This document provides new guidelines for triaging nurses regarding when to page doctors. It outlines situations where the nurse should discuss urgent dispositions like ED with their manager before informing the caller. For ED or within 24 hour dispositions, if the doctor's office will be closed, the nurse must page the on-call doctor for further instructions. The guidelines aim to ensure patient safety while avoiding overuse of emergency resources. Thorough documentation demonstrating critical thinking is emphasized.

1. When to Page the Doctor
Mandatory Inservice May 2014

2. Purpose
We know that some of you may be fairly new to triage and it is a
very difficult nursing field- but all of you were chosen because we
believe you have excellent nursing judgment and critical thinking
skills and are all more than capable of handling this type of calls.
We have supplied you with a lot of “tools” that will assist you with
making you disposition decisions but the most important “tool” is
your critical thinking.
Remember the guidelines are just that- guidelines to give your
triage structure and keep you and the caller on task.

3. What Physicians Expect
• TriageLogic was chosen by our clients because we have a reputation for
being highly trained, skilled and good at what we do!
• The physicians expect us to : Triage their patients, using
Schmitt/Thompson protocols, accurately describe their patients
symptoms and then make a knowledgeable decision about whet level of
care is needed at that time.
• The physicians certainly understand that some patients are going to be
emergent and need to be seen in the ED- the MD’s are aware we will be
paging them if they requested second level triage
• They work hard during the day and should have confidence that we are
taking good care of their patients when the office is closed. That
includes giving excellent customer service and accurately
assessing/triageing their patients so they can have some down time.

4. We are not gatekeepers so..
• With all that being said,- We should not be afraid to call the
physician if it is warranted.
• The next few slides will describe a new policy that will go into
effect immediately (5/12/2014) and become part of our trianing/
orientation process.

5. Red Line-ED Outcomes
• Red lines in the bottom of the note page indicate 2nd level triage
is required for all ED, ED (PCP triage), See in 24 hr dispositions IF
the office will not be open .
• For ED/ED(PCP triage) Outcomes: The nurse is to place her call on
“Park” and call the manager on duty. She can tell her caller that
“based on the symptoms you described your child may need to be
seen in an emergency room tonight, but I would like to discuss it
with my supervisor first. I will call you back in 5-10 minutes with
instructions’. Remember to “Un-park” your call and finish your
documentation.

6. Red Line- ED Outcomes (cont.)
• The nurse then will call her manager so they can discuss the
child’s symptoms and assure the disposition is the safest for the
patient. Once it is determined that ED is the mot appropriate
outcome, the triage nurse will call the parent/caller back and let
them know that she will page the MD (either as FYI or to call them
back with further instructions)
• THIS DOES NOT APPLY TO CALLS THAT TRIAGE OUT TO 911-
PROCEED WITH TELLING THE CALLER TO HAND UP AND DIAL 911
FOR THOSE SYMPTOMS

7. Red Line- See in 24 hours
• If your disposition is See in 24 hours and the practice will not be
open the next day:
• Let your caller know that their child may need to be seen within
the next 24 hours but they can do some home care today. Ask the
parent/caller to call back in AM to be reassessed.
• If the child/caller is better the next day- then a new assessment
needs to be completed- for safety reasons and so the new
disposition is recorded.

8. Red Line- See in 24 hours (cont)
• If the child/caller is not better- then the nurse will open a new
note, reference the original note number and document that
parent triage h/x and child is not better and then page the MD on
call for further instructions. Guideline: PCP no Triage, Disposition:
Follow-up call from parent regarding patient’s critical status AND
[2] Information is urgent:
• The nurse should make sure to explain to the MD that the original call was
yesterday, had a “See in 24 hours” disposition and that the patient has
already tried home care overnight and is no better. “What would the MD
like to do now?”
• Document all interactions and patient understanding

9. Green Line
• Green lines at the bottom of the nursing note indicates that we do
not have to notify the physician prior to sending a patient to the
ED but we still want to be sure that the Urgent dispositions are
the best choices for our customers (patients and physicians).
• ED/ED (PCP TRIAGE): The nurse is to tell her caller “based on the
symptoms you described your child may need to be seen in an
emergency room tonight but I would like to discuss it with my
supervisor first. I will call you back in 5-10 minutes with
instructions.”

10. Green line (cont)
• The nurse then will call her manager so they can discuss the
child’s symptoms to assure the safest disposition for the patient.
The triage nurse will then call the parent/caller back and advise
the caller to proceed to the ED
• THIS DOES NOT APPLY TO CALLS THAT TRIAGE OUT TO 911-
PROCEED WITH TELLING THE CALLER TO HANG UP AND DIAL 911
FOR THOSE SYMPTOMS

11. Green Line- See in 24 Hours
• If your disposition is See in 24 hours and the practice will not be
open the next day:
• Let the parent/caller know they can try home care advice for up
to 24 hours but if no better they will need to call the office in the
am to make an appointment. Make sure to give them all
applicable home care advice and encourage them to seek medical
attention sooner if the symptoms worsen. Also give these callers
the “call back if” symptoms.
• Document all instructions and caller understanding.

12. Check List:
• Does a statement in your nursing note justify sending patient to ED?
• Is it a RED line or a GREEN line?
• Do one past the ED disposition and see fi that is a “fit”.
• Ask and Verify: Ask lots of triage questions and verify the information
given
• Asthma- make sure they have done 2 back to back Albuterol tx’s 20 min
apart before paging the MD or sending to ED
• Severe abdominal pain- if < 1 hour and patient otherwise stable, use the
Urgent home care with followup and call parent back in 30 minutes to
see if better before sending to ED

13. Checklist: (cont)
• Breathing- get an accurate RR count, Retractions, Lip/face color, listen
to child breathing to make sure he is emergent.
• Talk to your manager before sending any patient to ED or paging MD
• Critical thinking: Ask yourself “what is ED going to do for this child
tonight- is this the most appropriate place for him/her to receive care?”
• We can NEVER under-ride a disposition but we want to be sure that we
are not over referring also and that we are not over reacting and sending
patients to the ED unnecessarily- (do a thorough assessment and ask
questions to clarify-count respirations, rate pain, listen to breathing, ask
parent to look for retractions, ask about skin coloring, etc..)

14. More Hints to A Good Triage
• Ask what is different tonight- If a child has had a cough for a week, what
is different tonight that concerns the parent enough to make them call?
• Re-cap and verify information given: Ex. “So you are calling today b/c
your child has been complaining of abdominal pain that started this am.
The pain is at his umbilicus and he rates it at a 9. He is holding his belly
and crying? Is this correct? Is he having any other symptoms?” Parent will
either verify or will say something like “well, the pain was sever earlier,
now he is playing video games”. If the child is comfortable now then he
is not emergent and may be able to wait until am to see MD. (Ask her to
re-rate the pain or what did he/she do to lessen the pain)

15. More Hints to a Good Triage
• Get an accurate assessment and timeline of all pertinent symptoms- ask
“Is your child stable now? “ Always ask “When did the symptoms first
start?”
• Pain Related: “Is it constant or intermittent? Where is the pain? Rate the
pain? Was there an injury to that area?”
• Respiratory Related: “Listen to respirations, frequency of cough-
wet/dry/congested/croupy/wheezing, severity of congestion, count RR
rate, is child sob, skin coloring.”
• GI Related: Ask about I&O’s- what’s normal and what is child doing now,
how many times has child vomited, had diarrhea and what does it look
like (color, consistency, amount)
• What is he/she doing right now- activity level. Don’t stop at “he is
lethargic”- as what do you mean. Is he just more tired than normal or
taking longer naps but when awake is alert/ answering questions? – that
is not lethargic. Give them the true definition of lethargy and ask if this
describes their child’s behavior correctly

16. What Your Documentation Should Look Like
• DOCUMENT, DOCUMENT, DOCUMENT! Your note should include, “Who has
symptoms, What those symptoms are, when they started, where
symptoms are located (if applicable), Why (exposed to family member
with v/d or cough, fell out of a tree and hurt arm, etc..) The reader
should be able to follow your though pattern and understand why you
chose the protocol and disposition you did.
• FINALLY- Make sure a statement in your nursing notes supports your
disposition chosen. Example: If your disposition chosen is: See in 24
hours d/t “Cough keeps child from eating and sleeping AND unresponsive
to home care measures given in guideline”- then your note needs to say
“childs cough is interfering with sleep and mom has tried warm fluids,
humidifies, saline drops, etc… and is not improving.
• AND: Follow the protocol starting with 911 symptoms and do not skip any
questions- Ask ALL the quesitons (unless not applicable, ex- your chile is
2 years old and question talks about infant <12 weks) only stopping when
you get a positive response that matches your child’s current symptoms.