Triaging the 24-Hour Nurse Helpline

— Sure, those helplines sound like a good idea, but how useful are they?

by Fred Pelzman, MD, Contributing Writer, MedPage Today July 24, 2023

Fred Pelzman of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.

Is it just me, or has anyone else noticed that there seem to have been a lot more of these conversations lately that our patients are having with clinical triage folks — those 24-hour helplines set up by the insurance companies?

I know that many of the large insurers have these programs, but it seems like they have been expanding and replicating, offering more and more options for patients calling to get some clinical advice. Or maybe it’s just that patients are using them more often, for reasons we may need to explore.

Calls That Run the Gamut

Over the past few weeks, I’ve gotten a whole bunch of communications from these helplines, faxed and emailed either from the insurance companies or from some external entities that they’ve apparently hired out to do this work for them.

Interestingly, they’ve run the clinical spectrum, from some really simple things like cuts, bruises, and minor rashes, to serious falls and people who think they’re having heart attacks or strokes. And of course, I’m getting these clinical summaries 24-to-48 hours later …

These communications are in the form of long, transcribed conversations that the patients have had with some nurse on call for the company, detailing what the patient called about, the clinical questions the nurse asked them, and the patient’s responses. And finally, there’s the medical decision-making and a plan.

As I said, I know these have been around for a while, but are there more and more of them now, or are the insurance companies just promoting them more, seeing them as a way to save money, to improve access, to improve care and customer satisfaction?

Parsing the Algorithms

I’ve seen the algorithms that are behind some of these triage protocols, that many of these groups have used. There are lots of different iterations out there, and even entire published manuals of clinical triage questions and decision trees for these nurses and other on-call providers available to go through with their patients.

Obviously, they are all driven by the initial complaint, or symptom, or question the patient may have for them. There are protocols for urinary tract infections, abdominal pain, shortness of breath, weakness, fatigue, and the common cold. And in the past few years, we now have new ones for COVID-19 as well.

Having worked with our scheduling teams to help refine some of these algorithms, I know that the companies that created them have used input from clinicians, those of us who do this every day, to help flush out what may be going on, and provide safe telephone care, as well as to make sure nothing really serious gets missed.

Obviously, these things are going to be quite formulaic, designed not to miss the badness that’s out there. So, for a patient calling for a headache, the goal of the menu of questions is to try to provide enough clues that they don’t miss a subdural hematoma or subarachnoid hemorrhage. For a potential urinary tract infection, they want to make sure things haven’t progressed to urosepsis, or aren’t about to. And for chest pain, they obviously don’t want anyone sitting at home finishing off their myocardial infarction, after they told them to take two aspirin and call back in the morning.

For the most part, these are patients that the people on the other end of the line have no medical records on, have never spoken to before, and have no long-term relationship with, beyond the relationship between an insurer and the people they insure.

A Pathway to the Emergency Department?

At first blush, it feels like a really nice service to have — one more opportunity for patients to get medical advice and safely make it through the night, or the weekend, or their vacation. But for the most part, especially for the ones I’ve seen over the past few weeks, most of them seem to end up with the person giving the clinical advice recommending that the patient go, or their family member bring them, into the emergency department so as not to miss some terrible outcome.

As I’ve described previously, when you’re on call at night and dealing with people who you don’t know, and even when you’re dealing with ones you do know, there are limits to how much of a medical decision we can make with the minimal information available to us over the phone.

This may be enhanced and improved moving forward by telemedicine, video visits, remote patient monitoring, and even the potential in the far-off future for us to do a more thorough remote physical exam — maybe even certain lab tests right at home. But for now, we all know the limits of the questions we ask of people we don’t know really well, the poor performance characteristics of these screening questions, and how, like it or not, we are often left with a great deal of uncertainty.

I can’t say that I blame those doing the triage; they’re sitting in a room somewhere with a loose-leaf binder full of pages indexed by signs, symptoms, and medical conditions, and they are running through a series of questions, a checklist, trying to decide what’s best for a patient who is on the other end of the line and obviously worried, maybe having already Googled their symptoms. We all do this over the phone during regular business hours, and even when a patient comes in to see us in the office for an actual visit, we decide that we are going to try something, try a medicine, check some labs, but if things get worse, then care will have to escalate.

Improving the Triage System

So, what’s the solution? Is this type of triage system really helping improve care? Is this a form of access we need more of?

The idealized healthcare system would have each patient paired with a single doctor, who cared for them 24 hours a day, 7 days a week. But none of us are going to tolerate this; there is no way that that makes any sense, and we’re never going to be able to build the system like that. (Unless you’re really smart AI doctor is on call…)

But if we can find a way to expand care so that patients can get the answers they need and the care they need when they need it, without having to be sent into the emergency room just because, then maybe we’re headed towards a better system. Truly patient-centered care would help find a way to keep the patient within the system that they call home, where their primary care provider lives, where all of their specialists live, and where everyone can put in their two cents whenever it’s needed.

I think if we build a better healthcare system that improves access, continuity, patient education, removes barriers and inequities, then patients are probably going to need us (and these helplines) less in the middle of the night.

True, there will always be off-hours emergencies: strokes, heart attacks, and diabetic ketoacidosis don’t always stay within the confines of the 9-to-5 day. But if we can enhance, improve, and deepen the care, and strengthen the bonds between patients and their providers, we can certainly go a long way to making them less likely to call during off-hours.