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Telephone Triage Nurse:Clinical Decision Maker,

Knowledge Worker,Informaticist

Sheila Wheeler, RN, MS

TeleTriage Systems

www.teletriage.com

© 2014 TeleTriage Systems

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Telenursing Defined■ Telephone Triage is

■ Getting patients to the right level of care at the right time and right provider.

■ “Timely Facilitation of Patient Access”■ “The safe, effective and appropriate

disposition of health problems by phone by clinicians” - Wheeler, 1993

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Telephone Triage: Identity Confusion

■ What Telephone Triage is not:■ Symptom Diagnosis■ Practicing medicine via phone■ “Gatekeeping” ■ Health Information Hotline

■ Telemarketing Service■ Physician Referral Service■ Physician Message-taking/Answering Service■ Crisis Hotline

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Telephone Triage Guideline: Evolution

■ 1970 No Protocols■ 1980 Protocols for Adult and Pediatric■ 1993 First Telephone Triage Training Manual■ 1995 - Current

■ Neuro Telephone Triage Advice, Selwa et al (American Assoc of Neurology)■ Telephone Nursing Practice in Adult Urology, Mueller et al■ Telephone Triage for Breastfeeding, Cadwill■ Telephone Triage for Home Care, Narayan■ Telephone Triage for Obstetrics & Gynecology, Long & McMullen■ Telephone Triage for Oncology Nurses, Hickey, Newton■ Telephone Triage in an Ophthalmic A&E Department, Marsden.■ Telephone Triage, a Manual for Orthopedic Nurses, Smith

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Telephone Triage Research ■ Nurses are as safe and proficient as physicians. NEJM

1978, Perrin and Goodman■ Nurses use pattern recognition and context, 1995,

Lephrohon & Patel.■ Common Errors:

■ Failure to collect key info, spend enough time, no standards of practice

■ Second Guessing or Over reliance on Caller■ Stereotyping: Clients or Symptoms■ Acting on Assumptions: “Non Diagnostic Diagnoses”

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Critical Thinking Research■ Common Pitfalls:

■ Inadequate Assessment & “Talk Time”■ Insufficient History Taking and Documentation■ Inadequate Training ■ Guideline Use

■ (Often related to User Unfriendly Format)■ Over-reliance or failure to use protocols■ “Out of Guideline Experience”■ Using wrong Guideline or Using Guideline Wrongly

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Telephone Triage Nurse Quality

■ Clinician Deficits■ Lack of experience■ Lack of Confidence/Overconfidence■ Decreased Sensitivity

■ Lack of Feedback■ Sensory Overload■ Decision Fatigue/Discomfort

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Best Practice = Risk Reduction■ Adequate numbers of high quality

Clinicians■ Provide Excellent Training ■ Rotate phone work/frequent breaks■ Pre-Triage Calls/Patient Brochure■ Provide Feedback Mechanism

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Telephone Triage:Best Practice in Hiring

■ Schmitt’s Rule of Thumb:■ “Lowest paid person who can safely do the job”

■ Qualifications■ 10 year’s clinical experience■ Life experience/Parenthood/Maturity■ Good judgement (Critical Thinking Skills)■ Excellent communications skills (Phone Preview)■ “Telecharisma” (Nordstrom's, ED, “Car Talk”)

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The Expert Telenurse■ Benner’s Domains of Nursing Expertise:

■ Helping ■ Unacknowledged Case Manager

■ Diagnostic/Monitoring■ Pattern Recognition, Urgency Estimation, Ruling out Urgent

symptoms, Interpreting patient responses.

■ Crisis Intervention: Identifying Emergencies

■ Teaching/Coaching ■ “Knowledge Worker, Medical Informaticist

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Critical Thinking Skills

Nurse must determine whether■ a problem exists■ a potential problem exists■ the patient is handling it well or not■ the problem needs further evaluation■ the problem sounds serious■ the problem is urgent or emergent

■ Adapted from Yura and Walsh (1978)

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Telephone Triage Research: Critical Thinking Skill

Critical Thinking/Decision Making Requires Time

■ Inadequate Time = Inadequate Data■ “Under time pressure, people use less

information to make decisions, which are often suboptimal.” Vimla Patel

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Telephone Triage Research: Critical Thinking Skill

Critical Thinking Requires Time ■ In the space of one call the nurse must:

■ Multi-task■ Listen, Talk, Empathize, Write, Teach, Read, Analyze,

Problem Solve, Make Decisions■ Manage High stakes Population

■ Veterans = High Risk Populations. Domestic Violence, Suicide/Homicide

■ Meet Conflicting goals■ Goals: Administrative, Patient, Provider, Own

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Telephone Triage Research: Critical Thinking Skill

■ Experts use “Rules of Thumb”■ A method or procedure based on experience

and common sense. ■ A general principle regarded as roughly correct

but not intended to be scientifically accurate■ Cardinal, Age, Symptom, Trauma-Based

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Telephone Triage Guideline Controversies

Philosophical Divide in Telephone Triage

Decision Support vs.. Decision-making Tool■ Algorithms vs.. Pattern Recognition Models■ Bottom Line: Expert Clinician Brain■ Guidelines remind us of info we have once

known, but may have forgotten

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Telephone Triage Guideline Limitations

■ Guideline Inadequacies■ Inflexibility (Strict Algorithms)■ Bias (previous exposure to other guidelines)■ Flaws (overly specific, deterministic, diagnostic)■ Failure to train nurses to perform thorough

assessment prior to consulting guideline

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Documentation: Integrated Nursing Process

■ Assessment: Problem/Patient History■ Diagnose: “Working Diagnosis" or

“Impression”■ Treat: Advice per guideline name ■ Evaluate: Teach patient self evaluation

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Telephone Triage Best Practice: Disposition Clarity

■ “Duty to Terrify” (Tennenhouse, 1993 )■ Best Practice: Five Tier Triage

■ Level of Care/Time Frame/24/7 Place of Treatment■ Acuity Boxes■ Overlapping, flexible ■ Conservative■ Limit Disposition options: Keep it Simple

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Telephone Triage:General Reminders

■ TALK DIRECTLY TO THE PATIENT■ Assess Early, Often and Aggressively■ Use Guidelines as the finishing touch■ Select the guideline for:

■ the most serious symptom ■ the symptom most likely to lead to appointment

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General Reminders

“What people vaguely call common sense is actually more intricate than most of the

technical expertise we admire.”

Marvin Minsky, Founder of the Artificial Intelligence Movement