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Telephone

Triage

by Primary

Care

Physicians

Susan Zelitch Yanovski, MD*; Jack A. Yanovski, MD, PhD; James D. Malley,

PhD; Richard L. Brown, MD, MPH*; and Donald

J.

Balaban, MD, MPH*

ABSTRACT. To determine if experienced primary care

physicians are more likely to reach correct decisions on

the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family

practice to evaluate three pediatric patients via a

tele-phone interview with a simulated mother and to decide

whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P

< .05) or injured (P < .01); however, less than half

ob-tamed histories considered adequate to rule out potential

serious illnesses. Faculty did better than either residents or private practitioners in managing a severely

dehy-drated child 100% of the faculty, but less than 60% of

the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all

residents and private practitioners reached inappropriate

management decisions despite obtaining information that should have altered their decisions.

In these simulations, experience in private practice was not associated with improved telephone manage-ment of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all

three simulations, attainment of the correct decision ap-peared to be determined not by the number or type of questions asked, but rather by the physician’s

interpre-tation of the information collected. Pediatrics

1992;89:701-706; Telephone, primary care, pediatrics,

fam-ily practice, management, triage, decision making.

The telephone call is a major means by which

physicians provide care for their patients. Twelve

percent to 28 percent of primary medical care is

delivered by telephone,”2 and up to half of all

phy-sician-patient telephone contacts result in further

medical evaluation.3 Nevertheless, how physicians

arrive at such decisions remains unclear.

Several studies of telephone management have

evaluated the effects of pediatric experience upon the

clinical judgment of physicians. Pediatric house

offi-cers have been reported to perform either as well as

or better than practicing pediatricians when scored

on history taking, interviewing skills, and

disposi-tion.4 Other investigators have found that serious

From the 6Greenfield Research Center, Department of Family Medicine,

Thomas Jefferson University, Philadelphia, PA; the Children’s Hospital of

Philadelphia, Philadelphia, PA; and the §Division of Computer Research and Technology, National Institutes of Health, Bethesda, MD.

Received for publication May 2, 1991; accepted Oct 18, 1991.

Reprint requests to (S.z.Y.) 5000 Battery Lane, #801, Bethesda, MD 20814. PEDIATRICS (ISSN 0031 4005). Copyright © 1992 by the American

Acad-emy of Pediatrics.

deficiencies in the questions physicians ask on the

telephone are not rectified by physician training or

experience.58 The consistent findings of unchanged

or even worsening physician performance with

in-creasing experience seem counterintuitive, and may

reflect artifacts of study design. For instance, adequate

history taking has been defined as not missing more

than one of a list of questions suggested by a

consen-sus panel.5 Whereas Perrin and Goodman attempted

to address this issue by weighting the importance of

historical data,4 their approach was still dependent

on the absolute number of “most critical items’

in-cluded, not all of which may be necessary in a given

clinical situation. Additionally, most studies of

phy-sician telephone decision making were carried out

more than a decade ago, and were limited by their

small sample size.

The purpose of this study was to examine telephone

decisions made by primary care physicians as a

func-tion of experience using their actual decisions as the

primary outcome measure. Our hypothesis was that

experienced physicians would more frequently make

the correct management decision when performing

telephone triage. We further hypothesized that

ex-perienced physicians would ask fewer, but more ap-propriate, questions in reaching their decisions.

Subjects

SUBJECTS AND METhODS

The sample comprised all first- and third-year residents in family

medicine at a university- and community-based residency program,

all first- and third-year residents in pediatrics at two

university-based residency programs, all faculty in family medicine and gen-eral pediatrics at the same programs, and the family physicians

and general pediatricians in full-time practice who admifted

pa-tients to these institutions. Subjects were excluded if they reported

that less than 10% of their patients were younger than 14 years of age, or if they participated in the development of the study.

We sent 141 physicians letters inviting each to participate in the study; nine (five pediatricians and four family physicians, all in

private practice) were unable to be contacted by telephone after

several attempts. Of the 132 physicians who were contacted by telephone, five (family practice faculty) saw less than 10% pediatric

patients and were excluded, leaving 127 physicians eligible for

inclusion in the study. Ten subjects refused to participate (one first-year family practice resident, one first-year pediatrics resident, three third-year pediatrics residents, and five private pediatricians). Thus, of the 127 eligible physicians who could be contacted by telephone, I 17 (93%) agreed to participate, and all completed the study. Some of the tape-recorded data for six cases involving four subjects could not be analyzed because of technical problems and were deleted for the purpose of analysis. However, the subjects’ triage decisions were available in all cases.

Characteristics of the study physicians are shown in Table 1. More pediatricians were studied than family physicians (P < .05).

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practi-TABLE 1. Characteristics of Study Physicians: Description of Subject’s Age, Qualifications, and Practice Patterns

Gender, Specialty

First-year

Residents

Third-year

Residents

Private Practice

Faculty Total

Numberofsubjects 31 29 36 21 117

Specialty

Family practice, % 26 38 47 19 34

Pediatrics, % 74 62 53 81 66

Mean age, y: 27 30 43 38 35

Gender

Male,% 42 48 83 81 63

Female, % 58 52 17 19 37

Any training in telephone medicine, 23 59 50 58 46

%

Board certification, % 89 100 93

Years in practice

<5y 33 38 35

>5y 67 62 65

Mean number of pediatric phone 45 1 1 32

contacts per weeks

Mean number of pediatric office via- 65 36 54

its per week9

*P< .05.

P< .001. §P< .005.

tioners reported seeing significantly more pediatric patients weekly

(P < .05) and handled significantly more pediatric phone calls (P

< .001) than did faculty physicians. Of the subjects, 46% reported training in telephone decision making, primarily by lecture. Interns

were significantly less likely than all others to have received any

training in telephone decision making (P < .005). All but four nonresident physicians (two family physicians and two pediatri-cians) were board-certified.

Case Development

Three cases were developed by the investigators with ‘correct’

management decisions based upon the most recent American

Acad-emy of Pediatrics guidelines for telephone management9 (employed previously4’#{176}), and upon the recommendations of texts on pedi-attic telephone decision making.’113 Taken together, these sources provided guidance on whether the patient needed to be examined

immediately or could wait until office hours the following day.

The cases described three pediatric problems commonly

man-aged by telephone: an 1 1-month-old with severe diarrhea and

dehydration who required immediate medical attention, an

18-month-old with minor head trauma, and a 2#{189}-year-oldwith fever,

neither of whom were felt to have problems of an urgent nature

(Table 2).

Administration and Scoring

The simulations were administered by one of the investigators (S. Z. Y.) by telephone at the subjects’ convenience. All interviews

were tape-recorded with the subjects’ consent. Subjects were

pro-vided identical written and verbal information describing the sim-ulated conditions to insure that subjects were working from similar

premises. This information included the time of day of the patient’s call, the physician’s previous knowledge of the patient, the physi-cian’s location, and the physician’s goals for the encounter. Other

information was given only in response to questions asked by the

physician-subject. The exact wording of the responses to individual questions was developed before the start of the study and was

standardized to minimize possible effects of investigator bias. If a

subject asked a question which did not have a predetermined response, it was answered by the simulated mother in a manner consistent with the overall content of the case, and this exact

response was used for all subsequent administrations. The three cases were administered in the same order during one telephone call for each subject, to minimize performance variability.’4 The order of the cases was: (1) 1 1-month-old with severe diarrhea and

dehydration, (2) 18-month-old with minor head trauma, and (3)

2#{189}-year-old with fever.

After all three cases had been completed, the interviewer

ob-tamed descriptive data and questioned subjects about their

percep-TABLE 2. Synopsis of Case Descriptions: Examples of Pertinent

Information Physicians Could Elicit from Simulated Mother for

Each Case

Case I : Severe Diarrhea and Dehydration

1 1-mo-old with watery stools for more than 24 h More than 10 stools last 12 h, each filling diaper

Drinking less than 12 oz last 24 h, won’t take more Won’t smile or play; whimpering last few hours Less alert than earlier, listless; has never been this sick

Is not making tears, eyes are sunken, mouth is dry

Case 2: Minor Head Trauma Without Loss of Consciousness 18-month-old, fell off changing table 3 ft onto a carpet

Cried immediately for 5 mm, then went to sleep

Able to wake up without difficulty, no vomiting

Now acting normally; moving arms/legs well, talking normally

Has lump on back of head which is tender, no other injuries

Case 3: Viral Syndrome with Fever

2’/2-y-old with temperature 102.6#{176}F(rectal) for 12 h Fever did not respond to acetaminophen

Dose of acetaminophen only 80 mg every 4 h (5 mg/kg) Emesis once, had two loose stools today

Minor pain at umbilicus, eating/drinking normally now

Otherwise acting well; has often been this ill in the past No significant past medical history

tions of the realism of the cases. Subjects were also asked to explain the reasons for their decision in each instance. Tapes of all

inter-views were reviewed to establish the decisions made by each

physician and the particular questions asked. Fifty percent of the

tapes were reviewed by two investigators. Inter-rater reliability for

the number of questions asked was 92% and for the specific

questions asked was 94%.

At the conclusion of the study, a complete list of the questions

asked by subjects and the responses offered by the simulated

mother were reviewed by five experienced physicians. This panel

consisted of two family physicians and three pediatricians of whom three were in private practice (one family practitioner and two

pediatricians). None of these physicians otherwise participated in

the study. Their task was to determine if, given all the information that subjects could elicit about each case, they would choose to see the child urgently. All five physicians agreed with the published guidelines that both the 18-month-old with head trauma and the 2#{189}-year-old with fever could wait until the next day to be exam-ined; all were similarly in agreement with the published guidelines that the 1 1-month-old with severe diarrhea and dehydration

(3)

*

+

I

Diarrhea & Dehydration

ill

F

Head Trauma

Fever TABLE 3. Comparison of Performance Between Family Physicians and Pediatricians on Diarrhea and Dehydration Simulation’

Group Percent Correct

Decisions

Time to Decision in Seconds

Total No. of Questions

No. of Critical Areas

Ad-dressed (of

nine

possi-ble)

Pediatric private practitioners, n = 19

Family practice private practitioners, n = 17

47 (24-71)

41 (18-67)

141 ± 10

143 ± 10

18.4 ± 5.5 17.5 ± 1.1

7.0 ± 0.3 7.2 ± 0.3 Pediatric faculty, n = 17

Family practice faculty, n = 4

100 (84-100)

100 (47-100)

138 ± 13 183 ± 40

18.1 ± 1.6 21.0 ± 2.1

7.6 ± 0.3

6.8 ± 0.4 Pediatric third-year residents, n = 18

Family practice third-year residents, n = 11

61 (36-82) 55 (23-83)

155 ± 15 178 ± 22

19.1 ± 1.4 20.5 ± 2.2

7.7 ± 0.2 7.5 ± 0.4 Pediatric first year residents, n = 23

Family practice first-year residents, n = 8

52 (31-73) 50 (16-84)

123 ± 6

189 ± 36

16.6 ± 0.7 21.5 ± 2.8

7.2 ± 0.2 7.8 ± 0.2

9Within each group (ie, faculty, private practitioners, first-year and third-year residents), family physicians and pediatricians performed

equally on each of the outcome measures.

: For the Percent Correct Decision, the standard exact asymmetric 95% confidence intervals are given in parentheses.

§Mean and standard error of the mean.

Recognizing that obtaining an adequate history does not neces-sarily require asking all of a predetermined list of questions, we developed the concept of critical areas. A critical area was defined as information that should materially influence the physician’s decision whether to see the patient promptly. For example, the state of hydration in the diarrhea case constituted a critical area that might be addressed adequately by one or more questions. Critical areas were reviewed for content validity by the five-physician panel. Only items about which there was 100% agree-ment were included (see the Appendix).

Data Analysis

Statistical analysis was performed using Statview II and KaleidaGraph on a Macintosh IIcx, and also using mainframe SAS. One-way analyses of variance were followed by the post hoc tests: Fisher LSD, Bonferroni and Scheffe multiple comparisons. All outcomes agreed for all applications. Across groups analyses were also checked diagnostically using the Kruskal-Wallis nonparametric

test. Statistical tests for counted data were done using chi-square,

contingency table analyses. Tests for trend in tables with ordered categories were examined using the Goodman-Kruskal Gamma and the Kendall taub statistic.

RESULTS

No significant differences were found between

spe-cialty groups (family practice vs pediatrics) in the

number of questions asked, the number of correct

decisions made, or in the number or type of critical

areas addressed for any of the cases (see Table 3 for

example). Because of the lack of difference in outcome

measures as well as the small sample size of some

groups (ie, family practice faculty), specialty groups

are combined and-data are shown based on level of

training and type of practice. However, all of the

findings presented below remained unchanged when

only the data from pediatricians were analyzed.

When evaluating a child who was severely ill with

diarrhea and dehydration, faculty physicians were

significantly more likely than all others to reach the

correct triage decision (Figure). All the faculty, but

only 44% of the private practitioners, made the correct

decision to evaluate the child urgently (P < .001).

First-year residents were more likely than all others

to see a child urgently when the case described a

patient with minor head trauma (P = .014) or fever

without serious illness (P = .005).

Experience was measured by number of years in

practice, number of pediatric patient visits per week,

and number of pediatric phone contacts per week.

100 90 80 C 0 U) #{149}3 70 U) U 0 U C

I:

10 0

Figure. Correct decision by level of training. Nominal P values

are reported. P < .0001, faculty physicians vs all other groups;

t P = .014, interns vs all other groups; # P .005, interns vs all

other groups; U, first-year residents (n = 31); 0, third-year residents

(n = 29);

#{149}

private practice (n = 36);

,

faculty (n = 21).

These measures of experience were examined both

individually and jointly to determine if correct

deci-sions or number of critical areas addressed were

re-lated to experience. No significant correlation was

found between these measures of experience and

physician performance for private practitioners or

faculty in any of the cases.

Training in telephone decision making was not

correlated with any measure of performance; nor did

triage decisions differ significantly according to the

sex of the physician for any simulation. There was no

association between board-certification and any

out-come measure.

When evaluating the children with problems that

did not require urgent evaluation, many physicians

failed to obtain adequate histories to rule out serious

illness (Table 4). Sixty percent of physicians did not

determine circumstances surrounding the injury in a

child with head trauma sufficiently to rule out child

abuse. More than half of the subjects failed to

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condition or was taking any medications other than acetaminophen.

While interns were less likely to inquire about the

presence of concomitant underlying ifiness in a child

(P < .05), there were no significant across-group

differences either in the total number of questions

asked or in the number of critical areas assessed.

Furthermore, neither the number of critical areas

ad-dressed nor the total number of questions asked was

associated significantly with correct decision making

for any of the groups in any of the three case

simu-lations. Of the four critical areas in the diarrhea and

dehydration simulation that indicated the child had a

significant medical ifiness (see Appendix A), at least

one was addressed by all study physicians. The

fre-quency with which any of the four critical areas was

addressed did not correlate with correct decision

mak-ing. Thus, more than one third of all residents and

private practitioners reached inappropriate

manage-ment decisions despite obtaining information that,

according to published guidelines,9’”3 should have

altered their decisions. Upon receiving the same

an-swers to their questions, all faculty physicians chose

the correct decision.

DISCUSSION

This study was designed to determine if

experi-enced physicians demonstrate superior telephone

triage skills as determined by the frequency with

which they reach the correct management decision

and by the nature of their questions. The design was

developed specifically to explore adequacy of clinical

judgment in an explicit manner and to avoid reliance

on a ‘cookbook’ approach or checklist to demonstrate

good management skills. Because of differences in

on-call responsibilities of faculty, private

practition-ers, and residents, we believe that biases among

groups were minimized by administering the cases to

all subjects under optimal conditions, with specific

instructions given as to conditions of the simulation.

For example, most interns and faculty physicians in

this sample did not take patients’ telephone calls at

night and thus could only be studied through the use

of case simulations.

For the two children without serious illness,

expe-rienced physicians were more likely to reach the

correct management decision than were first-year

res-idents. Thus, interns recommended that more

chil-then with benign, self-limited ifinesses be seen

im-mediately. Although such actions may increase the

cost of health care and may inconvenience patients

and their families, children who are examined are

unlikely to experience an adverse medical outcome.

More importantly, both residents and physicians in

private practice were likely to underestimate the

de-gree of illness in a child with severe diarrhea and

dehydration regardless of the information they

elic-ited through their telephone evaluations. Faculty

phy-sicians were much more likely than private

practition-ers to see the ill child promptly. This may be because

faculty physicians have more contact with seriously

ill children than those in private practice. Faculty

physicians might be more familiar or more in

agree-ment with practice guidelines such as those developed

by the American Academy of Pediatrics and these

results conceivably may reflect the differences in

de-cision making of policymakers/teachers and

practi-tioners. Despite instruction prior to the simulation

that the physician would be required to assess the

patient at a local emergency department in the event

the child warranted urgent evaluation, this finding

may reflect the fact that the task of examining a

patient is usually delegated by faculty to their house

staff. Under such circumstances, faculty might be

TABLE 4. Percent of Subjects Addressing Specific Critical Areas’

First-year Residents

Third-year Residents

Private Practice

Faculty Total

Case 1 : Diarrhea

Age 90 100 100 100 97

Fever 100 100 86 100 96

Stool character 90 93 75 95 87

Stool frequency 87 93 83 86 87

Vomiting 71 79 83 62 75

State of hydration 42 62 36 62 49

Urine output 77 70 64 71 72

Fluidintake 97 97 95 95 96

Severity of illness 74 73 81 71 75

Case 2: Head Trauma

Age 90 100 92 86 92

Loss of consciousness 65 66 72 71 68

Neurologic status 97 97 89 90 93

Otherinjury 48 31 44 42 42

Circumstances of in- 38 52 39 29 40

jury Case 3: Fever

Age 94 100 97 90 96

Heightoffever 100 93 94 95 96

Severity of illness 39 34 36 38 37

Other medical condi- 16 59 33 43 37

tions

S Percentage of subjects who asked questions about the areas considered critical by a consensus panel

for each case.

(5)

expected to request examination of more children

with self-limited illnesses; however, faculty

per-formed as well as private practitioners in detecting

children who did not require urgent evaluation.

Rather than reflecting a bias on the part of faculty

that children are likely to have serious illnesses, a

“wellness bias,”5 in which the most favorable

diag-nostic possibility is embraced, may be present in

experienced general physicians for whom the vast

majority of contacts are with patients who have mild

and self-limited illnesses. This bias may have

contrib-uted to the observed tendency of private practitioners

to minimize the severity of symptoms reported.

Al-ternatively, faculty may be more adept in listening

skills or may interpret the information they gather

differently from their colleagues in private practice.

Faculty physicians also may be less likely to have

trust in a family’s ability to continue close

communi-cation with the physician, and thus insist on earlier

evaluation.

Physicians who knew they were being recorded

and evaluated might be expected to be at least as

thorough as in an actual after-hours call situation.

Thus, our overall results should represent optimal

physician decision making. It was surprising,

there-fore, to find that even when physicians were not

under time constraints and knew that their skills were

being studied, their assessments were often

inade-quate and the consequent decisions incorrect.

Contrary to our hypothesis, neither the quantity

nor the quality of questions asked was associated

with any of the measures of experience examined.

We acknowledge that experience measured as the

number of years a physician has been in practice may

be confounded with the calendar time when the

physician completed training, but addressing this

is-sue was beyond the scope of this study.

Physicians who addressed a greater number of

critical areas were not more likely to reach the correct

triage decision. It has been suggested that the

ade-quacy of assessment and plan may not correlate with

the amount of information gathered or the number

of hypotheses generated.6’’17 Thus, factors other

than the information obtained by asking questions

recommended by experts in telephone decision

mak-ing would seem to be of greater importance in guiding

the telephone decisions of the physicians in our

sam-ple.

Although it was impossible to determine the exact

point during a simulation at which the physician

determined the severity of the problem and was

pre-pared to prescribe therapy, some physicians appeared

to make a triage decision early in the course of the

conversion, and then ‘shut off,’ ignoring subsequent

data which should have led them to reconsider their

decision.4 The following is an excerpt from an

inter-view with a third-year pediatrics resident who has

not yet adequately assessed hydration or the severity

of the child’s illness:

Resident: It sounds like your baby has a viral

gas-troenteritis but is well-hydrated and should do just

fine at home. What we worry about with these

little ones is that they can get dehydrated which

can make them very ill. We can tell this if the baby

isn’t urinating, if the mouth is dry ...

Mother: But doctor, I think her mouth is dry. Resident: Well, it’s often hard to tell that. Just keep

doing what you’re doing, and if she’s not better in

the morning, bring her into the office.

In combination with the ‘wellness bias,’ which can

be even more accentuated when the patient is not

physically present for the physician to evaluate, a

shutting out of information could have serious

con-sequences.

In postsimulation discussions, private practitioners

often commented that they relied on their knowledge

of most of their patients (and their mothers) when

making the decision about the seriousness of a child’s

ifiness. Unfortunately, today many practitioners do

not know all of the patients with whom they have

telephone contact.18 Even small groups often share

coverage, and large, staff-model health maintenance

organizations are becoming more prevalent. Many

primary care physicians no longer have the luxury of

relaying on a previously established relationship with

the patient to guide telephone decision making. Thus,

expertise in telephone management becomes

essen-tial.

As assessed by these case simulations, clinical

de-cisions by primary care physicians improved in some

areas with experience. However, many physicians in

private practice did not demonstrate the skills needed

to perform adequate telephone triage despite their

great number of patient contacts. We have found, as

have others using blinded simulations,4’7’8”9 that

phy-sicians performing telephone triage may not always

ask all the right questions. However, most physicians

in this study did obtain information sufficient to

determine the severity of a child’s illness. Thus,

fac-tors other than the type or amount of information

obtained may account for deficiencies in telephone

management. Physicians must not only ask good

questions, but must carefully listen to and evaluate

the answers if they are to manage patients effectively on the telephone.

ACKNOWLEDGMENTS

We are indebted to Dr Robert E. Merrill for his critical review of

our work and valuable suggestions. We would also like to thank

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APPENDIX: CRITICAL AREAS

Simulation 1: Severe Diarrhea with Dehydration

1. Age of patient 2. Presence of fever 3. Description of stools

Defined by asking at least 2of the following:

Consistency

________Color

________Amount ________Blood ________Duration 4. Frequency of stools’ 5. Presence of vomiting

6. Urine output(Note: In the present simulation, the mother cannot estimate urine output, as every diaper is fified with watery

stool.) 7. Hydration’:

Defined by asking at least 1of the following: Presence of tears

Dry mucous membranes

Sunken fontanelle

Skin turgor Sunken eyes

8. Intake’

9. Presence of severe illness’:

Defined by asking at least 1of the following:

_________Will she smile

________Will she play

Question eliciting that child is whimpering

Is child easily comforted Is mother worried about her ________Does mother think she is very sick ________Does mother think she is getting worse

Questions on child’s activity Questions on child’s alertness

indicates areas which, in this simulation, the answer given to a single

question may have been sufficient to lead to urgent evaluation of the child.

Simulation 2: Minor Head Trauma, No Loss of

Consciousness

1. Child’s age 2. Rule out Abuse

Defined by asking at least 1of the following:

_______Mechanism of injury (What happened, Did you see it happen, how did he fall, etc.)

_______Past history of injuries, illnesses, hospitalizations 3. Loss of consciousness

4. Neurologic assessment

Current general appearance or at least 2 questions assessing

the following:

Walking normally

Talking normally

Normal behavior

Playing normally

Normal vision

Normal pupils/eye movements

________Moves all extremities Presence of headache Presence of seizures

Is child easily awakened

Presence of vomiting

Elicits that child is currently watching television ________Normal activity

________Presence of irritability 5. Other significant injury

Is he hurt anywhere? or

Defined by asking at least 2of the following: Bleeding

Lump Bruising ________Pain

Fluid from nose/ears

Simulation 3: Viral Syndrome with Fever 38.5#{176}C

1. Age of patient 2. Height of fever

3. Presence of severe illness

Defined by asking at least 2 of the following:

_______Will she smile

_______Will she play

Questions on child’s alertness

Questions on child’s responsiveness Talking normally

Tating normally

_______Assessment of fluid intake Is mother worried about her _______Does mother think she is very sick

_______Does mother think she is getting worse

Questions on child’s activity Is child easily comforted

4. History of underlying ilinesses/hospitalizations/medi-cations

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1992;89;701

Pediatrics

James D. Malley

Susan Zelitch Yanovski, Richard L. Brown, Donald J. Balaban, Jack A. Yanovski and

Telephone Triage by Primary Care Physicians

Services

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http://pediatrics.aappublications.org/content/89/4/701

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(8)

1992;89;701

Pediatrics

James D. Malley

Susan Zelitch Yanovski, Richard L. Brown, Donald J. Balaban, Jack A. Yanovski and

Telephone Triage by Primary Care Physicians

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American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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