Long Calls: Common Themes and Tips to Manage
Call center standards rely on a balance of proficiency, efficiency and quality. As part of those standards, nurse triagers routinely have their average call time (ACT) monitored. Longer call times contribute to longer wait times for patients. This can negatively impact both caller and RN satisfaction levels. However, experienced triagers know there are always those occasional long calls that simply cannot be avoided. This article reviews the common causes of longer calls. We also offer practical strategies to help support nurse triagers and organizations to minimize these types of calls.
To better understand why some calls extend beyond expected time frames, we did a QI study at Children’s Hospital Colorado. Teresa Hegarty, RN, former nurse manager of the Pediatric Call Center, audio-reviewed 21 “long calls”. The definition of a “long call” was over 15 minutes. At the time of the study, our benchmark ACT was 10 minutes. The calls reviewed were from 3 guidelines representing 3 different anatomical systems. (Reason: To identify common drivers of lengthy calls independent of related guidelines.) The 6 identified causes of long calls along with strategies to improve efficiency are outlined below.
Caller Anxiety and Lots of Questions (Non-urgent dispositions and patients stable) – 6 calls (29%)
Avoid overwhelming the caller with too much information. Do not use medical terminology. Reason: Increases caller anxiety.
Limit care advice to the 2 or 3 items most appropriate for the caller’s situation. Prioritize what they need to do now and when to call back.
Give simple and concise instructions.
Do not repeat yourself unless the caller requests clarification or doesn’t understand. Summarize at the end of the call: “Are there other questions you have about what we’ve gone over?“
If the caller has a lot of questions, email them a care advice handout (e.g., PCA or ACA) to clarify complex care advice and use as a written resource later. Another option is to provide a professional internet resource, such as the AAP’s website for parents (healthychildren.org) or a hospital/office website that has patient information on it.
Give the caller permission to call back if they have further questions or plan of care is not working.
Consider providing a RN follow-up call after you have given your recommended care advice if the caller continues to ask questions. This improves the comfort of the RN and the caller.
Caller with Concerns About an Urgent Disposition and Triager Needing to Spend Time Justifying Rationale – 5 calls (24%)
Interestingly, 2 patients in this category were admitted despite the caregiver being reluctant to go in now. Both calls involved an extensive discussion with the nurse about being seen urgently and questioning the RN’s rationale.
If patient safety is a concern and resolution with the caller cannot be reached efficiently, involve the PCP at the time of call.
If appropriate to the clinical situation, consider whether a virtual after-hours visit might work better (if the option is available).
If the caller wants to select a different disposition or choice of site and patient safety is not a concern, document it as such.
Triager Inefficient Call Process (Number of questions asked or disorganization of call process): 3 calls (14%)
Use a systematic call process. Avoid interspersing care advice during assessment and triage. If caller digresses, redirect the conversation back to current symptoms to keep the call on track.
Keep control of the call after you have listened to the caller’s initial story. Developing this skill takes practice and experience. Use gentle interruption when the caller pauses, such as, “So, you’ve had a cold for 10 days and now a fever. Let me ask you a few more questions about your symptoms”. Once in the guideline, you should be able to keep control of the call and become more efficient.
Benchmarking your call center’s most proficient staff members during various parts of the call can provide a goal for newer triagers or struggling staff. While workflows vary by organization, an example of an efficient call progression might look like this with a goal of 10 minutes per call:
Your own benchmarking data can be used for your nurses to pace themselves through each call phase to stay on target. A visible software call timer can help the nurses track their progress and improve overall time awareness.
Complex Calls (Reasons listed below): 3 (14%)
Recently Seen or Discharged from the Hospital: Use the follow-up guidelines for specific diagnoses for these calls if available. Reviewing previous visit notes or discharge instructions may be helpful. These patients may require urgent reassessment for new onset of complications or a worsening condition. If you are unable to reach agreement with the caller about being reseen, involve the PCP. Another option is to consult with an ED or hospital provider (or specialist) where the patient was seen or discharged. Nurses also need to recognize when the call extends beyond the scope of their nursing practice and requires more advanced health care provider decision making.
Chronic Disease: Patients with complex or chronic diagnoses are challenging as well. They often require in-depth assessments, especially if the chief complaint relates to their chronic condition. Many of these patients need advice from their subspecialists or an urgent evaluation now.
Multi-symptoms: Calls about multi-symptoms are always difficult. Focus on identifying the most serious symptom and select the one guideline which results in the highest level of care. See References for more tips on handling these challenging calls.
Extended Documentation Time After Call Ended: 2 calls (9%)
Learn to chart as you go and keep moving forward in your documentation.
Auto document whenever possible and use software tools to improve efficiency.
Use organizationally-approved medical abbreviations to streamline documentation.
Focus on documenting essential and clinically relevant information only.
Call wrap-up time and call talk time ideally should be within a minute of each other.
At the end, briefly review documentation for accuracy. Avoid excessive editing or adding unnecessary detail.
Triager Having Difficulty Making a Disposition Decision: 2 calls (9%)
Convey confidence in your decision making and choice. Callers expect to hear confidence in your voice regarding clinical decisions.
If it doesn’t feel right or you are unsure, consider other options. For example:
o Recommend caller try some things at home and call back if not working.
o Consider a RN follow-up call.
o Involve the PCP.
o Consult an experienced colleague.
o Consider other options such as an ED visit or virtual visit if available and you are uncomfortable.
Summary
There are common causes of lengthy calls. Group staff education and discussion focusing on these top causes will increase staff awareness of options for managing these calls. Individual mentoring may also be needed for staff who are struggling with efficiency. If you identify certain guidelines associated with longer call times, guideline review may be helpful in a group setting. These reviews may include opportunities for guideline teaching about high-risk symptoms or refinement of assessment skills. Staff input and suggestions can help streamline any call center process that contributes to inefficiency. Also, consider having a staff member present a portion of a lengthy call they did to have group discussion about what might have helped. These approaches promote shared learning and help identify practical strategies to improve efficiency.
Using your call center’s data can improve overall staff engagement and commitment to meeting unit efficiency goals. To conduct a review in your call center, follow these steps:
Run a report to identify the top guidelines with the longest call times.
Select the top 3-4 guidelines for review, ideally representing different anatomical systems. (Reason: There may be different causes of long calls for different kinds of guidelines).
Randomly select long calls done by different RNs in order to identify common themes across staff.
Assign a single reviewer to listen to the calls to ensure consistency in evaluation.
Share findings with the RN team for group discussion to develop targeted efficiency strategies.
Authors
Teresa Hegarty, RN, STCC Pediatric Special Projects Coordinator
Kelli Massaro, RN, STCC Pediatric Guideline Nurse Editor
References:
Massaro, K. When Time is of the Essence: Efficiency Tips for Phone Triage. December 2016. Available at: https://www.stcc-triage.com/s/Clinical_Update_for_Telephone_Triage_Dec-2016.pdf