-safe, effective, and appropriate disposition of health-related problems via telephone by experienced, trained RNs using physician-approved guidelines or protocols (Wheeler, 2009). -Telephone triage interactions may require assessment, patient education, and crisis intervention.-controversial – is it telephone advice, telepractice or telehealth?
Nearest hospital is 30 miles away in Detroit Lakes, MN or Mahnomen, MN BLS ambulance in White Earth, ACLS ambulance in Detroit Lakes, Life Flight is in Fargo, ND
EHR. Template available with prompts, scheduling GUI available to schedule primary provider as well as BDG provider
-Focus of telephone triage is on assessment and disposition of patient -presenting problem and medical histories, recognize and match symptom patterns to those in the protocol, and assign acuity. -, recognize and match symptom patterns to those in the protocol, and assign acuity. Telephone triage aids in getting the patient to the right level of care with the right provider in the right place at the right time -Telephone encounters, if handled sensitively, can reduce inappropriate appointments, reduce anxiety, educate clients, and increase client satisfaction levels in addition to reducing risk when there are medical complications. Patients value the care that they receive. In fact, one study showed that reassurance was more important than the relief of symptoms (Wheeler, 2009). Clearly, reassurance and thoughtful attention to client concerns—whether medical, informational, or even administrative—often meet patients' needs and satisfy them.
-Articulate Able to communicate well at fifth- to eighth-grade level Engaging telephone manner Concise, clear documentation skills Proven typing skills at 30 WPM Computer literate (as appropriate-Works effectively with: Culturally diverse populations Educationally diverse and illiterate populations High-risk populations -Tolerates ambiguity well -Demonstrates compassionate and caring manner with clients -Functions well in a high-stress environment and under time pressure -Excellent communication skills (written and verbal) Excellent negotiation skills Works well independently -Life experience as parent/caregiver
-. In telephone triage, the key functions of the helping role are creating a healing relationship through (1) attending to (listening) or "presencing" (i.e., being present), (2) maximizing clients' control, and (3) providing comfort through the voice (rather than touch). -cannot diagnose , However, within limits, nurses can detect and document significant changes in the client's condition, perform pattern recognition and matching, anticipate problems, and formulate treatment strategies. -monitor patients at home- what is blood pressure, blood sugar, how are they feeling
- Modified version of nursing process occurs with triage, dx consists of formulating a working diagnosis or an impression. Assessment is the most important and substantive step of telephone triage, since pattern recognition is dependent upon the systematic collection of data. Always start the assessment process with the documentation form rather than the protocol. Once you have a general sense of the problem(s), use the protocol that best matches the patient's presenting problem. When patients present with multiple symptoms, use the protocol that has the highest likelihood of leading to an appointment, or ask the patient which symptom is the most bothersome. diagnosis" step requires interpreting and analyzing patient data, identifying patient resources, and formulating a working diagnosis, or impression. Planning and intervention looks at protocol disposition and advice. level of acuity, or disposition: emergent, urgent, acute, and nonacute levels. The nurse prevents, reduces, or resolves problems identified by adhering to the protocol disposition and directives.The treatment plan is composed of two parts: the disposition and the advice.Disposition: Always advise the patient when and where to come for treatment. The site of care may vary depending on the hour and day of the call. After hours, patient may need to be seen in the ED. Keep abreast of changes in clinic hours, which may be expanded to include evenings, weekends, and holidays. Advice: Home treatment advice often includes information related to over-the-counter (OTC) medications and common home treatments. Evaluation is carried out with pt teaching and self eval for follow up instructions.
-While protocols are an important component of the telephone triage system, the bottom line is the experienced, well-trained RN. Current standards of practice stress that RNs should perform decision making because protocols alone cannot guarantee safe practice.-
Emergent-level calls. Generally speaking, these calls require paramedic transport. They involve severe, life-threatening symptoms. Patients must be kept NPO (nothing by mouth). Whenever possible, try to remain on the line with the caller or implement a three-way conference call as appropriate with services such as suicide prevention, 911, poison control, or rape crisis. When callers are advised to go to the ED or to labor and delivery, always call and notify the department of the impending patient arrival. Urgent-level calls. Urgent-level callers should be seen within 1 to 8 hours. However, some urgent symptoms may need to be seen as soon as possible at the most appropriate site. These patients must be kept NPO and will require paramedic transport if there is no readily available car or if the driver (caretaker/parent) is alone and/or too anxious to drive. Acute-level calls. In this model, acute-level calls are seen within 8 to 24 hours or given a next-day appointment. Nonacute-level calls. Generally speaking, nonacute-level callers are directed to come in as appropriate. Nonacute symptoms usually can be managed with telephone advice and/or an appointment.
always err on the side of caution" is a cardinal rule in telephone triage. Nurses must rely on their best professional judgment and use every means at their disposal to ensure that patients are treated in a timely manner. Time frames designated on the template are intended as a general guide. When in doubt, have the patient come in sooner rather than later.Nurses may upgrade dispositions as appropriate (from urgent to emergent, nonacute to acute). However, nurses must never downgrade (urgent to nonacute) without physician consultation. If the patient is noncompliant, always seek advice from the physician advisor.
Telephone Triage Nurse Hoban Pepper
Telephone Triage OutcomesLarry Hoban, RN, White Earth ServiceUnitLT Deanna Pepper, White EarthService Unit
Objectives Define Role of Telephone Triage Nurse Establish Telephone Triage Protocols Identify How Telephone Triage Affects Patient Outcomes
Definition of Telephone Triage safe, effective, and appropriate disposition assessment, patient education, and crisis intervention. new subspecialty, controversial – is it telephone advice, telepractice or telehealth? interaction between patient and nurse that takes place via phone.Reference: http://www.nursingceu.com/courses/290/index_nceu. html Retrieved 05/31/2011
WESU Telephone TriageNurseFacilitate access to careProvide consultation and assistance to patients and their familiesCrucial to the delivery of safe and effective health care
White Earth Service Unit •Located on White Earth Reservation in Northern MN •Primary care and same day clinic •Two field clinics (NTW and Pine Point) •User population is 13, 093 •Reservation population is 9,562 (2101 census report)
White Earth Service Unit (WESU) Variety of services New facility in 1998 Same day clinic opened 06/2000 Many changes in process since Same Day clinic opened Triage nurse position began in 2000
Triage at WESU Dedicated Triage nurse Utilizes nursing judgment as well as triage protocols Same day appts, future appts, home measures Collaborative effort with entire clinic staff, outside entities Orders labs and x-rays with standing orders Policy for triage pending
Nurse Triage Standing Orders LAB CIRCUMSTANCE ORDEREDHCG For late menses, prior to starting contraceptionUrinalysis For dysuria, frequencyUrine C&S + nitrites and blood in UASTD screen For pt concern, STD symptomsRapid strep test For sore throat w/fever, exudate or pt concernBlood sugar For hypo/hyperglycemia symptomsCardiac panel For acute chest painWet prep For vaginal discharge, itchingSerum HCG Pregnant pts with vaginal bleedingTSH Hx or sx of hypo/hyperthyroidism, or med refillsCBC S/sx of infection/anemia/RLQ abdominal painX-ray of extremity Obvious deformity
How telephone triage affects patientoutcomes TTN can assess a patient over the phone who may be reluctant to come in to the clinic. TTN can give that caller home care advice or instruct the patient on the rationale for a clinic appointment or an UC visit. TTN can potentially reduce deteriorations of the patient’s condition.
How telephone triage affectspatient outcomes Added benefits: -TTN has access to pt’s EHR record while speaking to the pt. -Can advise pt of any upcoming or overdue preventive care, such as immunizations or women’s health appts.
Triage nurses in IHS : Facilitates access to care Provide consultation and assistance to patients and their families Triage via phone, walk in Collaborate with family members, CHR, home health nurses, etc. Some with certification from NCC
Focus of Telephone Triage Focus is assessment and disposition Data collection Telephone triage aids in getting the patient to the right level of care with the right provider in the right place at the right time (AAACN, 2007). Benefits of TriageReference: http://www.nursingceu.com/courses/290/index_nceu.html Retrieved 05/31/2011
Who Performs Telephone Triage?RN Clinical experience triage experience preferred (walk-in or telephone) Current BLS certification High levels of experience or expertise in: Crisis intervention Teaching/coaching Diagnostic/monitoring good judgment and critical-thinking skills
Telenurse Functions The helping function The diagnostic function The crisis-intervention function The monitoring function
Teletriage and the NursingProcess Modified version of standard nursing process -assessment, -diagnosis -planning and intervention -evaluation
Establish Telephone TriageProtocols Are protocols decision-making or decision- support tools? -critical thinking skills Resources for protocols: -Adults: Telephone triage Protocols for Nurses by Julie Briggs; Telephone Triage Protocols by Sheila Wheeler, Telephone Triage Decision Support Tools doe Nurses by Dale Woodke -Peds: Pediatric Telephone Advice by Barton D. Schmitt, MD
When In Doubtalways err on the side of caution"Upgrade, never downgrade.
RESOURCES American Academy of Ambulatory Care Nursing (AAACN) http://www.aaacn.org Emergency Nurses Association http://www.ena.org Teletriage Systems (Author Sheila Wheelers website) http://www.teletriage.com
Questions?Thank you for attending this presentation. Weappreciate your time and attendance. Have a wonderful day.