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Routing Primary Care Telephone Calls – Adult/Pediatric – Ambulatory

Routing Primary Care Telephone Calls – Adult/Pediatric – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, In the Clinic


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Routing Primary Care Telephone Calls
- Adult/Pediatric - Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ............................................................................ 3
SCOPE ....................................................................................................... 3
METHODOLOGY ....................................................................................... 4
INTRODUCTION ........................................................................................ 5
RECOMMENDATIONS .............................................................................. 5
Process ................................................................................................ 5
General Considerations ....................................................................... 5
Patient Prioritization in Primary Care.................................................... 7
UW HEALTH IMPLEMENTATION ............................................................. 9
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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CPG Contact for Content:
Name: Department of Clinical Staff Education
Email Address: staff.educators@uwmf.wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Guideline Author(s):
Jennifer Brazelton- Director, Pediatrics Clinics, AFCH
Jennifer Cullen- RN, MSN Director, Clinic Operations, UWMF
Lori Hauschild- RN, MHA, VP, Clinic Operations, UWMF
Review Individuals/Bodies:
Care Model Oversight Group (CMOG)
Committee Approvals/Dates:
Primary Care Leadership Committee (PCLC) (04/18/2014)
Clinical Knowledge Management (CKM) Council (10/22/2015)
Release Date: October 2015 | Next Review Date: October 2016
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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Executive Summary
Guideline Overview
This document provides reception/scheduler staff with guidance for the expected
documentation and appropriate routing of telephone calls based upon problems or
complaints expressed by a patient or their family member.
Key Practice Recommendations
1. Reception staff will quote the patient when documenting and will not interpret or
advise. Reception staff may NOT offer medical advice, personal opinion, offer
triage, or refer patients to Urgent Care or the Emergency Department.
2. For EMERGENT conditions, immediately transfer the caller to RN or Provider.
3. For URGENT conditions, attempt to warm transfer caller to RN.
4. For ROUTINE conditions, routing will be to the RN Pool or to the appropriate Clinical
Pool (RN/LPN/MA).
Pertinent UW Health Policies & Procedures
1. UW Health Guideline for Routing of Message between UW Health Locations and
Departments
2. Health Link Training- Routing of Messages Between UW Health Locations and
Departments
3. UW Health Clinical Policy 8.07- Procedures, Communication of Critical Results and
Critical Tests
Patient Resources
1. Health Facts For You #7637- Ambulatory Telephone Nurse Triage at UWHC
Scope
Disease/Condition(s): Incoming clinic telephone calls
Clinical Specialty: Primary Care
Intended Users: Reception/Schedulers
Objective(s): To provide reception/scheduler staff with expectations for
documentation and routing of incoming clinic telephone calls.
Target Population: Adult and pediatric patients (or their guardians) calling a primary
care clinic via telephone.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline
author(s) and workgroup members to collect evidence for review. Expert opinion and
clinical experience were also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members arrived at a consensus through discussion of the literature and
expert experience. All recommendations developed or endorsed by the guideline
workgroup were reviewed and approved by other stakeholders or committees (as
appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the
Recommendations:
Internally developed recommendations, or those adopted from external sources without
an assigned evidence grade, were evaluated by the guideline workgroup using an
algorithm (see Figure 1) adapted from the methodology developed for Grading of
Recommendations Assessment, Development and Evaluation (GRADE).
Figure 1. GRADE Algorithm
Rating Scheme for the Strength of the Evidence/Recommendations:
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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GRADE Ratings for Recommendations
Strong for using/Strong against using The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak for using/ Weak against using The evidence is weak or the balance of positive and
negative effects is vague.
Introduction
This document provides reception/scheduler staff with guidance for the expected
documentation and appropriate routing of telephone calls based upon problems or
complaints expressed by a patient or their family member.
Recommendations
Process
Telephone calls from patients or those concerning the patient’s clinical care will be
documented in Health Link as a Telephone Encounter. A telephone encounter gives
UW Health the ability to document the interaction with the patient, or on behalf of the
patient, and then be able to find that interaction afterward in Chart Review. If the
concern or call is “emergent” or an immediate response is required,
reception/scheduler will create a telephone encounter in addition to calling or
paging clinical staff/providers.
“RE: Patient” messages are not part of the legal medical record. They can be seen only
within the internal Health Link messaging system. These messages are not easily
tracked and cannot be linked to one another without more extensive data collection
behind the scenes. Therefore, RE: Patient messages should be used for communicating
NON-CLINICAL information or for coordinating care regarding information that is
already documented in the medical record. Refer to the UW Health Link Guideline for
Routing of Message between UW Health Locations and Departments for specific routing
information.
General Considerations
A. Reception will select the correct patient including a minimum of two patient
identifiers (name and date of birth) and include the preferred call back phone
number as part of the message taking process.
B. Telephone Encounters will be created using the appropriate Smart Phrase when
information or action is requested by or on behalf of a caller to the clinic (if no MRN
exists, please follow new patient registration guidelines). Calls should then be
routed to the provider or the department’s RN or MA/LPN Pool. Notes should
include pertinent information including “second call to clinic” and “returning clinic’s
call.” Call backs should be added to the call pending in that clinic/department’s
telephone encounter.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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This may include, but is not limited to, calls pertaining to the following:
ξ Test results
ξ Medication requests
ξ Orders for test(s) requested
ξ Appointment requests not accommodated
ξ Referrals
ξ Advice/Health Concerns
o Incoming calls related to health concerns should be handled using the
Patient Prioritization Guidelines in response to the patient or caller
reporting the items listed
o For reports of health concerns not listed on the Call Prioritization
Guidelines, an appointment may be made at the patient’s requests or a
Telephone Encounter created and routed to the department’s clinical pool
for appropriate handling
ξ Information from the electronic medical record
ξ Symptomatic calls
ξ Self-reported readings
ξ General message
C. Reception staff will quote the patient when documenting and will not interpret
or advise. Reception staff may NOT offer medical advice, personal opinion, offer
triage, or refer patients to Urgent Care or the Emergency Department.
Example: Patient states “My stomach pain seems worse”;
ξ Receptionist will document: Patient reports, “My stomach pain seems worse.”
ξ Receptionist should NOT document Patient is not improving, is getting worse.
o One is a quote and the other is a clinical assessment
o Clinical assessment is NOT the role of the receptionist
ξ Receptionist will NOT ask additional questions, such as
o “What have you done for your stomach pain?”
ξ Receptionist will NOT make suggestions such as: You should take Tums.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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Patient Prioritization in Primary Care
A. For Emergent Conditions, immediately transfer the caller to RN or Provider.
(UW Health Very low quality evidence, weak recommendation) Keep the patient on the line
until you reach a RN or Provider. Receptionist or Scheduler should create and
route a telephone encounter, high priority, including, but not limited to patient
name, MRN number and callback number.
Immediately transfer the caller to RN or Provider if patient reports any of the following
emergent situations: “911 type of calls”
Adult Patient – Emergent Conditions Pediatric Patient - Emergent Conditions
Chest pain “Discomfort or pressure in chest”
Rapid heart rate “pounding heart”
Irregular heart rate “skipping a beat”
Fever in an infant under age 3 months of age
Difficulty breathing with or without wheezing
Shortness of breath
Difficulty breathing
Wheezing
Difficulty Swallowing Difficulty swallowing
Swallowed an object “my child swallowed…”
Uncontrolled bleeding; bleeding that will not stop Uncontrolled bleeding; bleeding that will not stop
Headache – “Worst ever”
Slurred speech
Loss of vision
Blurred or double vision
Facial weakness or facial “droop”
Head, neck or eye trauma/Injury
Head trauma with behavior changes/vomiting
Seizure – new onset
Fell and hit head
Lost consciousness; “Blacked out”
Seizure
Fell and hit head
Loss of consciousness; “Blacked out”
Allergic reactions- rash or hives, throat swelling, or itching
(e.g. Bee sting, food or medication reaction)
Allergic reactions- rash or hives, throat swelling, or
itching (e.g. Bee sting, food or medication reaction)
Muscle weakness/Paralysis – “Loss of movement”
Numbness of any body part
New fracture
Possible poisoning or overdose, including medications,
chemicals, carbon monoxide, etc.
Provide Poison Control number 1-800-222-1222
Poisoning, ingestion or drug overdoses, including
medications, chemical, carbon monoxide, etc.
Provide Poison Control number 1-800-222-1222
Vomiting or Coughing up blood Burns, including chemical and electrical burns
Comments regarding physical abuse (sexual
or non-sexual)
Suspected child abuse (sexual or non-sexual)
Suicide (or other self-harm) threat/attempt
Homicidal (cause injury to others) threat/attempt
Suicide (or other self harm) threat/attempt
Homicidal (cause injury to others) threat/attempt
Critical Lab/Test Results (UWHC locations follow Critical Lab
Result Policy 8.07)
Critical Lab/Test Results
Pregnant woman with:
a. Abdominal/Back pain or Contractions
b. Bleeding, Abnormal vaginal discharge
or Leaking fluid
c. Motor vehicle accident
d. Fever ≥101°F
e. Decreased fetal movement – “baby not moving”
Abdominal or testicular pain
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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B. For Urgent Conditions, attempt to warm transfer to RN. (UW Health Very low quality
evidence, weak recommendation) If RN is not available, notify any RN there is an urgent
message. Receptionist/Scheduler should create and route a telephone encounter,
high priority, including, but not limited to patient name, MRN number and callback
number.
Warm transfer the caller to any RN if patient reports any of the following urgent
situations:
Adult Patient – Urgent Conditions
Fever ≥103° F Uncontrolled pain
Patient states: Severe, excruciating, worst ever
Dizziness – sudden onset Rectal bleeding “blood in stool or bleeding with a
bowel movement”
Burns, including chemical and electrical burns Fainting “passed out”
Fall with or without obvious injury
Any trauma, accident, or injury Abdominal pain – new or sudden onset
Blood Pressure “patient reports too high or too low” Patient insistence or upset/demanding patient
High or low blood sugar per the patient Pharmacy or lab calling with patient waiting
Recurrent seizure Calls regarding Coumadin, warfarin or blood thinners
Recent surgery/Post-op procedure
“having problems” other than emergent conditions
listed above
a. problems with incision
• redness or swelling at incision
• pus, drainage, or bleeding from incision
b. chills, fever or temperature ≥101° F
c. increased pain
d. nausea/vomiting
e. calf pain/tenderness, redness, warmth, swelling
Dislocation of joint
New or suspected fracture
Patient states “I think I broke my”
C. For ROUTINE conditions, routing will be to the RN Pool. (UW Health Very low quality
evidence, weak recommendation)
1. Route to RN Pool, marked as routine, for calls for both adult and pediatric patients.
**Clinics that have gone through PCR Package 2, attempt to warm transfer to
RN and if not able to take the call, then route to RN Team Nurse or RN Care
Coordinator.
Examples of routine conditions to route to RN pool include:
ξ No improvements in symptoms
ξ Lab results
ξ Appointment requests for today/this week when none are available
ξ Fracture follow-up
ξ Self-reported readings
ξ Nursing Home and Hospice calls
ξ Health related questions
ξ Patient/Parent/Guardian asks to speak with a nurse
ξ Other symptom-based calls not listed
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org

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2. Route to MA/LPN Pool, marked as routine, for calls for both adult and pediatric
patients. Examples of routine conditions to route to appropriate Clinical Pool include:
ξ Coroner or Funder Home calls
ξ Request or questions regarding forms
ξ Information from the EHR
ξ Specialty clinics needing information
ξ Referral Request
ξ Request to have lab or other tests
ξ Medication refill requests **For clinics that have gone through PCR
Package 2, this is for non-controlled substances only
D. Pediatric patients (assigned either to a GPAM or Family Medicine PCP) may be
scheduled for a same-day appointment or at patient request, without RN
Triaging for the following:
1. Parent insistence
2. Recheck directed by MD (e.g. ears, cough, etc.)
3. Medication Check
4. Suture/Staple Removal (specify Date of Injury, Location)
NOTE: Calls for Ear Pain, Sore Throat; and Follow-up from ED, Urgent
Care or PAC need to be triaged
UW Health Implementation
Potential Benefits:
ξ Patient satisfaction
ξ Timely access to medical information and referrals
Potential Harms:
ξ Patient dissatisfaction
ξ Liability
ξ Remaining on hold
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
3. Links to this guideline may be added within the Telephone Encounter Navigator Health Link.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2015CCKM@uwhealth.org