Special Medical Reports - September 15, 1999 - American Academy of Family Physicians

Special Medical Reports

AAP Report Discusses Success Factors for Pediatric Call Centers
Verna L. Rose

In response to an increase in the number of pediatric call centers in the United States, the Provisional Section on Pediatric Telephone Care and the Committee on Practice and Ambulatory Medicine of the American Academy of Pediatrics (AAP) have issued guidelines for the administration and management of these call centers. Major medical centers, physician practices and other health care organizations have established pediatric call centers that provide after-hours telephone care to patients of physicians or organizations who subscribe to the service. The guidelines, published as an insert in the November 1998 issue of AAP News, are intended to provide an outline for the operation of pediatric call centers and to form a framework for standards of care (see table).

Call Priority Definitions

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The AAP defines pediatric call centers as medical units that provide health care management to patients whose primary care clinician practices within the broad scope of pediatrics. These include pediatricians, nurse practitioners, and general and family physicians. Services may include telephone triage and advice, physician referral, scheduling, utilization management, and disease and wellness management.

The AAP guidelines are divided into five sections: call center operations, patient access, nursing, physician interaction and total quality management.

Selected information from the five sections of the guidelines follows:

The personnel of a call center should include a medical director, a clinical (nurse) administrator and call center registered nurses. The call center nurses should provide the type of patient care that ensures the health, safety and comfort of all patients. Additional personnel who the AAP believes could help improve nurse productivity include a medical advisory committee, a nonclinical manager, clerical and technical support staff, and nurses with expanded roles such as a supervisor or a nurse who provides patient education.

All patients of a subscribing physician's practice or a contracting organization should have universal access to the call center regardless of insurance status, socioeconomic status or communication problems. They should be informed and educated about the triage and advice program. When patients call the center, they should immediately be told the status of the person with whom they are speaking.

The AAP emphasizes that specialty training and continuing education are essential to the success of telephone triage nursing care--an area that is heavily dependent on traditional nursing skills and extensive communication skills.

A physician representing a subscribing practice should be on-call at all times during which the call center is covering for that practice to help in the following situations listed in the guidelines:

When callers insist on speaking with a physician.

When health questions are beyond the comfort level of or the resources available to the nurse taking the call.

When the physician elects to be contacted for certain acuity levels.

When the nurse feels the caller will not comply with the advice.

All calls should be answered in a timely manner that reflects the nature of the call. Determining the urgency of a call should be based on the presenting problem as stated by the caller (see the table). The AAP report also contains tables listing policies and procedures related to risk management, policies and procedures to assist the triage process, documentation items, a suggested call-processing sequence and call priority definitions.

The AAP states that the guidelines will undergo modification and clarification as research into this growing field is performed and as clinical benchmarks are identified. Application of these and subsequent guidelines, according to the AAP, will mean that safe and quality patient care will always be the foremost goal of pediatric call centers, and this goal should not to be compromised by financial pressures.

ACOG Urges a Cautious Approach to Vaginal Birth After Cesarean Delivery
Verna L. Rose

The American College of Obstetricians and Gynecologists (ACOG) has issued a new practice bulletin on vaginal birth after previous cesarean (VBAC) delivery. The new statement, published in the July 1999 issue of Obstetrics and Gynecology, replaces an earlier version published in 1998. The focus of the new practice bulletin remains the same. The new report clarifies ACOG's position on the need for institutions offering VBAC to have the facilities and personnel, including obstetric, anesthesia and nursing personnel, immediately available to perform emergency cesarean delivery when conducting a trial of labor for women with an existing uterine scar. While strongly supporting the concept of VBAC delivery, ACOG recommends a cautious approach and consideration of individual risk factors before attempting a trial of labor.

The report discusses the background of VBAC, clinical considerations and recommendations, selection of candidates for a trial of labor, risks and benefits, contraindications to VBAC, patient counseling and management of labor. An algorithm for determining the feasibility of VBAC in a patient is also included in the ACOG practice bulletin.

According to ACOG, no randomized trials have proved that maternal and neonatal outcomes are better with VBAC than with repeat cesarean delivery. Published evidence suggests that the benefits of VBAC outweigh the risks in most women. However, reports note that maternal and infant complications also are associated with an unsuccessful trial of labor. These developments have led to a more circumspect approach to a trial of labor than was previously indicated.

ACOG emphasizes that it is ultimately up to the physician and patient to decide whether to attempt VBAC. The following are the criteria that ACOG lists for identifying a candidate for VBAC:

One or two previous low-transverse cesarean deliveries.

Clinically adequate pelvis.

No other uterine scars or previous rupture.

Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery.

Availability of anesthesia and personnel for emergency cesarean delivery.

VBAC should not be undertaken in women who have had a previous classic or T-shaped incision or other transfundal uterine surgery. Other contraindications for VBAC are a contracted pelvis; medical or obstetric complication that precludes vaginal delivery; and inability to perform emergency cesarean delivery because of the lack of an available surgeon, appropriate anesthesia, sufficient staff or appropriate facility.

The following recommendations from ACOG, based on consistent scientific evidence, have been excerpted from the practice pattern:

Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should receive counseling about VBAC and be offered a trial of labor.

Epidural anesthesia may be used for VBAC.

A previous uterine incision extending into the fundus is a contraindication to VBAC.

The following recommendations, according to ACOG, are based on limited or inconsistent scientific evidence:

Women with two previous low-transverse cesarean deliveries and no contraindications who wish to attempt VBAC may be allowed a trial of labor. They should be advised that the risk of uterine rupture increases as the number of cesarean deliveries increases.

Use of oxytocin or prostaglandin gel for VBAC requires close patient monitoring.

Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.

The following recommendations are based primarily on consensus and expert opinion:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician.

Copyright © 1999 by the American Academy of Family Physicians.
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