We sought to determine the safety and efficiency of a telephone-based triage system for influenza-like illness, during the 2009 pandemic, at our institution. A triage system was implemented that involved initial telephone screening by a provider who determined whether outpatient telephone-based care or assessment in a centralized evaluation unit was needed. Those who received outpatient care were empirically treated. Those seen in the evaluation unit were assessed for inpatient admission. Of the 230 women who were evaluated, 41% were treated as outpatients and 59% were seen in the evaluation unit. Of those treated as outpatients, 9% were eventually seen in the evaluation unit and only 4% were ultimately admitted, with a maximum hospitalization of 4 days. Of the 135 patients initially seen in the evaluation unit, 32% were admitted and 44% had a positive polymerase chain reaction for respiratory pathogens. This triage system improved efficiency of resource utilization without incurring apparent influenza-like illness morbidity.
Pregnant women infected with influenza have increased morbidity and mortality compared to nonpregnant women, with correspondingly increased rates of hospitalization and intensive care unit (ICU) admission. Consequently, the 2009 H1N1 pandemic raised the specter that health care resources would be overwhelmed due to the increased volume of pregnant women presenting to outpatient and inpatient settings for evaluation and treatment of influenza-like illness (ILI). An additional concern was the potential for horizontal transmission due to the proximity of pregnant women with influenza to noninfected pregnant women admitted for other reasons in the same health care institution.
The increase in hospital volume and adverse health outcomes associated with obstetric influenza emphasizes the need for well-developed systems of assessment and treatment of pregnant women during periods of pandemic influenza. Ideally, protocols would enable both the efficient use of resources and the optimization of patient care. One potential mechanism to achieve these goals is the use of a telephone-based system to triage potential ILI patients prior to their arrival. Thus, those not in need of immediate face-to-face evaluation could quickly receive treatment without having to wait to be seen, those in need of more intense evaluation could be seen more quickly, and those being evaluated in person for reasons other than ILI could have less chance of becoming horizontally infected.
In the nonpregnant population, telephone triage systems have been developed and used to maximize resource utilization within a health care system. Yet, despite the recognized increase in morbidity and mortality related to influenza in an obstetric population, as well as the possibility of resource scarcity in the setting of a pandemic, few studies have evaluated a telephone-based triage protocol for influenza in pregnancy. Our study sought to determine the outcomes of a protocol beginning with telephone triage for evaluation and treatment of ILI in pregnant women. We hypothesized that the introduction of this system would decrease in-person in-hospital evaluation without incurring additional morbidity.
Materials and methods
During influenza season 2009 through 2010, physicians at our urban tertiary care medical center were educated regarding influenza and the importance of vaccination. This education occurred via hospital-sponsored physician forums, grand rounds presentations, and literature distribution. In addition to being encouraged to vaccinate all of their pregnant patients, physicians were introduced to a newly developed telephone-based triage system for ILI. At this institution there are 17 practices that serve obstetrical patients. Our general demographics include 70% private insurance and 30% public aid coverage. Patients are 65% Caucasian, 15% African American, 15% Latina, and 5% other.
In this system, physicians were charged with educating their patients during routine visits to call their office immediately if they developed symptoms of ILI, including fever >100°F with a cough or sore throat. Names and contact information for all patients who contacted the physician offices were prospectively collected and these lists were faxed by office personnel on a weekly basis to a hospital-based ILI safety committee.
Based on the initial telephone contact, personnel (physicians or nurses) in the offices determined whether women could be treated as outpatients or required in-person evaluation at an obstetrical evaluation unit according to predefined criteria ( Figure 1 ) . Those judged to be appropriate candidates for outpatient treatment received a prescription for oseltamivir 75 mg orally twice a day and were given further instructions regarding signs and symptoms that should precipitate a return call. If the patient did not call, office staff then routinely called these women within 24-48 hours after their initial contact to ensure they were taking their medication and that symptoms were improving.
Conversely, referral to the hospital-based obstetric evaluation unit for further assessment was made if patients had severe symptoms of ILI or medical comorbidities predisposing them to ILI complications ( Figure 1 ). We utilized our current obstetrical triage unit for evaluation of ILI patients, but reconfigured it such that women who presented with ILI were not assessed in proximity to those who presented for other reasons. Patients presenting to the evaluation unit were given masks immediately and were taken from the waiting room into individual triage rooms to limit exposure to other patients. Separate triage rooms were designated for evaluation of ILI, and these rooms were in close proximity to the waiting room so as that ILI patients did not have to traverse through more heavily trafficked areas.
Viral respiratory panels (testing for influenza A, influenza B, and respiratory syncytial virus via polymerase chain reaction [PCR]) were performed on all patients seen in this unit for ILI evaluation, and in those patients who were admitted, this panel was extended to include additional testing for adenovirus, rhinovirus, and parainfluenza. Evaluation of all patients included vital signs (temperature, pulse, respiratory rate, pulse oximetry), physical examination, laboratory evaluation (complete blood cell count, basic chemistry profile, and urine analysis), and fetal heart rate monitoring if appropriate based on gestational age. A chest x-ray was performed if there was clinical suspicion for pneumonia. The decision whether to admit the patient to the hospital or treat her as an outpatient also was made based on predefined criteria ( Figure 2 ) . Those who met ILI criteria and were not admitted as inpatients were treated with oseltamivir 75 mg orally twice a day for a maximum of 5 days, although it was discontinued if the results of a respiratory viral panel were negative or revealed a noninfluenzal pathogen. If patients were discharged from the evaluation unit with oseltamivir, they were called by their providers within 24-48 hours to ensure improvement of symptoms.
Outcomes of all patients who called and were treated as outpatients, as well as detailed clinical information for all women who were assessed in the evaluation unit, were prospectively collected as part of a quality management process. Additionally, data were collected for women who did not call but who presented to the evaluation unit, or were admitted to any inpatient unit with ILI. Complete ascertainment of these ILI admissions was made through daily reviews of the unit rosters as well as of all viral respiratory panels run in the hospital laboratory.
Descriptive data for outcomes related to the introduction of this triage system for ILI are presented. When relevant, comparisons were made and statistical significance was assessed by the Student t test and χ 2 analysis. All tests were 2-tailed and P < .05 was used to define statistical significance. Software (Stata; StataCorp College Station, TX) was used for all analyses. This study was approved by the Northwestern University Institutional Review Board.