources, categorizing the scope of the service, developing categories
of patients according to acuity level and developing disposal guidelines for each
category, developing an algorithm for dealing incoming hotline calls, developing a
standardized tool for postdischarge phone calls, developing job description and training
requirements for the dedicated hotline nurses, designing a system for maintaining
patient records, and sharing information with all relevant services, i.e., consultants,
clinic management staff, and emergency department.
The services included two distinct goals:
Telephonic triage system: Each patient was provided with the hotline number at the
time of discharge to call in case of any query or emergency. The service was available
24/7, whereby the hotline nurse answered all the queries raised by patients and families
Postdischarge follow-up: All discharged patients were contacted within 72 h of discharge
by a member of health-care team.
The postdischarge follow-up call consisted of the following components, assessment
of current health status, prescription check, clarification of clinic appointments
and laboratory tests, co-ordination of postdischarge home services, and review of
warning signs.
The following categories were made to identify the level of care or advice patients
required:[[Table 1 ]]
Table 1: Categories of calls on hotline
Emergent: Medical care that directly addresses a threat to life or permanent disability.
It included chest pain, shortness of breath, decreasing/altering level of consciousness,
signs of acute stroke, or any life-threatening symptoms. These patients are advised
to visit the emergency department as soon as possible. In such cases, the emergency
department is notified of the patients' arrival
Urgent: When the condition is not life threatening but requires care in a timely manner
(within 24 h). These patients are advised to visit the emergency department within
24 h, or facilitated with appointments on an early basis, or explained nursing care
or other related guidelines to treat at home by keeping doctors in knowledge
Nonurgent: Routine care for stable patients whose condition will not deteriorate over
time and/or will typically resolve on its own or the problem is not directly related
to patient health. It includes issuing a medical certificate, laboratory orders, appointments,
and prescription refills. These patients get facilitated as per need.
We compared 30-day readmission rate and number of emergency room (ER) visits in three
categories:
Prehotline Period: January 2017–June 2017, when there were no hotline services
Immediate posthotline period: October 2017–March 2018. Startup period after initiation
of hotline services
Late posthotline period: April 2019–September 2019, when hotline services were a part
of care for 1.5 years.
One senior registered nurse was assigned to deal with hotline incoming calls and making
follow-up discharge calls during the morning hours. She was given an office in our
neurosurgery ward in the main hospital building. During the morning hours, the nurse
assigned to the hotline was not responsible for any clinical duties of the ward. To
provide 24/7 services, during the evening shifts, the team leader was responsible
for all incoming calls to the hotline.
Results
We initiated the hotline in October 2017. From October to December 2017, we received
352 incoming calls and made 772 postdischarge calls of the 929 discharges during that
time period.[[Table 2 ]] Similarly, in 2018, we received 1245 incoming calls and made 2652 postdischarge
calls of the 3392 discharged patients.[[Table 3 ]] In 2019, of the 3402 patients discharged, we made 2721 postdischarge follow-up
calls and received 1144 calls on the hotline from discharged patients. [[Table 4 ]]
Table 2: Emergency department visits and readmissions in prehotline period
Table 3: Emergency department visits and readmissions in immediate posthotline period
Table 4: Emergency department visits and readmissions in late posthotline period
On analysis, we found a 25% decline in readmission rate in the immediate period of
hotline followed by a further decline to 37.2% in the late period as compared to the
prehotline period. [[Table 5 ]]
Table 5: Comparison of readmission rate
Among discharge patients visiting the emergency department, we found a decline of
18.5% in the immediate posthotline period which further declined to 77.7% in the later
phase as compared to the prehotline period. [[Table 6 ]]
Table 6: Comparison of emergency department visit rate
Patient satisfaction rate is not directly related to implication of hotline services
but indirectly measures patient satisfaction to overall care provision. We have traced
these results via institutions quarterly overall patient satisfaction survey report.
The cumulative percentages for the years 2017, 2018, and 2019 are 87.45%, 86.73%,
and 90.6%, respectively. [[Table 7 ]] There was a decline of 0.7% in patient overall satisfaction rate in the immediate
posthotline period, but there was an increase of 3.87% in the overall patient satisfaction
rate in the late posthotline period [[Table 7 ]].
Table 7: Comparison of emergency patient overall satisfaction rate
Discussion
In a country like Pakistan where health care is mainly out of pocket, the hotline
service can be a useful tool to cut down costs without compromising on patient care
and safety. Furthermore, telephone contact with patients after discharge provides
a continuum of care. It allows early recognition of problems and avoids unnecessary
emergency department visits and readmissions. In 1996, a survey done by Bowman et
al. demonstrated the use of a telephone service postdischarge on 85 patients.[[2 ]] Of the 85 patients, 48 (56%) reported health problems, 16 (19%) patients reported
social problems, and 36 (42%) patients sought advice. They concluded that a telephone
follow-up could be a useful means of monitoring a patient's progress.
In 1997, Chewitt et al. developed a protocol for a surgical hotline at Victoria General
Hospital, Winnipeg, Canada.[[3 ]] The questionnaire was developed with the input of the surgeons and was related
to 11 major areas of postoperative patient concerns. 57.6% of the callers were given
advice by hotline nurses while the remainder were directed to the emergency department,
told to call their surgeon, or a combination of all three. Eighty-five percent of
the patients calling the hotline felt that it was a positive factor in their recovery
process. Of the callers surveyed, 85% stated that the hotline met their needs, and
98% claimed that they would recommend the hotline to other postsurgical patients.
Comments from callers also indicated that advice from hotline nurses prevented unnecessary
visits to the emergency department.
In Lothian, a region of Scotland, a quality improvement report conducted by Kerr et
al., in 2010, used a telephone hotline for transient ischemic attack and stroke to
improve rapid access to specialist stroke care.[[4 ]] They concluded that the stroke hotline resulted in a significant reduction in delays
to assessment and an increase in the proportion of patients started on appropriate
medication after an ischemic event for secondary prevention.
A hotline service has time and again shown to benefit patients positively cutting
down costs for patients and the burden on the health-care system, as it results in
decreased visits to the ER. In a health-care system like Pakistan, which is constantly
overburdened, the hotline service results in fewer readmissions for problems that
can be managed at home or in outpatient clinics. This allows more beds available for
patients with medical problems that require hospital admissions.
Components of this project were challenging to implement in acute health-care settings
because hotline nurses in clinical hours, i.e., from Monday through Friday, efficiently
handled call volume, and determine the disposition of care to ensure that the patient
is being responded to the call and the query is resolved. Yet, in evenings, nights,
weekends, and public holidays, the team leader in service line is responsible to provide
the services. The team leaders are at times busy in areas, which makes it difficult
for them to timely respond. Although there were many limitations in the implementation
of the services, so far, no additional staff members were hired to implement these
changes.
By looking at frequency of incoming calls at hotline and categories of patient complaints,
we suggest to improve patient discharge instructions by reinforced discharge teachings
and patient discharge checklist to ensure patients and families are provided with
enough information to strengthen transition in care.
Conclusion
Implementing a telephone triage system can help improve health outcomes for many patients.
The telephone triage system can not only reduce unnecessary ER visits and lower costs,
but also it can help people who actually need to go to the ER by assessing emergent
and urgent patient phone calls and potentially improve patient and caregiver satisfaction.
This also identifies opportunities for providers and hospital systems to adopt discharge
improvement initiatives.
