DECISION-MAKING

In telephone triage, nurses must make decisions in a matter of minutes based on limited information. Information may be partial or inaccurate, and circumstances may involve life-and-death decisions. One of the pitfalls of telephone triage is time pressure, which can lead nurses to perform cursory assessments and jump to conclusions, resulting in suboptimal outcomes.

Decision-making is made more complex by sensory deprivation, conflicting goals (such as call quotas vs. quality interactions), “noise” (irrelevant data, long-winded histories), interruptions, and multitasking (thinking, listening, talking, questioning, reading, writing, synthesizing information, pattern recognition). The nurse must focus on the meaningful bits of information (salient information), recognize patterns, estimate symptom urgency, and formulate an impression or working diagnosis.

How do clinicians make decisions under such conditions of uncertainty and urgency? How does decision-making on the phone differ from critical thinking at the bedside?

Experience and Decision-Making

Certain qualities and skills have been studied and found to be essential for nurses working in the field of telephone triage. Nurses with more years of clinical experience have more confidence in making decisions regarding patient assessment and disposition. Clinical judgment, experience, and use of critical-thinking skills all contribute to decision-making accuracy when working with patients in the practice of telephone triage. For this reason, nurses who enter this field most often need to have at least three years of nursing experience or more to be candidates for telephone triage nursing positions (Manetti, 2018).

Nurses often use intuition based on this previous experience to help guide decision-making. Klein (2003, 2010) advises learning to detect problems through emotional cues—a “gut feeling” when something is not right. He recommends developing an active stance, so that if something does not make sense, it acts as an alarm that is not to be dismissed. He also suggests becoming conscious of organizational barriers such as rigid procedures or institutionalized inertia. Finally, he suggests reframing the situation and consulting with colleagues to review with fresh eyes.

Good decision-making relies on this sort of balance of conscious and instinctive thinking. Reducing complex problems to their simplest elements aids in decision-making. It is also essential for nurses to continuously improve critical-thinking skills by avoiding behaviors such as stereotyping others, resisting change, and seeking conformity (Manetti, 2018).

Heuristics, or Rules of Thumb

Many experts recommend using heuristics, or “rules of thumb,” as practical decision-making tools. Rules of thumb are defined as “general principles regarded as roughly correct but not intended to be scientifically accurate” (Merriam-Webster, 2023b). They are considered easily applied procedures for approximation—an educated guess, intuitive judgment, or common sense. Rules of thumb may be used to expedite decision-making, guide decisions, and reduce error.

Examples of several types of rules are described below. Many of these rules of thumb represent expert nurses’ collective “pearls of wisdom” in telephone triage. They can be used by novice practitioners to improve their decision-making proficiency and efficiency. These examples are only a partial list.

CARDINAL RULES

Cardinal rules include associated strategies to avoid root causes of error (i.e., errors of communication, assessment, continuity of care, informed consent, human error). Following are example of cardinal rules with the types of errors they are intended to avoid:

  • Always err on the side of caution; when in doubt, bring the patient in sooner rather than later. (Continuity)
  • “When in doubt, send ’em out.” (Continuity)
  • Always speak directly to the patient; if “too sick to talk,” bring them in. (Assessment, communication)
  • Always obtain the age of the patient. (Assessment)
  • All frequent calls (within hours or days) are a red flag. Always ask how many calls the patient has made regarding this problem. (Communication, continuity)
  • Treatment delayed is treatment denied. (Continuity)
  • Trust but verify. Always update, correct, and confirm the back-story (patient history). (Assessment, communication)
  • Always remain suspicious of the “nondiagnostic diagnosis” (patient’s self-diagnosis). (Assessment, communication)
  • Always remain suspicious of the previous diagnosis (at recent ED or office visit); it may be wrong or complications may have arisen. (Assessment, communication)
  • Always remain on the line with callers in crisis. (Continuity)
  • Always treat flu-like symptoms with suspicion. (Assessment)
  • Beware the middle-of-the-night call; it may be a red flag. (Assessment, communication)
  • Speed does not equal competence; avoid premature closure. (Continuity)
  • Time is tissue, time is muscle (with myocardial infarction [MI] or cerebrovascular accident [CVA] symptoms). (Continuity)
  • To err is human, to delay is deadly. (Continuity)
  • Beware of “failure to improve” on current prescription (antibiotic, antipsychotic, pain medications). (Assessment, human error)
  • If a symptom (or symptoms) is unlike any you have experienced before, make the call, get a “reality check.” (Assessment, human error)
    (Clawson & Democoeur, 2020; Wheeler, 2009, 2017a)
CASE

A telenurse received a call from the mother of a 5-month-old infant who was irritable and crying a lot. Mom suspected that the infant was fussy due to hunger and requested advice about introducing solids into the diet. The nurse failed to perform a thorough assessment. She concurred with mother’s opinion and consulted the guideline about initiating solid foods. Several days later the mother brought the infant to the hospital, where the infant was diagnosed with meningitis.

Discussion

While it is important to listen carefully to the patient’s own perception of the problem, be sure to maintain clinical objectivity. Patients may stereotype symptoms, concluding that “it’s the flu” or “the same old back pain.” Resist the impulse to accept patients’ self-diagnoses; always perform an independent assessment based on newly collected data. With sick children (and all immunodeficient populations), always suspect sepsis and ask questions to rule out early signs of sepsis or dehydration.

CASE

At 10 p.m. a mother called about her 2-year-old toddler, describing symptoms of a temperature of 101 °F orally, “cold and cough,” and “breathing funny at times.” The mother denied nasal flaring, retractions, and cyanosis and stated that her child was acting fairly normal, but she was most worried about the “funny breathing.”

Discussion

The experienced pediatric nurse asked to listen to the patient breathe by having the mom hold the phone near the baby’s mouth. She immediately became concerned about the raspy character of the respirations. Recalling the cardinal rule to “err on the side of caution,” she advised the mother to take the toddler immediately to the emergency department (ED) because the symptoms were worrisome. In the ED, the child was diagnosed with pneumonia and hospitalized for treatment.

AGE-BASED RULES

Pediatric age-based rules include:

  • “Kids get sicker quicker.”
  • Always err on the side of caution with children, especially with infants and toddlers.
  • Infants under 3 months with fever of 38 °C or 100.4 °F should be seen immediately.
  • Pediatric populations are at greater risk for hypothermia and hyperthermia; the younger the patient, the greater the risk.
  • Assess all sick children for possible dehydration and sepsis.
  • Assume any symptom of sexually transmitted infection (discharge, lesions) in a child to be sexual abuse until proven otherwise.
  • All parents have the potential to abuse their children at some time.
  • All sudden confusion in children is considered emergent.
  • Always elicit an immunization history; lack of or inadequate immunizations place a child at risk. An appointment is required for serious delays in completing the schedule of immunizations.
  • Under 4 years of age: symptoms tend to be very generalized; over 4 years of age: symptoms tend to be more specific.
  • Depression (or any other significant behavior change) in teenagers is a risk factor for suicide.
    (Wheeler, 2009, 2017b)

Geriatric age-based rules include:

  • The older the patient, the greater the risk of hypothermia or hyperthermia.
  • Assess all sick older adults for possible dehydration and sepsis.
  • All sudden confusion in a frail older adult is considered emergent.
  • Greatest suicide risk is in White males, over 65 years of age, who are widowers, retired, or jobless.
  • Incontinence in older adults may be related to urinary tract infection.
  • Developmentally disabled populations typically age prematurely.
    (Wheeler, 2009, 2017a)

SYMPTOM-BASED RULES

General symptom-based rules include:

  • All severe pain should be seen within eight hours or less.
  • All first-time seizures must be seen.
  • All rashes are considered contagious until proven otherwise.
  • Once an ectopic (pregnancy), always an ectopic.
  • Any bleeding in pregnancy is an ectopic until proven otherwise.
  • Presentations may be atypical, silent, or novel/unique, especially with children and older adults.
  • Remain suspicious of “flu” symptoms, which might be symptoms of MI, sepsis, or other serious conditions.
  • The vaguer the symptoms, the greater the need for good data collection.
  • Beware of pain that awakens the patient or prevents sleep at night.
  • Beware of afebrile pelvic inflammatory disease symptoms (possible ectopic pregnancy or ovarian cyst).
  • Beware of shoulder pain with or without abdominal pain in women of childbearing age (possible ectopic pregnancy).
  • Epigastric pain in males over 35 years and females over 45 years is considered an MI until proven otherwise.
  • Worst headache is considered a brain aneurysm or subarachnoid hemorrhage until proven otherwise.
  • Symptoms should improve after 24 to 48 hours on antibiotics.
  • Rectal temperature of 100 °F in an infant age 3 months or less must be seen immediately.
  • Extremes of outside temperature often trigger medical symptoms.
    (Clawson & Democoeur, 2020; Wheeler, 2009, 2017a)

Chest pain–related symptom-based rules include:

  • The first symptom of an MI is often denial.
  • Smokers who have chest pain are more likely to die and die suddenly (within the hour) of MI.
  • Chest pain in men over 35 years or women over 45 years is suspicious.
  • Time is heart muscle (possible MI); patients treated within the first hour have a substantially improved outcome.
  • A little chest pain may be as bad as a lot.
  • Any chest pain in a high-risk caller should be treated as MI until proven otherwise.
  • Beware of atypical or novel presentations (e.g., severe indigestion, pain in jaw).
  • MI in women, older adults, and individuals with diabetes may present as vague, silent, or atypical symptoms.
  • Patients over 70 years typically do not experience chest pain.
  • All chest trauma is considered urgent until proven differently.
    (Clawson & Democoeur, 2020; Wheeler, 2009, 2017a)
CASE

A 45-year-old woman called with a chief complaint of “cold” symptoms. The patient was actually worried about shortness of breath and chest tightness but did not relay her concern to the nurse. The patient minimized her symptoms with the hope that it was “just a cold.” As the nurse performed the assessment, the patient reported watery eyes, runny nose, nausea, and a cough. Investigating further, the nurse elicited that the patient had been experiencing shortness of breath and chest tightness. The nurse referred her to the ED, where the patient was later diagnosed with an acute MI.

Discussion

Because the telenurse performed a thorough assessment, she prevented what some clinicians call a “near miss.” The nurse also followed the symptom-based rule of thumb for MI and chest pain.

Distractors, or “Red Herrings”

A major task in decision-making is to determine which data are relevant and which are not. Data must be collected, considered, and weighed in order to perform pattern recognition and arrive at a proper disposition. For example, key pieces of contextual information—age, gender, and previous medical history—are always relevant; key symptoms may be relevant; and other more general and nonspecific symptoms may be given less weight.

Some information is less relevant and must be considered a lesser priority in order to reach a more accurate assessment and to make safe decisions. Such data is called a “red herring” and diverts the nurse from more significant data. Red herrings can originate from many sources. Both patients and nurses may misinterpret symptoms or miscommunicate. Red herrings may cause the nurse to jump to conclusions, rely on stereotypes, or end the call prematurely.

Examples of common sources of red herrings are described below:

  • Age and gender. With chest pain, nurses may stereotype and discount symptoms of MI because the patient is “too young” or “too healthy.” With common sexually transmitted infection symptoms, nurses might stereotype the patient as “too old” or “too young” to engage in sexual activity.
  • “Nondiagnostic diagnosis.” A patient’s interpretation of symptoms and symptom acuity may not be accurate. For example, a patient who calls in with “the flu” may actually be experiencing symptoms of sepsis or MI.
  • Previous or recent medical diagnoses. A patient who is immediately postoperative may call with symptoms of severe nausea and vomiting. The nurse may prematurely conclude that the symptoms are due to effects of anesthesia and fail to explore or assess the patient further for possible complications, leading to a possible delay in care. Or a patient who was “seen recently in the ED” may now be experiencing new, unrelated symptoms, which must be re-evaluated onsite.
  • Existing treatment plan appears to be incorrect or ineffective. The nurse or patient may not recognize that new symptoms might be due to complications. Either of them might ascribe it to a failure of treatment or medication (e.g., inadequate pain medication in the case of uncontrolled post-op pain).
  • Denial, downplaying, explaining away. For example, the first response to an MI or other life-threatening situation is denial.
  • Nonacute initial presentations. The rule of thumb to beware of the developing disease applies particularly in cases of abdominal pain, respiratory problems, diarrhea, nausea and vomiting, fever, or marked change in activities of daily living (ADLs). For example, what starts out as vague abdominal pain with low-grade fever may quickly develop into the classic picture of appendicitis.
TOP FIVE REASONS ADULTS AND INFANTS ARE SENT TO THE ED BY A TRIAGE NURSE

Nurse triage call center research has found the following to be the top five reasons adults are referred to the ED:

  1. Chest pain
  2. Abdominal pain (female)
  3. Back pain
  4. Breathing difficulty
  5. Postoperative complications

The top five reasons infants are sent to the ED include:

  1. Cough
  2. Fever
  3. Vomiting with diarrhea
  4. Wheezing
  5. Head injury

(Raheja, 2016)

Cognitive Biases

Being aware of and avoiding one’s cognitive biases is another important aspect to effective decision-making. Common cognitive biases include:

  • Confirmation bias, or selective search for evidence. Tending to gather facts that support certain conclusions while disregarding other facts that support different conclusions
  • Premature termination of search for evidence. Accepting the first alternative that looks like it might work (i.e., jumping to a conclusion)
  • Recency. Placing more attention on more recent information and either ignoring or forgetting more distant information
  • Selective perception. Actively screening out information that one does not think is important (e.g., stereotyping of patient or symptoms)
  • Inertia. Being unwilling to change old thought patterns in the face of new circumstances
  • Wishful thinking or optimism bias. Wanting to see things in a positive light, which can distort one’s perception and thinking (over-reassurance)
  • Wellness bias. A belief that a person is healthy or not seriously ill
  • Anchoring and adjustment. Allowing initial information to shape and unduly influence one’s view of subsequent information (closed-mindedness)
  • Source credibility bias. Rejecting something if one has a bias against the person or group to which the person belongs; accepting something if one likes the person (prejudice)
  • Implicit bias. Attitudes and beliefs about race, ethnicity, age, ability, gender, or other characteristics that operate outside a person’s conscious awareness
    (Adapted from Plous, 1993; Bellman, 2002; Sabin, 2022)
AVOIDING STEREOTYPING

Stereotyping of patients and problems is a common pitfall in telephone triage. Nurses can avoid stereotyping both patients and symptom patterns by careful and sensitive assessment and by using screening or “rule-out” questions. For instance, it is easy to stereotype a patient by age or gender. For example, with a teenage girl who complains of abdominal pain, exploring recent unprotected sexual activity and possible pregnancy should be a standard rule-out question.

CASE

The telenurse receives a call from a mother of a 25-year-old who reports that her son had a severely itchy raised rash on his back. Her son reports a sore throat. He has experienced these symptoms before when he ingested nuts, but taking an antihistamine eliminated his symptoms.

The telenurse requests to speak directly to the son, but he declines, stating that he needs to continually clear his throat. They are requesting the correct dose for diphenhydramine. The nurse assumes the patient and his mother are familiar with his symptoms and proceeds to provide homecare advice, assuming that, since this young man is healthy, not on any other medications, and has no allergies listed in his record, this is an appropriate level of care. The son proceeds to experience an anaphylactic reaction.

Discussion

Wellness and optimism bias is a risky practice, especially when a patient is experiencing a life-threatening situation. This clinician incorrectly assumed that this patient did not have any respiratory symptoms and did not do a complete assessment, which led to a bad outcome.