Perfecting the On-Call System

So, this past weekend I’ve been on call for our practice.

Starting at 5 p.m. on Friday afternoon, and going through 9 a.m. Monday morning, our telephones roll over to an answering service that pages the on-call doctor. For much of the weekend, a couple of our amazing Internal Medicine residents take first call, and I’m there for backup and medical advice, to discuss complex cases and help them figure out the best way to manage patients when they have questions.

We’ve also opened up our practice for Saturday patients, intending these appointment slots for semi-urgent visits, patients who were triaged during week as needing an appointment in the next day or two for which no availability was found, or else patients that couldn’t get to the practice because of work or other commitments, and sometimes those who just found a Saturday appointment more acceptable. In reality, most of these appointments — which involve the on-call physician — end up being the latter types, and this weekend my schedule was packed full of my own primary care patients. They were people who were excited about the possibility of coming in on a weekend day, with less time pressure, less crowds, less traffic, and less chaos.

24/7 Availability

The call system is designed so that someone is always available, so that our patients can always reach a live physician to discuss their acute concerns. A lot of times, we get calls from patients who want to discuss chronic issues, refill routine medicines, go over test results, and for other nonemergent situations for which they just couldn’t reach someone during the week, or just never got around to it. Ideally, these interactions between patients and the physician should be to get the patient the appropriate level of care they need.

If someone’s really sick, someone seems in extremis, or if a potentially life-threatening diagnosis is discovered or even deemed possible during our triage calls with them, then they can be directed to a higher level of care in the emergency department. But the overwhelming majority of cases we manage just as we would during the week, finding a way to take care of them and keep them safely at home, while alleviating or mitigating their symptoms, or providing a short-term interim solution to get them through the weekend, after which they can come in for additional care.

The types of calls we get on weekends are not that much different from what happens on weeknights — patients with an acute concern for which we offer medical advice, treatment options, and sometimes just a person on the other end of the phone to talk to.

Several months ago, during the very early morning hours of an overnight call, I was called by the page operator to speak to a patient, and they started telling me about some symptoms they had been having, complaints that initially sounded like it might need to be escalated to an in-person visit either the next morning or in the emergency department right away.

As the conversation went on, it became clear that the patient had some mild cognitive impairment, and that they were currently residing in a long-term care facility. They told me that they had pushed their bedside nursing call-bell asking to speak to the nursing home doctor, but the nurse told them that the physician wouldn’t be around until at least 8 o’clock the next morning. So they decided to call us, their primary care doctors. I talked to them for a while, reassured them that the treatments the nurse was getting for them already would probably be okay to tide them over until the morning, and they ultimately thanked me and went back to sleep.

“Doc, I Can’t Sleep”

One of our favorite middle of the night pages is the 2 a.m. phone call in which the patient says, “I’m having trouble sleeping,” for which most of us on call think, “Well, now two of us are awake.” But by being available, by treating patients with “primary care-responsive” issues without having to send them to the emergency department, is an incredibly wonderful and important service that we are able to provide for our patients.

Over my past few calls, we’ve handled cellulitis; bronchitis; multiple cases of COVID-19 requiring Paxlovid; COPD and asthma exacerbations; mild pyelonephritis and diverticulitis; and even one case of appendicitis for which a patient refused to go to the emergency department, no matter what. This stopgap care, something between “Take two aspirin and call me in the morning” and “Call 911 and go to the emergency department,” fills an incredibly important gap in healthcare.

It reminds me of what happened during the early weeks and months of the COVID-19 pandemic. Our emergency department was overwhelmed. The providers there were swamped, the hallways were filled, every inch of the hospital had been turned into an intensive care unit, and patients were crashing and being intubated left and right.

There was not much we could do for patients beyond supportive care in those early days, so ultimately, as the numbers swelled beyond the manageable, we all needed to find something to do to handle the less critical cases, those not likely to be intubated in the next couple of hours. We needed to find a way to keep them from waiting hours in the emergency department when there were so many that needed the critical attention right then.

In emergency departments across the country, to prevent patients from being triaged and dumped, the EMTALA (Emergency Medical Treatment and Active Labor Act) laws were created so that once a patient was triaged into the emergency room, emergency care had to be delivered there. My colleagues in the emergency department tell me that probably 70% to 80% of the cases that come into the emergency department, while they often seem like an emergency to the patient, are usually not emergencies, and are in fact those “primary care-responsive” issues and complaints. They send many of these patients to their own urgent care center and do telehealth visits on site for others, but the numbers suggest that even more could be well and safely served by offloading them to us, right across the street.

For COVID-19, we found a way to preemptively triage patients, and we were able to send all those patients deemed not about to be intubated or die that day to be transferred over to our primary care practice across the street, where we had capacity, testing, x-rays, labs, and the ability to send patients home with portable oxygen generators, thermometers, and pulse oximeters — pretty much all the treatment and monitoring tools we had in those first weeks and months.

Slowing the ED Train

Percolating in the minds of myself and a couple of colleagues right now is a way to think about how we can better implement this again, to catch patients before they check into the emergency department, to do a better job of triage and routing them to an outpatient primary care clinic right next door to more swiftly and efficiently and safely get them the care they need. Perhaps there is a place for technology, smart systems to collect enough triage data and biometrics to correctly move patients onto the emergency department track or back to primary care?

Low-acuity visits in the emergency department often have long waits, while sicker and more critical patients rightly get the most attention of the clinical staff. Rather than making folks wait for hours, wouldn’t it be much better to get them in to see us, the primary care doctors, who could see them and treat them and send them on their way?

We’re not trying to steal visits or business from the emergency department. We’re just trying to help make everyone more efficient, we’re trying to make care better for everyone — the right care for the right patient at the right time. If we can keep people out of the emergency department for urinary tract infections, a simple ankle sprain, Strep throat, or Lyme disease, perhaps we can make the ED work better as well, by letting them focus on the kind of patients that really need to be there. Our hope is that this would be better for everybody, but we’ve got a few administrative hurdles to go through before we can fully implement this.

I’d be curious to hear if others out there have tried something like this and found a way to do it successfully.

We were able to bend the rules during the pandemic — partly because there were no rules — but now this may take some doing. Will let you know how things go.

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