Commentary

The tension between cost effective and safe care is played out nightly on the telephone when anxious parents call asking what to do about a child’s presumed illness. The network of after hour, telephone advice services using protocols to direct decision making has grown exponentially in North America in the past decade.¹ In the UK, National Health Service Direct was launched in 1998, and 40% of calls concern children.² Previous studies have found appropriate rates of referral to emergency departments and low risk of morbidity and mortality after telephone advice provided by non-physicians who used clinical algorithms.³ However, the study by Lee et al contributes to our understanding of this phenomenon by examining an important subset of the advice seeking population: those who are deemed “well enough” to delay care. This study attempted to ascertain the safety of advice given by nurses to delay care or to provide self care compared with that given by paediatricians. The results suggest that nurses using triage algorithms are safe substitutes for physicians. In the 2 cases where nursing advice was followed up by significant unadvised care that included hospital admission, detailed clinical summaries suggest that hospital admission was not indicative of poor advice from nurses.

It is important to recognise the context of the study. The sample was drawn from a highly educated, privately insured population accustomed to having a paediatrician available for their after hours calls. Further studies should be done in populations that are less educated and have fewer resources. Studies with parents who are less knowledgeable and have poorer communication skills may reveal differences not apparent in this study.