Telephone Triage in OBJECTIVES College Health Upon completion of this lecture, the participant will be able to: Discuss comppypyonents of a symptom analysis WENDY L . WRIGHT , MS, RN, ARNP, FNP , FAANP Adult / Family Nurse Practitioner Discuss legal issues associated with Wright & Associates Family Healthcare telephone triaging Amherst, NH Discuss issues related to documentation Partner - Partners in Healthcare Education Senior Lecturer - Fitzgerald Health Education Editor-in-Chief: www.APCToday.com
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Telephone Triage Historical Perspective
Process by which telecommunication Began during WW I in France devices are used for the long-distance Designed to salvage the “walking wounded” managgpement of patients and not “waste” valuable resources on Patient education victims with fatal injuries Support patient at home Probably performed even before WW I because it is known that one of the first phone calls made by Alexander Graham Bell was for assistance with a battery acid burn Wright 2010 3 Wright 2010 4
Why Such A Demand Today? Telephone Triage
People living longer with chronic illnesses Triage means “sorting out” Shift from inpatient to outpatient management of many illnesses and conditions It involves ranking patient complaints in HMO’ s/Managed Care Organizations terms of urggyency, in order to book those Reduction in number of primary care providers appointments that are necessary Study showed reduction in primary care workload by It also involves deciding when the 40% – 50% with the hiring of a triage nurse appointment should occur Cell phones Cost of healthcare It involves educating and advising the patient regarding a number of health related issues
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Wright, 2010 1 Responsibilities of the Triage Nurse Telephone Triage
It is fundamental to the survival of most Assess a patient’s health concerns without the advantage of face to face interaction practices Must be able to listen thoroughly to identify Providers can not see everyyp person health problems calling in with a question nor can they return every call Effectively communicate to deliver recommendations With demands to see more patients being placed on health care providers, more Identify problems through non-verbal clues and more practices are and will be utilizing triage nurses Wright 2010 7 Wright 2010 8
Where Is Triage Occurring? Who Is Doing The Triage?
Primary care offices In many offices… Receptionists Specialty practices Medical Assistants Emergency rooms Licensed Practical Nurses Insurance companies / HMO’s – many are Registered Nurses requiring that a patient call a triage Nurse Practitioners number prior to going to an emergency Physician Assistants room Physicians
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National Council of State Boards State Law of Nursing Nurse Practice Act
All states have different laws regarding Nurses must use the nursing process and who can and who can not triage must not make medical diagnoses Many states allow LPN’ s, medical assistants and certified nursing assistants to triage Other states only allow RN’s to triage
What does your state say?
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Wright, 2010 2 AAACN 2007 Statement Examples of Medical Diagnoses
Telephone triage does not involve making R/O Strep throat diagnoses—nursing or medical—by phone. R/O UTI Telenurses do not diagnose but rather collect sufficient data related to the presenting problem and ? Sinusitis medical history, match the symptom pattern to the Probable appendicitis protocol, and assign acuity Telephone triage aids in getting the patient to the right level of care with the right provider in the right What should a nurse write in the chart? place at the right time (AAACN, 2007).
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Statistics Important for Statistics Important for Scheduling Scheduling Phone calls occur on average once Monday and Friday tend to be the heaviest in every 6 minutes terms of call volume More freqqyuently in famil yp,y practice, internal medicine and pediatrics ItilMdIn particular, Monday morn ing an dFidd Friday afternoon Offices report anywhere from 100-1000 calls/day Tuesday tends to be the lightest day Most studies have found that the majority of these calls occur during office hours (particularly between the hours of 10:00 am and 12:00 noon) Wright 2010 15 Wright 2010 16
What is An Ideal Triage Set-up? Statistics Important for Scheduling
Triage person dedicated to triaging Of the calls received… 3% are for life threatening emergencies Rotation 47% appointments/referrals/prescription refills 50% are for telephone advice 2/3 of all calls result in advice only (no appointment needed)
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Wright, 2010 3 Statistics Important for Who Calls? Scheduling
The majority of calls received are from women Majority of the calls are about respiratory Many calls concern the health of their children problems, fever, GI problems, skin or husband disorders, infectious diseases and trauma. Elderly individuals also make a number of calls to a practice for advice The average nurse has approximately 3 – 5 minutes per call and must therefore must be skilled at handling these calls efficiently and thoroughly
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Please Remember… So…
Nurses are not educated regarding telephone triage in nursing school Most of the education comes from “trial by fire” or personal experiences with their HAWDiHow Are We Doing own family members and children With Telephone Triage?
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In A Study Conducted by Study Continued… Verdile…
A research assistant, posing as the daughter of a 56 year One nurse advised the caller to give old man with bad indigestion and heartburn (and a smoker), “sublingual nitroglycerin every 5 minutes.” called various offices/emergency rooms. Here’s what happened… When the ppgatient’s daughter asked the 3 out of 46 nurses refused to give any information nurse what nitroglycerin was, the nurse Receptionists managed 9% of the calls stated…”Ask any cardiac patient, they all Over half (56%) of the nurses failed to ask the caller any have nitroglycerin.” questions about the patient or his complaints Only 4 nurses advised the caller to call 32% of nurses instructed the woman to give the client an antacid despite being given information that pointed 911 toward myocardial ischemia Wright 2010 23 Wright 2010 24
Wright, 2010 4 There Are Serious Problems With The Telephone What Can We Do To TiTriag ing Be ing Per forme dId In Improve Telephone This Country!! Triage At Your Facility? They Must Be Corrected!
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It Begins When The Phone First and Foremost… Rings!!!
You need to decide what kind of triage you want to go on here Introduction Identify Self Do you want the nurses doing triage or do Name, title you want every caller to be scheduled for How may I help you? an appointment? Greeting Friendly Upbeat Warm, yet official
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The First Two Lines Should Basic Elements of a Telephone Never Be… Call Good morning, Wright & Associates Introduction Family Healthcare, This is Wendy. Gather Information Will you hold please? Name and phone number And before they even have a chance to Is this a medical emergency? respond, the call is slammed on hold. Never put on hold without finding out if there is an emergency
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Wright, 2010 5 Communication Skills Communication Skills Attitude Sets the tone for the entire interaction A poor att i tude can pr ev en t you fr om receiving the information you need to The Most Important make appropriate decisions It is NOT the patient’s problem that you are busy, tired, frustrated, underpaid and handling Part of Triage the 100th call of the morning Put a smile on your face and answer the phone like you are happy to be there Wright 2010 31 Wright 2010 32
Communication Skills Communication Skills
Listening techniques Language Most important part of the conversation Make sure you communicate with the patient so it can be understood Study showed that letting a patient speak uninterrupted for 3 minutes often times Nurses will often talk in language that (90%) resulted in the patient giving you is understandable to other health care the diagnosis or at least significant clues professionals but not the patient to the problem Have a translator available if you can not speak the patients language
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Communication Skills Getting To The Heart Interviewing techniques of The Matter…A Avoid leading questions
Y’You’re no thit having c hthest pa in are you ? Symptom Analysis is Use open ended questions, when needed Essential Tell me what’s going on… Use closed ended questions for the rambler, long-winded patient
Are you having pain? Wright 2010 35 Wright 2010 36
Wright, 2010 6 Symptom Analysis
Getting To The Heart of Chief Complaint The Matter…A Symptom Onset Analysis is Essential Date Manner Precipitating and/or predisposing factors
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Symptom Analysis Symptom Analysis
Headache x 5 days (Chief Complaint) Characteristics Character Location PttdithhdhPresents today with a headache that began 5 days ago (Date). Intensity or Severity Began suddenly and without Timing Aggravating and Alleviating Factors obvious cause (Manner and Associated Symptoms precipitating / predisposing factors).
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Symptom Analysis Symptom Analysis
Headache is described as a dull ache It is made worse by bending over (Character) located in the temporal (Aggravating) and better with 2 Extra regions only and is non-radiating Strength Tylenol (Alleviating). It is (Location). Described as a 3 on a 1 -10 associated with mild nausea (Associated). Denies fever, chills, stiff scale (Intensity) and is constant neck, visual changes, photophobia, (Timing). rash, vomiting, trauma (Pertinent Negatives).
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Wright, 2010 7 Symptom Analysis Symptom Analysis
Course Since Onset This is the first time a headache like Incidence this has occurred (Incidence). Since Progress beginning, it is slightly improved (Progress).
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Health History A Symptom Analysis
Takes 3 – 5 minutes Medications Gives you a diagnosis 80 - 90% of the time if Allergies: NKDA, NKFA, NKEA conducted thoroughly and accurately Should be done on all phone calls unless the LMP patient says…I am having pain in the center of PMH my chest, am nauseated and feel like I am going to die (or something similar) PSH Feel free to cut the call short in order to call 911 Immunizations Family History, if applicable
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Based on the Symptom Concluding A Telephone Call Analysis…
The nurse must make a decision… Conclusion 911 Give very clear instructions ER or urgent care SklldtthtSpeak slowly and restate what you Appointment now have heard, if needed Appointment today Always end call with-call me should… Appointment - first available Pt advised to return or call for PCWAS Advice only
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Wright, 2010 8 PCWAS
Nationally accepted abbreviation utilized in telephone triaging P ersistent Documentation C hanging W orsening A nxiety provoking S ymptom specific
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Documentation Principles of Documentation
Documentation is crucial to practice and is NOT DOCUMENTED……. essential at a malpractice trial It provides a record of the quality of care you provided and tells a story so that other’s after you will know what has been NOT DONE!!!!! done Lack of documentation can make you vulnerable to a malpractice claim
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Document, Document, Document What Else Can You Do?
Always document telephone calls and Always Document conversations no matter how trivial they Clearly may seem Leggyibly It might be crucial later Correct Spelling Neatly Accurately
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Wright, 2010 9 What to do if you forget to Forms document?
It is very helpful to have a form, specific for Late entry triaging Must be explained why you are late SavesalotoftimeSaves a lot of time Date and time Has been shown to be much more thorough than just SOAP notes written into Changed records a chart Include date, reason for change, signature and title of the person making a change
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Documentation Document All
Use accepted abbreviations only No shows Document all nursing care Cancelled appointments Telephone calls made to a patient to Document all teaching check on him/her Document what patient said in response Letters sent and calls made to remind patient of a particular test needing to be done
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Never Record Your Feelings In The Chart Never….
Always record objective information in the Alter records chart NOT subjective information Use white out in a chart Example: Patient calls to schedule an Leave blank flow sheets (implies care not appointment. He is offered 3 appointments; performed) none of which is convenient. He is unable to Flow sheets should not be in a chart if make any of them due to work, children. He yells into the phone…No one in that office they are not used cares. Be very careful what you enter into a chart
How could you document this?
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Wright, 2010 10 Examples of Information Seen Additional Examples During Chart Audits DFO – “done fell out” or “passed out” COM (Crotchety old man) FLK (Funny looking kid) PPBABS – “Place pine box at bedside” FLK from FLP (Funny looking kid from funny looking TOBASITH – “Take out back and shoot in parents) the head” Two hands stamped on the chart (Treat with kid Positive “O” sign – Unconscious with gloves) tongue visible in open mouth FFC (Fit for coffin) Positive “Q” sign – Unconscious with DIIK tongue hanging out of open mouth 29 year old well-endowed beautiful young woman Courtesy – Wesley Myers, NP; North Carolina T/T = 2/3 Wright 2010 61 Wright 2010 62
Charts
What Else Is Important Whenever possible, have the chart available when providing any advice To Improve The In my office, the policy is… No Chart, No Triage Triaging That Is Being This is not always possible depending upon Conducted At Your your worksite etc… Facility?
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The Phone Calls Should Be Additional Techniques Private
The phone conversations should not be Avoid creating guilt overheard by other patients, such as those Why didn’t you call sooner? in the waiting room and other exam rooms Why haven’t you checked her temperature? Create realistic expectations Don’t say….Everything will be fine, I’m sure
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Wright, 2010 11 Empathy Additional Techniques
Convey empathy Be aware of wellness bias Try to convey to the patient that you Studies have shown that health care are truly sorry for the problems they professionals often think people are are having better than they actually are Remember…you can’t possibly Trust instincts understand their grief or pain but If it doesn’t feel right, respond you can surely act concerned for Be accommodating their issue Don’t argue with the patient Wright 2010 67 Wright 2010 68
Breach of Confidentiality Hobbs vs. Lopez, Ohio, 1994
It is essential to understand those things that College student had pregnancy test performed by can cause a breach in confidentiality MD. Told MD she wanted a 1st trimester abortion if positive. Test was positive. Physician Examples instructed RN to call and give information to Discussing a patient where others can hear patient. RN called and reached Mrs Hobb’s Releasing information without permission (patient’s mother). Gave mom the results and Leaving a message on an answering machine information on locations of abortion sites. Patient Discussing a patient’s condition with family members sued for medical malpractice, breach of privilege, Leaving record in view of others and negligent infliction of emotional distress. Not shredding documents
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Starkey vs. St Rita’s Medical Always Assume the Worst Center, 1997
When triaging, nurses should always 36 year old male began experiencing chest pain and consider the most worrisome diagnoses pressure, fatigue, diaphoresis at work. Came home first… and went to bed. Wife gave him antacid with no improvement. He went to bed and wife called a In particular, consider myocardial infarction, general triage number at the local hospital. Nurse ectopic pregnancy, testicular torsion, breast advised her that it sounded like he may be having a cancer, appendicitis, aneurysm heart attack but not to wake him. Let him rest and see how he was when he awoke. When he awoke, symptoms continued. Suffered an MI and is now unable to work.
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Wright, 2010 12 Document a Patient’s Refusal of Cardinal Rules of Triage Care Always err on the side of caution. Document that you have explained the When in doubt, send 'em out! risks, benefits and alternatives of Beware the middle-of-the-night call. treatment Be alert to ppyp,,possible atypical, silent, or novel presentation. Also discuss and document the risks of Serious symptoms may present as a single symptom or a complex of symptoms. refusing treatment Always speak directly with the client when possible. Assume the worst until proven differently.
Clawson ,1998
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Cardinal Rules of Triage Common Triaging Errors
Make corrections for your own fallibility. Using leading questions The more vague the symptoms the greater the need for good data collection. Using medical language Speed does not equal competence; avoid premature closure. Inadequate data collection Never abandon the caller in crisis. Temperature extremes often trigger medical problems (Clawson, Inadequate talk time 1998). All severe pain should be seen urgently. Stereotyping clients or problems Several calls in a short period of time may be an indicator of acuity. Failure to talk directly with the client Beware the developing disease. Believing the client’s self-diagnosis
Clawson ,1998 Not believing a client
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Developing a Good Little Things Mean More Than Relationship with the Patient You Know
Encourage them to call in 24 hours with an Pleasant receptionists and nurses update Do not create guilt Receptionists and nurses should not argue with Call them back in 4 hours to check on patients regarding referrals, prescriptions, them appointments A study published in the Journal of Avoid long waits for phone calls to be returned Emergency Nursing showed that parents Calls coming in during the morning hours should were satisfied with the interaction they had ideally be returned in the morning with an office if the nurse who triaged them Give the patient a realistic time frame as to when the seemed to care and listen to their call will be returned
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Wright, 2010 13 Greenberg, ME in Nurs Happy Patients Do NOT Sue Economics
Published May-June 2000 Over 80% of the callers surveyed (120 calls) reported that if they hadn’ t been able to speak to a nurse, they would have sought medical attention elsewhere
Angry Ones Do!!!! Wright 2010 79 Wright 2010 80
Telephone Triage Protocol Unfortunately…. Books
The number of malpractice cases involving Telephone triage protocol books are currently recommended for all practices that employ telephone triage nurses is increasing nurses for triage The nurse is not the only one who will be Protocol books protect the nurse as well as the held liable health care provider The clinician(s) under whom he/she is triaging All providers (MD’s, NP’s, PA’s) within the will also be named in the case practice should review the protocol books and sign them This provides documentation that they have read them and that they are in agreement with them Wright 2010 81 Wright 2010 82
Telephone Triage Protocol Telephone Triaging Protocols Books
In addition, all nurses should read them Pediatric Telephone Protocols: Schmidt and sign them Telephone Triage: Briggs This provides documentation that the Pediatric Telephone Medicine - Brown; nurses have read them and agree to $30.00 practice under these guidelines Telephone Triage - Wheeler; $41.95 If the nurse sways from an established Telephone Health Assessment - Simonson; protocol, she/he needs to document this $33.95 deviation AAFP-1-800-944-0000; $26.00 - $222.00 Centra Max $8000.00 -$9000.00 per seat Wright 2010 83 Wright 2010 84
Wright, 2010 14 Study (2001) Telephone Triage Can Work
Goal: Assess patient satisfaction and return on In an article published in the Wall Street Journal investment of telephone triage services (1991), a telephone triage center received 10,000 calls in 1 year. Results: Saved 2 ,951 emergency room visits Average nurse response time: 50 seconds Saved $48,000 90%+ of patients were satisfied Significant reduction in hospital emergency room Physicians agreed with decisions made by the usage nurses 99% of the time Reduced health plan expenditures Patients were satisfied with the care 92% of For every $1.00 spent - $1.70 saved the time
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Thank You!!!
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