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Telephone triage nurse: current role and skills

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The role of telephone triage nurses will evolve quickly in the coming tele health era. Telephone triage requires expert skill in pattern recognition: identifying emergencies, estimating and ruling out urgencies, and interpreting patient responses. Telenurses will also serve as knowledge workers and medical informaticists.

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Telephone triage nurse: current role and skills

  1. 1. * Telephone Triage Nurse: Clinical Decision Maker, Knowledge Worker, Informaticist Sheila Wheeler, RN, MS TeleTriage Systems www.teletriage.com © 2014 TeleTriage Systems
  2. 2. * 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
  3. 3. * 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
  4. 4. * 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
  5. 5. * 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”
  6. 6. * 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
  7. 7. * Telephone Triage Nurse Quality ■ Clinician Deficits ■ Lack of experience ■ Lack of Confidence/Overconfidence ■ Decreased Sensitivity ■ Lack of Feedback ■ Sensory Overload ■ Decision Fatigue/Discomfort
  8. 8. * 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
  9. 9. * 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”)
  10. 10. * 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
  11. 11. * 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)
  12. 12. * 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
  13. 13. * 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
  14. 14. * 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
  15. 15. * 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
  16. 16. * 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
  17. 17. * Documentation: Integrated Nursing Process ■ Assessment: Problem/Patient History ■ Diagnose: “Working Diagnosis" or “Impression” ■ Treat: Advice per guideline name ■ Evaluate: Teach patient self evaluation
  18. 18. * 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
  19. 19. * 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
  20. 20. * 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

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