Outcomes associated with pediatric after-hours care by call centers: A multicenter study

Objectives. - To assess 1) parental opinion regarding appropriateness of triage, 2) utilization outcomes, and 3) the frequency of underreferral with subsequent hospitalization for children triaged by nurses at pediatric call centers. Design/Methods. - From August 19 to October 1999, after-hours calls were randomly sampled from computerized records at 4 call centers at children's hospitals. Telephone surveys were conducted 3 to 7 days after the index calls. An expert panel to assess appropriateness of disposition reviewed audio recordings of calls given a nonurgent disposition and then hospitalized within 24 hours. Results. - Surveys were completed for 70.5% (N = 1561). Parental agreement with urgent or home care recommendations was >70% but with intermediary recommendations was <50%. Hospitalizations were more common among children urgently referred (4.6% vs 0.45%; P = .0003). Calls judged urgent by call center nurses and referred to a physician for secondary triage had lower rates of urgent visits (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.53-0.65; P < .0001) and higher rates of never having a visit (OR 1.37; 95% CI 1.24-1.51; P < .0001) than those referred directly by nurses. The weighted rate of underreferral with hospitalization was 0.3% (95% CI 0.1-0.7%) or 1 in 481 calls (95% CI 1/152 to 1/1538). Conclusions. - Our data demonstrate an underreferral rate with subsequent hospitalization of 1 in 500 calls and a significant reduction in visits when those cases judged urgent by call center nurses undergo secondary triage by physicians.