Dr. Barton Schmitt Interview: 
Telephone Triage Protocols

Fall, 2003

One of the pioneers of telephone triage protocols is Dr.Barton Schmitt.  His telephone triage clinical content for pediatrics is used by McKesson, LVM Systems, Epic, Intellicare, Fonemed, and United Health Care (Optum).  Together that is over 400 call centers.  The book form is used in an estimated 10,000 pediatric offices.  With a 30 year history behind it, we recently asked him to share his story with readers.  Here is what he had to say:

How has the triage protocols changed over the last 30 years?

They have become more complete and more comprehensive including lots of background information to help nurses learn this field.  They have also become more experience-based (I know 10 times more now than I knew then), and more evidence-based, thanks to research on them and the ever-expanding medical literature.

How did you get started?  Why did you write the Telephone Triage Protocols? 

I've always enjoyed the challenge of taking parent phone calls and trying to make the correct diagnosis without seeing the patient.  In 1973, while I was Medical Director of the Urgent Care Center (UCC) for children at the University

By 1975, the collection of triage protocols had grown to 100.  Graduates of our program who were going into practice began to ask for them and I provided them in binders.  Over the course of a few years, I'd given away over 200 of these binders.  By 1978, I'd expanded the collection to over 180 topics and tried to find a publisher.  I submitted to the leading medical publishers.  The book received unanimous rejection letters.  The main reason they gave was that "it was heresy to suggest that nurses could (or should) ever triage medical calls."

In 1980, the book Pediatric Telephone Advice was finally published by Little, Brown & Co. in Boston, who was just breaking into the medical publishing business.  Within a matter of years, it was also published in French, Portuguese, and Japanese.  It has continued to be a good seller and is going into its third edition.  This book has remained a self-study guide for nurses or physicians in training.

In 1990, I wrote a streamlined (telegraphic) version for use by the advanced practice telephone triage nurses who worked in our call center at The Children's Hospital (TCH) in Denver.  The new book was called Pediatric Telephone Protocols.  In 1994, I self-published this book because of the demand for it by call centers at other hospitals.  I updated it yearly.  In 2000, the American Academy of Pediatrics (AAP) picked up the publishing and distribution rights.  The 10^th edition will be released in early 2004.  In 1994, I also started collaborating with NHES (National Health Enhancement Systems) to produce a software version of pediatric telephone triage.  Because our call center was covering for over 120 pediatricians, we needed to improve efficiency.  In 1999 I became software vendor neutral.  In 2000, I collaborated with David Thompson, MD. 

Why did you partner with David Thompson, MD, FACEP? 

David and I share similar backgrounds, and therefore we find it very easy to work together.  Working in the Emergency Department (ED), David is involved with direct patient triage on a daily basis.  That's required in a setting where you have 10 patients in different rooms and you need to prioritize exactly who you're going to see next, who gets a procedure, who gets an x-ray, and who can safely wait.  I worked in an emergency department for five years, and know how important it is to have razor-sharp decision-making.  At the present time, David is on the American College of Emergency Physicians (ACEP) and Emergency Nurse Association (ENA) National Triage Task Force that's attempting to standardize emergency department triage. 

The advantage of us working together is that the adult triage protocols and the pediatric triage protocols share parallel layouts, dispositions, and logic.  This makes it easy for the nurse in a full age range call center to move back and forth from pediatrics to women's health to adult health to geriatric decision making.  Nurses appreciate the seamless flow between protocols.  Having two people responsible for keeping the protocols compatible is an attainable goal.  We have developed over 100 rules that we follow closely to achieve and preserve clarity and consistency.  David is my best critic.  We spur each other on to producing a better triage product.

How important is feedback from others? 

It's the lifeblood of the fine-tuning process.  I've been medical director of the Children's Hospital After-Hours Call Center since its inception in 1988.  It is the crucible in which I test my protocols.  I have the privilege of working with 40 pediatric telephone nurses who have specialized in this field.  Their critiques and feedback are invaluable. 

In addition, I work with 30 ED physicians who see the patients our call center refers in, and they have no hesitation in questioning my triage guidelines or judgment if we over refer to them.  If their concern makes sense, I make changes in the protocol.  I also have over 400 primary care physicians (PCPs) throughout Colorado, half of whom have trained here, that give me feedback if they think we have over referred or under referred one of their patients.  For any under referral, we always do a complete review of the complaint, including listening to the phone encounter which is automatically recorded on all calls.

I also receive unexpected communications from nurse managers, medical directors and triage nurses in various call centers throughout the country.  I value these questions and critiques.  I respond to them directly and make appropriate changes in the protocols when indicated.  In summary, I welcome input from anyone who uses my clinical content.

What are some of the health care goals behind your triage protocols? 

• Prevent all under referrals of emergent or urgent conditions (safe care).

• Minimize over referrals (unnecessary ED and office visits) (cost-effective care and family-focused convenient care).

• Help triage nurses use the most appropriate protocol through optimal search words and cross-linkages.

• Provide the caller with targeted, current health care information/education.

• Educate callers about misconceptions that lead to frequent unnecessary calls (e.g. fever, phobia, green nasal discharge, or productive coughs).

• Achieve more than 98% triage nurse satisfaction with clinical content.

• Achieve more than 95% caller satisfaction with service provided.

• Achieve more than 90% primary care physician concurrence with decision-making.

• Continuously improve clinical content by incorporating user feedback, reviewer feedback, quality improvement outcomes, research outcomes, and the current medical literature.

How do the philosophies of the three versions differ?

• All versions use the same criteria for recognizing 911 symptoms or conditions. 

• All versions have similar triage questions and care advice.  This helps with consistency of care.  Mainly, the dispositions within each set are different. 

• The After-Hours version is for evening, weekend, and holiday coverage by call centers or physicians.  Approximately 20% of patients are referred in to the ED or UCC.  Whenever it is safe to do so, patients are referred to the physicians' office on the following day.

• The Office-Hours version is for triage when the office is open.  No one is sent to the ED without the PCP prior approval.  Approximately 50% of callers are brought to the office.  Anyone who wants to be seen is worked into the office schedule.  The remaining callers are provided with specific home care and self-care advice.  The software version of office-hours triage is an expanded version of the book the AAP distributes to office pediatricians.  This has the advantage of having the parent hear the same advice from the call center and their PCP's office.

• The managed care version is for health insurance companies.  If a caller needs to be seen and doesn't need to go to an ED, they are re-directed to call their PCP for further triage.  Those who can safely be treated at home are advised similarly to the other versions. 

Tell us about HouseCalls Online.

HouseCalls Online are Internet-based self-care guidelines.  There is both a pediatric and an adult version.  They are available in English and Spanish.  Over 20 hospitals currently have them on their Website and most report frequent use and a lowered call volume; in essence, they are off-loading some of their low-acuity calls to the web.  An exit survey to one Website documented 100% of parents thought both the triage and advice they received were understandable and easy to use and 60% said it prevented a call to their doctor's office.  An added benefit is that the content is compatible with Schmitt/Thompson nurse triage guidelines.  Some call centers have launched marketing campaigns to redirect unnecessary calls to this resource. 

Tell us about the after-hours call center program at The Children's Hospital (TCH).

It is in Denver, Colorado and was established 1988.  It is a statewide system in Colorado and Wyoming.

Will you highlight the stats for the call center?

• Volume: 10,300 calls per month (2002)

• Total: 123,000 calls/year (2002)

• Provided for 477 physicians

▪  Private physicians: 337 (324 pediatricians and 13 family physician) 
(includes 98% of metro Denver pediatricians)

▪  Kaiser Permanente physicians: 140 (50% pediatricians)

• Provided by 40 Pediatric RNs (both full-time and part-time)

▪  1 RN can cover 15 pediatricians

▪  1 RN can take 6 calls per hour or 42 calls per shift

• Disposition of TCH Nurse-Triaged Calls

• See patient after hours: 20% (admission rate 1:88 calls or 1.1%)

• See patient within 24 hours: 30% (usually in physician's office)

• Telephone advice for home care only: 50%

• Excludes: advice-only calls 6%

▪  Clinical Nurse Manager: Kris Light RN

▪  Software Systems Coordinator: Teresa Hegarty RN

▪  Medical Director: Barton Schmitt MD

Thank you for taking time to share with our readers: Thank you

For more information, contact Dr. Schmitt at schmitt.barton@tchden.org.