Telephone triag egraphic1

TELEPHONE TRIAGE Hans L. Duvefelt, M.D., ABFM

tri-age (French) sorting, sifting “The sorting of and allocation of treatment to patients and esp. battle and disaster victims according to a system of priorities designed to maximize the number of survivors.” Merriam Webster’s Collegiate Dictionary

Outcomes of triage call Activate Emergency Response

Outcomes of triage call Activate Emergency Response Urgent Office Visit

Outcomes of triage call Activate Emergency Response Urgent Office Visit Non-urgent / Routine Office Visit

Outcomes of triage call Activate Emergency Response Urgent Office Visit Non-urgent / Routine Office Visit Advice from nurse/provider/other party

Outcomes of triage call Activate Emergency Response Urgent Office Visit Non-urgent / Routine Office Visit Advice from nurse/provider/other party Activate Existing Plan (“Dr X told me to call next time this happened, so she could try me on Supercillin. ”)

Common Triage Decisions Chest Pain Acute Allergic Reaction Seizure Respiratory Distress Major Trauma Emergency

Common Triage Decisions Sore Throat Earache Bronchitis UTI / Blood In Urine Sprains, Strains Most rashes Urgent

Common Triage Decisions Common Triage Decisions Physicals Chronic Problems Routine

Non-Medical Staff Triage? Sure!

Non-Medical Staff Triage? Sure! When to activate Emergency Response System

Non-Medical Staff Triage? Sure! When to activate Emergency Response System When to interrupt nurse / provider (the Time Factor…)

Non-Medical Staff Triage? Sure! When to activate Emergency Response System When to interrupt nurse / provider (the Time Factor…) When to offer a call back

Non-Medical Staff Triage? Sure! When to activate Emergency Response System When to interrupt nurse / provider (the Time Factor…) When to offer a call back When to make a Routine Appointment (and when not to…)

Activate Emergency Response Stated Concern About… Heart Attack Stroke Serious Allergic Reaction Respiratory Distress Major Trauma If the patient declares an emergency, it may not be wise to talk him/her out of it.

Involve the Nurse? Interrupt or Not?

Involve the Nurse? If you’re not sure whether it is an emergency. Interrupt or Not? The Time Factor!

The Time Factor I “ I have a terrible headache.” “ When did it start?” “ When I was in Vietnam.” “ What made you decide to call today?” “ I got tired of it.” “ Let’s make you an appointment!”

The Time Factor II “ I have a terrible headache.” “ When did it start?” “ Yesterday, and I can’t get rid of it.” (There are no acute slots.) “ I’m going to have the nurse call you back as soon as she is free.”

The Time Factor III “ I have a terrible headache.” “ When did it start?” “ 20 minutes ago, and it’s getting worse every minute.” “ I’m going to let you talk to a nurse right away!”

Five Fundamentals of Triage Expect the worst

Five Fundamentals of Triage Expect the worst Common things are common

Five Fundamentals of Triage Expect the worst Common things are common Consider the time factor

Five Fundamentals of Triage Expect the worst Common things are common Consider the time factor Is the cause known or suspected?

Five Fundamentals of Triage Expect the worst Common things are common Consider the time factor Is the cause known or suspected? Location Matters

Common Things Are Common “ Has anyone else been sick with anything like this?”

Common Things Are Common “ Has anyone else been sick with anything like this?” “ Have you had anything like this before?” Most patients with indigestion, headache, backache, the flu or hemorrhoids have just that. It is more likely that the patient has a slightly unusual presentation of a common ailment than something exotic.

IS THIS AN EMERGENCY? (The Time Factor…with some Cause…) Johnny has an awful cough…

IS THIS AN EMERGENCY? (The Time Factor…with some Cause…) Johnny has an awful cough… …after just running around with those glass beads in his mouth!

IS THIS AN EMERGENCY? (The Time Factor) Johnny has an awful cough… …after just running around with those glass beads in his mouth! EMERGENCY

IS THIS AN EMERGENCY? (The Time Factor) Johnny has an awful cough… …after just running around with those glass beads in his mouth! …it started yesterday and his inhaler isn’t stopping it! EMERGENCY

IS THIS AN EMERGENCY? (The Time Factor) Johnny has an awful cough… …after just running around with those glass beads in his mouth! …it started yesterday and his inhaler isn’t stopping it! URGENT EMERGENCY

IS THIS AN EMERGENCY? (The Time Factor) Johnny has an awful cough… …after just running around with those glass beads in his mouth! …it started yesterday and his inhaler isn’t stopping it! …that lasts a week every time he goes to the zoo! URGENT EMERGENCY

IS THIS AN EMERGENCY? (The Time Factor) Johnny has an awful cough… …after just running around with those glass beads in his mouth! …it started yesterday and his inhaler isn’t stopping it! …that lasts a week every time he goes to the zoo! URGENT EMERGENCY ROUTINE

IS THIS AN EMERGENCY? (The Time Factor…with some Cause…) I have a rash…

…I just got stung by a bee and I’m breaking out in hives! IS THIS AN EMERGENCY? (The Time Factor) I have a rash…

…I just got stung by a bee and I’m breaking out in hives! IS THIS AN EMERGENCY? (The Time Factor) I have a rash… EMERGENCY

…I just got stung by a bee and I’m breaking out in hives! …I must have come in contact with poison ivy over the weekend! IS THIS AN EMERGENCY? (The Time Factor) I have a rash… EMERGENCY

…I just got stung by a bee and I’m breaking out in hives! …I must have come in contact with poison ivy over the weekend! IS THIS AN EMERGENCY? (The Time Factor) I have a rash… URGENT EMERGENCY

…I just got stung by a bee and I’m breaking out in hives! …I must have come in contact with poison ivy over the weekend! …my elbows are thick and scaly like psoriasis! IS THIS AN EMERGENCY? (The Time Factor) I have a rash… URGENT EMERGENCY

…I just got stung by a bee and I’m breaking out in hives! …I must have come in contact with poison ivy over the weekend! …my elbows are thick and scaly like psoriasis! IS THIS AN EMERGENCY? (The Time Factor) I have a rash… URGENT EMERGENCY ROUTINE

IS THIS AN EMERGENCY? (The Cause Factor) Johnny got hit in the head…

IS THIS AN EMERGENCY? …by a wrecking ball that knocked him to the ground! (The Cause Factor) Johnny got hit in the head…

IS THIS AN EMERGENCY? …by a wrecking ball that knocked him to the ground! (The Cause Factor) Johnny got hit in the head… EMERGENCY

IS THIS AN EMERGENCY? …by a wrecking ball that knocked him to the ground! …by a baseball! (The Cause Factor) Johnny got hit in the head… EMERGENCY

IS THIS AN EMERGENCY? …by a wrecking ball that knocked him to the ground! …by a baseball! (The Cause Factor) Johnny got hit in the head… URGENT EMERGENCY

IS THIS AN EMERGENCY? …by a wrecking ball that knocked him to the ground! …by a baseball! …by a Nerf ball! (The Cause Factor) Johnny got hit in the head… URGENT EMERGENCY

IS THIS AN EMERGENCY? …by a wrecking ball that knocked him to the ground! …by a baseball! …by a Nerf ball! (The Cause Factor) Johnny got hit in the head… URGENT EMERGENCY ROUTINE

IS THIS AN EMERGENCY? (The Cause Factor) Mary’s belly hurts…

…her period is way late and she’s wicked pale and lightheaded! (The Cause Factor) Mary’s belly hurts… IS THIS AN EMERGENCY?

…her period is way late and she’s wicked pale and lightheaded! (The Cause Factor) Mary’s belly hurts… IS THIS AN EMERGENCY? EMERGENCY

…her period is way late and she’s wicked pale and lightheaded! …she’s got cramping and diarrhea. The rest of us have just gotten over the stomach flu! (The Cause Factor) Mary’s belly hurts… IS THIS AN EMERGENCY? EMERGENCY

…her period is way late and she’s wicked pale and lightheaded! …she’s got cramping and diarrhea. The rest of us have just gotten over the stomach flu! (The Cause Factor) Mary’s belly hurts… IS THIS AN EMERGENCY? URGENT EMERGENCY

…her period is way late and she’s wicked pale and lightheaded! …she’s got cramping and diarrhea. The rest of us have just gotten over the stomach flu! …every morning before the school bus! (The Cause Factor) Mary’s belly hurts… IS THIS AN EMERGENCY? URGENT EMERGENCY

…her period is way late and she’s wicked pale and lightheaded! …she’s got cramping and diarrhea. The rest of us have just gotten over the stomach flu! …every morning before the school bus! (The Cause Factor) Mary’s belly hurts… IS THIS AN EMERGENCY? URGENT EMERGENCY ROUTINE

(The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY?

…abdomen …head …chest (The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY?

…abdomen …head …chest (The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY? EMERGENCY

…abdomen …head …chest …big toe …ankle …knee (The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY? EMERGENCY

…abdomen …head …chest …big toe …ankle …knee (The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY? URGENT EMERGENCY

…abdomen …head …chest …big toe …ankle …knee …tooth (The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY? URGENT EMERGENCY

…abdomen …head …chest …big toe …ankle …knee …tooth (The Location Factor – stay away from the high rent districts!) I suddenly got this excruciating pain in my… IS THIS AN EMERGENCY? URGENT EMERGENCY ROUTINE

COMMON SYMPTOMS AND WHAT WE DO FOR THEM

FEVER Is there a dangerous temperature?

FEVER Is there a dangerous temperature? Not really! Fever is a symptom. We look for the cause. Sometimes we don’t find it…

FEVER Is there a dangerous temperature? Not really! Fever is a symptom. We look for the cause. Sometimes we don’t find it… In infants under one year we MUST find the cause, because they may have atypical presentations of meningitis and other serious infections.

POISONING We can’t keep track of all of them, se we advise our callers to contact POISON CONTROL 1-800-442-6305 1-800-222-1222

INGESTED OBJECTS Usually, once swallowed, objects make it all the way through to the other end..

INGESTED OBJECTS Usually, once swallowed, objects make it all the way through to the other end. Sometimes we x-ray the abdomen to make sure they make it through the stomach and into the small intestine.

DIARRHEA AND VOMITING We try to QUANTIFY to decide on severity “How many times have you had diarrhea? Every time!” (…is not good enough!)

DIARRHEA AND VOMITING We try to QUANTIFY to decide on severity “How many times have you had diarrhea? Every time!” (…is not good enough!) Generally no cure.

DIARRHEA AND VOMITING We try to QUANTIFY to decide on severity “How many times have you had diarrhea? Every time!” (…is not good enough!) Generally no cure. Don’t make it worse - advise the BRAT diet: Banana Rice Applesauce Toast NO MILK

DIARRHEA AND VOMITING We try to QUANTIFY to decide on severity “How many times have you had diarrhea? Every time!” (…is not good enough!) Generally no cure. Don’t make it worse - advise the BRAT diet: Banana Rice Applesauce Toast Caution: Bloody or black diarrhea is an emergency, although Pepto Bismol makes stool black. NO MILK

PAIN AND SWELLING Is the cause known or suspected?

PAIN AND SWELLING Is the cause known or suspected? Ankle pain after falling off a roof?

PAIN AND SWELLING Is the cause known or suspected? Ankle pain after falling off a roof? Is somebody liable?

PAIN AND SWELLING Is the cause known or suspected? Ankle pain after falling off a roof? Is somebody liable? If it happened on the job, it MUST be processed as a Worker’s Comp case.

PAIN AND SWELLING Is the cause known or suspected? Ankle pain after falling off a roof? Is somebody liable? If it happened on the job, it MUST be processed as a Worker’s Comp case. Motor vehicle accidents with personal injuries must be investigated by the police.

WORK INJURIES Must be processed as such.

WORK INJURIES Must be processed as such. Employer chooses provider for the first 10 days.

WORK INJURIES Must be processed as such. Employer chooses provider for the first 10 days. First visit will be billed as a New Patient Visit, takes longer and involves enough paperwork to document future court case.

WORK INJURIES Must be processed as such. Employer chooses provider for the first 10 days. First visit will be billed as a New Patient Visit, takes longer and involves enough paperwork to document future court case. M-1 form must be completed first and last visit, and every 30 days in between.

MOTOR VEHICLE ACCIDENTS Motor Vehicle Accidents with personal injuries must be reported to the police at the time of the accident.

MOTOR VEHICLE ACCIDENTS Motor Vehicle Accidents with personal injuries must be reported to the police at the time of the accident. Often many x-rays are needed, which can strain our staff resources. CT scans are often needed.

MOTOR VEHICLE ACCIDENTS Motor Vehicle Accidents with personal injuries must be reported to the police at the time of the accident. Often many x-rays are needed, which can strain our staff resources. CT scans are often needed. MVA’s are often referred to the ER.

BACK PAIN Is the cause known? (Yes)

BACK PAIN Is the cause known? (Yes) Unless there is neurological deficit (urine, bowels, leg weakness), mechanical back pain is generally not an emergency. Most mechanical back pain gets better lying down. Generally no acute x-rays needed.

BACK PAIN Is the cause known? (No)

BACK PAIN Is the cause known? (No) Uncommon causes include: Kidney stone Gallbladder Attack Blood clot in lung Collapsed lung Ruptured aneurysm Pancreatitis UTI

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