By Janet Byron, Senior Communications Consultant
When the phone rings at Kaiser Permanente’s Northern California
advice and call center, the person on the other end of the line may be
experiencing chest pain.
Should that person go straight to the nearest emergency department, or is it safe for them to receive care another way?
Dana Sax, MD, lead author of study in Health Affairs
“Careful and timely evaluations of chest pain are critical, as
missing or delaying the diagnosis of a heart attack can have devastating
consequences,” said Dana R. Sax, MD, an emergency physician at Kaiser Permanente’s Oakland Medical Center.
Chest pain is the second-leading reason why people show up in the
emergency department. It accounts for about $5 billion of the $80
billion spent annually in the United States on emergency care, according
to the Agency for Healthcare Research and Quality.
A new Kaiser Permanente study led by Sax, published today in the December Health Affairs,
finds that “tele-triage” of patients with chest pain over the phone can
safely and effectively direct people to the right place for receiving
“We found that telephone consultation with a nurse or physician can
be used to safely and effectively triage patients with chest pain,” said
Sax, the study’s lead author. Sax will present the findings on Dec. 4 at a Health Affairs briefing on telehealth in Washington, DC.
When physicians take the call
Kaiser Permanente members in Northern California can call the
Appointment and Advice Call Center 24 hours a day, 7 days a week, with
trained Kaiser Permanente nurses and on-call emergency physicians
available at all times to tele-triage health concerns. The free service
receives over a million calls per month from members seeking advice and
to make appointments.
When nurses receive calls about chest pain, they routinely consult
with on-call emergency physicians regarding how to best refer patients.
In 2013, the call center began referring chest pain complaints directly
to the on-call emergency physicians whenever possible.
This change gave researchers the opportunity to compare chest pain
calls directed initially to nurses with those referred to physicians.
In 2013, physician-directed calls were briefer (8 minutes) than
nurse-directed calls (13 minutes), and physicians directed fewer people
(10 percent) to the emergency department than nurses (16 percent).
Overwhelmingly, patients followed the provider’s recommendation about
where to receive care, although the rate was slightly higher for
physician-directed calls (86 percent versus 82 percent). Regardless of
who people with chest pain spoke with, there were no significant
differences in adverse outcomes within a week and a month, including
“Sending chest pain calls directly to physicians brought added efficiency to the process,” Sax said.
Tele-triage in an integrated health-care system
Senior author Mary Reed, DrPH, research scientist at the Division of Research, studies telemedicine.
More often than not, the researchers found, the right place to care for chest pain is outside of the emergency department.
“Out of about 23,000 complaints chest pain received by Kaiser
Permanente’s Northern California call center in 2013, nearly 9 out of 10
were referred to venues other than the emergency department for care,
such as home care or an appointment or telephone visit with their
primary care doctor,” Sax said. “Among those who were referred to the
emergency department, 4 out of 5 were discharged after an evaluation
without being admitted to the hospital.”
Senior author Mary E. Reed,
DrPH, a research scientist at the Kaiser Permanente Division of
Research who studies telemedicine, noted that integrated health care
settings like Kaiser Permanente may be the ideal environment for
David Vinson, MD, co-author of study in Health Affairs, leads Kaiser Permanente’s CREST Network of emergency physicians who do research.
“We found that the physician-led tele-triage was not only safe but
efficient. The technology in this setting offers the unique opportunity
for callers to hear advice from physicians who have the patient’s full
electronic health record at hand in order to inform their
recommendations,” Reed said.
With quick access to the patient’s electronic health record,
emergency physicians may feel more comfortable referring patients with
chest pain to a place other than the emergency department for care, said
study co-author David R. Vinson, MD, emergency physician at Kaiser Permanente’s Sacramento Medical Center and physician researcher at the Division of Research.
“Chest pain is a major contributor to overcrowding in U.S. emergency
rooms,” Vinson said. “Emergency physicians know from first-hand
experience that the vast majority of people with chest pain are not
having a heart attack or another life-threatening emergency.”
The study was funded by the Kaiser Permanente Northern California Community Benefit Program.