LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have increased your knowledge of telephone triage nursing. Specific objectives to address potential knowledge gaps include:

• Define “telephone triage” and its related terminology.
• Discuss the components of a high-quality telephone triage system.
• Summarize the essential aspects of good communication required for telephone triage.
• Identify how telephone triage decision-making is influenced by rules of thumb, distractors, and cognitive biases.
• Describe mnemonic tools used in patient and symptom assessment.
• List the essentials of safe, effective, and appropriate documentation specific to telephone triage care.
• Discuss patient disposition and the use of telephone triage guidelines.
• Summarize common risk management issues in telephone triage practice.

WHAT IS TELEPHONE TRIAGE?

Telephone triage is a complex process by which trained clinicians identify a patient’s problem, estimate the level of urgency, and render advice to the patient over the phone (Haddad et al., 2019). Telephone triage, however, does not involve making diagnoses—nursing or medical—by phone (ANA, 2019).

Telephone triage is focused on assessment and disposition. The clinician’s disposition, also known as a referral, is defined as a directive to the patient about the time, place, and reason for further evaluation and/or treatment. Safety in telephone triage requires that referrals be appropriate and timely in order to avoid delays in care—evaluation, diagnosis, and/or treatment—and to ensure that patients are seen before symptoms escalate.

Telephone triage is a subspecialty practiced by licensed medical professionals (most frequently nurses) and occurring within a range of practice settings, including emergency departments, general practice, primary care, pediatric practice, and managed care environments. The American Academy of Ambulatory Care Nurses (AAACN, 2018) and the Emergency Nurses Association (ENA, 2019) consider nurses to be the most qualified clinicians to safely perform telephone triage. Similarly, most state boards of nursing support using a professional nurse as a medical decision maker.

Nursing telephone triage has become an integral mode of delivering healthcare services, especially during off-hours, on a national and international level (Haddad et al., 2019).

Terminology

Naming conventions and titles for telephone triage services are confusing and sometimes misleading. Terminology for the field has included telephone triage, teletriage, telepractice, telenursing, telephone advice, and telehealth. Titles for telephone triage practitioners have included phone nurse, advice nurse, and teletriagist.

For the purposes of this course, telephone triage is defined as “clinical management of symptom-based calls by telephone only.” Most often, telephone triage services are provided by nurses.

Telehealth has now taken on its own meaning and is commonly used as an umbrella term describing the delivery of healthcare services through electronic modes including the telephone, telemonitoring, etc. (Visser & Montejano, 2018).

Telemedicine is broadly defined as the delivery of healthcare services by telecommunications and can range from a virtual visit with a care provider to virtual interactions on a health-related app or smartphone (Covarrubias, 2020).

Telephone Triage and Emergency Medicine

Some telephone triage standards, qualifications, and competencies mirror those of emergency medicine. Both disciplines require triage, and emergency medicine is similar in terms of approach, language, philosophy, and sometimes setting.

For example, both telephone triage nurses and emergency medicine physicians are often confronted with patients they have little information about. They must both perform rapid pattern recognition and make safe decisions about next steps based on guidelines, experience, and limited data. Both roles require anticipating the need for further resources or evaluation.

It is fair to say that, while still an emerging subspecialty, telephone triage is part of the continuity of care. Phone calls often precede emergency department visits. Thus, telephone triage could be considered a form of prehospital and posthospital care—albeit, not typically as urgent as that of emergency medical services.

For example, telenurses occasionally encounter crisis-level calls, such as poison ingestions, domestic abuse, rape crisis, cardiopulmonary resuscitation (CPR) coaching, or threatened suicide. However, in many communities, nonmedical personnel with specialized training staff crisis hotlines such as poison prevention, rape crisis, and suicide prevention, customarily manage such calls.

Likewise, 911 medical dispatchers operate medically developed guidelines and coach callers in initial interventions, such as first-aid treatment, CPR, and the Heimlich maneuver until paramedics arrive (Clawson & Democoeur, 2020).

Telephone triage services are designed to reduce delays in care, to improve continuity of care, and to facilitate access to appropriate care in a timely, safe way. A secondary goal is to reduce inappropriate emergency department and office visits and thereby reduce the cost of care.

Practice Settings

Currently, formal telephone triage is practiced in a variety of settings. Research has found that the majority of nurses practice in one of the following major settings (AAACN, 2018):

• Office and group practices
• Clinical call centers
• HMOs (health maintenance organizations)

Less-frequent practice settings include military facilities, health insurance companies, and clinics, such as student health centers.

MEDICAL OFFICES

While HMOs were the first to recognize telephone triage as a separate nursing subspecialty in the 1970s, primary care is the most common setting for telephone triage today. Traditionally, telephone triage performed by physicians’ office staffs has been informal and devoid of standards, training programs, or guidelines. This may be due to physicians’ failure to appreciate the importance of formal telephone triage and their failure to develop their own systems (and office systems) accordingly over the intervening decades.

In addition to telephone triage (i.e., symptom-based calls), services offered by telephone within a primary care office may involve reporting negative test results, prescription refill requests, taking messages, making nonurgent follow-up or annual physical appointments, responding to insurance and administrative questions, and scheduling classes for patients—many of which may be safely handled by nonclinicians.

Telephone triage nurses should not be expected to serve as the “dumping ground” for all calls that come to offices. Management must develop formal, written policies for nurses practicing in this specialty, including:

• Written job descriptions
• Training in how to deflect inappropriate requests while maintaining collegial working relationships
• Detailed policies for task delegation
• Scope of practice guidelines

CLINICAL CALL CENTERS

In the 1970s HMOs set about formalizing telephone triage. Currently, clinical call centers are thought to represent the industry standard because they have complete systems and operate 24 hours a day, 7 days a week, 365 days a year (Wheeler et al., 2015).

Clinical call center staff members typically utilize computerized decision support systems (CDSSs) or electronic guidelines and have access to patient demographic information via an electronic medical record (EMR) on which to rely. Typically, demographic information includes patient medical history, medications, allergies, and recent procedures. The EMR software program creates a “paper trail,” enabling managers to track and trend calls, and generates reports and statistics on call volume, types of calls, and individual staff workflow and dispositions.

However, while CDSSs are ostensibly intended to make the process safer, the presence of CDSS and EMR do not guarantee safety or even user compliance (Wachter, 2015). Even with the most complete systems, call volume within this setting can be extremely high, creating decision fatigue, making the work stressful, and increasing the risk of malpractice (Baumeister & Tierney, 2012; Wheeler et al., 2015).

Telephone Triage Utilization Patterns

Over the last three decades, researchers have identified predictable call patterns, peak call periods, and high-utilizing caller populations (e.g., by gender or age), as well as common health complaints. Generally speaking, the who, when, and why of patients’ calls have not varied greatly.

HIGH-UTILITIZING POPULATIONS

Not surprisingly, frequent callers are often related to high-risk age groups: infants and children, the frail elderly, and women of childbearing age. Early and current studies show that women call twice as often as men; and calls about children under 4 years of age tend to be more frequent than calls about older children (Dahlgren et al., 2017; Raheja, 2016).

COMMON COMPLAINTS

In ambulatory care settings several predictable complaints and questions make up the bulk of calls. Most common are:

• Medication questions
• Upper respiratory infections
• Fever
• Gastrointestinal problems (vomiting, constipation)
• Viral infections
• Minor trauma
• Rash or skin reaction
• Back pain
• Anxiety
• Otitis
• Urinary tract infections
• Postoperative symptoms and questions
  (Raheja, 2016)

In pediatric practice settings calls are typically about respiratory problems, fever, gastrointestinal problems, immunization reactions, skin and infectious diseases, and trauma (Raheja, 2016).

These common complaints (both adult and pediatric) likely represent frequent calls to clinical call centers as well as other ambulatory care settings.

CALL VOLUME AND TIMING

In primary care and office settings, the peak calling time falls between 10 a.m. and noon, with the majority of calls occurring Monday through Friday. Typical weekday office hours lead to a pattern of heavy call volume on Monday mornings, Friday afternoons, and any day preceding or following a holiday or three-day weekend.

Patients may call late in the afternoon when they become aware of their own symptoms after the demands of work are finished. When calling about their children, parents may notice that their children are not well when they are reunited with them after work late in the day.

It is reasonable to assume that clinical call center call volume and timing patterns are similar, with the understanding that clinical call centers operate 24/7/365, making them more accessible by phone and possibly avoiding high-volume peak times.