COMPONENTS OF A TELEPHONE TRIAGE SYSTEM

Quality telephone triage programs are made up of five integrated components that work together to provide safe, timely delivery of care or access to care:

• Qualified and experienced clinical staff
• Training
• Guidelines (protocols)
• Documentation forms
• Standards

Researchers have not yet determined which guidelines work best; however, the Institute of Medicine (2011) has set forth standards for protocols and decision support tools that are grounded in best practices.

Telephone triage guidelines based on the nursing process and related research, with built-in fail-safe systems, offer the best decision-making support for telenurses. Along with incorporating training and guidelines, it is helpful to have the ability to record and audit calls for quality assurance and training opportunities. Patient confidentiality should be addressed by informing callers of this process.

The Telephone Triage Nurse

Telephone triage services are commonly performed by specially trained, licensed registered nurses. Ideally, telenurses should have a minimum of three to five years of decision-making experience at the bedside.

BASIC QUALIFICATIONS

Safe practice in telephone triage depends on having adequate numbers of experienced, qualified, trained staff.

Minimum qualifications include:

• 3+ years of clinical experience
• Excellent written and verbal communication skills
• Knowledge of basic pathophysiology
• Knowledge of basic and current pharmacology
• Ability to make decisions independently
• Ability to problem solve
• Cultural sensitivity

Personal characteristics of successful telenurses include:

• Curiosity; an investigative/probing manner in eliciting information
• High tolerance for ambiguity and stress
• Resourcefulness
• Ability to take initiative
• Autonomy
• Integrity
• Self-discipline
• “Telecharisma,” a warmth and ability to connect instantly with the caller

CORE COMPETENCIES

Skilled telephone triage clinicians demonstrate five core competencies, similar to those described by the Accreditation Council for Graduate Medical Education (2019) as essential for any clinician practicing in the emergency department. Within each core competency, the telenurse demonstrates additional skills and abilities.

Interpersonal and Communication Skills

• Intradepartmental relations, teamwork, and collaboration
• Patient and family experience of care
• Communication
• Complaint management
• Conflict management
• Crisis management
• Cultural sensitivity and diversity awareness
• Negotiation

Practice-Based Learning and Improvement

• Evidence-based practice
• Pattern recognition
• Contextual reasoning

Knowledge Translation

(These are the activities involved in moving research into practice.)

• Performance evaluation, clinical audit
• Patient safety and medical errors
• Practice guidelines
• Education
• Principles of quality improvement

Professionalism

• Patient advocacy
• Ethical principles
• Medical ethics
• Electronic communications/social media
• Time management/organizational skills
• Work/life balance (well-being, fatigue and impairment, work dysphoria/burnout)

Systems-Based Practice

• Nursing process
• Clinical decision support
• Clinical informatics
• Electronic health records
• Health information integration
• Patient triage and classification
• Policies and procedures
• Compliance and reporting requirements
• Confidentiality and HIPAA
• Patient informed consent, compliance, and refusal of care
• Emergency Medical Treatment and Active Labor Act
• Risk management
  (Adapted from ACGME, 2019)

Training

A training program should address the most needed topics: pathophysiology, medications, and decision-making. Physicians, preceptors, and pharmacists might provide this training over weeks or months, using a combination of online self-study, offsite conferences, and in-house instruction. The approach must focus on nursing process, error avoidance, and assessment of unseen patients. Research shows that a form of frequent testing known as retrieval practice, using case studies, is most effective (Agarwal, 2017; Paul, 2015).

Formal standardized training is often the weak link in telephone triage systems. While the American Academy of Ambulatory Care Nurses offers a conference, onsite training, and several telephone triage courses, training is typically on the job and not formal or standardized.

Physicians rarely receive more than a few hours of training in telephone medicine, if that. Nurses typically receive at least on-the-job training by another staff member. Some facilities provide formal in-house training, have preceptor programs, or use online training.

Telenurse Roles and Expertise

Telenurses must demonstrate excellent skills in communication, assessment, decision-making, and metacognition (or “ thinking about one’s thinking”). In addition, telepractice encompasses at least five domains of nursing expertise (helping, diagnostic, crisis intervention, coaching/teaching, and monitoring), first described by Benner (1984, 2013). Telephone triage nurses require expertise in these areas:

• Helping function: In telephone triage, the key functions of the helping role are creating a healing relationship through 1) attending to (listening) or “presencing” (i.e., being present), 2) maximizing patients’ control, and 3) providing comfort and connection through the voice (rather than touch).
• Diagnostic function: Telephone triage nurses do not make medical diagnoses. Rather, they use the steps of the nursing process (especially assessment) and nursing diagnosis to estimate symptom urgency. They can “form an impression” or a “working diagnosis.” Thus, clinicians can collect information and use context to estimate and rule out urgencies and document significant changes in the patient’s condition. Clinical skills include performing thorough assessments, pattern recognition, and interpreting patients’ responses. User-friendly guidelines support this process.
• Crisis intervention function: Nowhere else is the instant grasp of rapidly changing situations more vital than in crisis intervention by phone. Because some rural communities lack resources such as 911, suicide prevention, or rape crisis hotline systems, telenurses may be inadvertently cast in the role of first responder as they field calls regarding imminent births, trauma, suicide, and ingestions.
• Coaching and teaching function: Teaching and health promotion is a large part of telephone triage calls. Timing, eliciting interpretations of illness, and providing rationales for home treatment are key teaching and coaching functions. Informing patients about their rights, such as informed consent, is an act of empowerment.
• Monitoring function: Currently, most telenurses advise and monitor simple home treatment interventions and instruct patients in self-evaluation. In the future, technology currently used for disease management will likely make telemonitoring a standard function of telepractice, allowing more patients to be managed and monitored at home through the use of tablets and smartphones.

Telephone Triage Process

Generally speaking, telephone triage nurses utilize a modified version of the nursing process (i.e. assessment, guideline selection [intervention], working diagnosis, and evaluation).

• Assessment—based on the time-honored medical tradition of history and physical—is modified and limited to verbal communications. Nurses systematically ask questions using assessment tools, the guideline, and patients as their proxy to self-evaluate.
• The diagnosis process consists of formulating a provisional/working diagnosis, or impression.
• The plan or intervention is based on the selected guideline’s disposition, and advice is provisional.
• Evaluation is carried out when the nurse provides patient instruction in self-evaluation and follow-up instructions from the guideline.

STEP 1: PRELIMINARY ASSESSMENT

Assessment is the most critical and substantive step of telephone triage, since pattern recognition is dependent on the systematic collection of data. It is a common misperception that guidelines eliminate the need for a preliminary assessment. Preliminary assessment should precede the selection of a guideline. The benefit of the guideline is degraded in the absence of an adequate preliminary assessment.

It is essential to start the assessment process by asking questions, aided by a specific checklist. Eliciting and interpreting responses facilitates pattern recognition and helps to identify high-risk patients and symptoms.

(See also “Assessment” and “Documentation” later in this course.)

Assessment, the first step of the nursing process, is critical because:

• It can provide a quick way to prioritize and establish urgency.
• It helps identify the correct specific guideline.
• It incorporates many of the same questions as specific guidelines, ultimately saving time.
• It helps to avoid “wrong train syndrome,” or jumping to conclusions (a cognitive error), which might otherwise occur in the decision-making process by initially selecting the wrong guideline.

STEP 2: WORKING DIAGNOSIS/IMPRESSION (DIAGNOSIS) AND DOCUMENTATION

Once the nurse has elicited key information utilizing the assessment tool(s), a provisional or working diagnosis, also called an impression, can be formulated. The next step is to choose a guideline based on the principle of prioritizing.

Patients rarely present with the classic picture of any disease. Presentations vary due to age, immune response, medical history, and the timing of the call in relation to the disease process. Thus, telenurses must carefully navigate the multitude of possible presentations.

For example, a myocardial infarction may present as one key symptom (like chest pain); or a few generalized or “soft” symptoms (ear pain, arm tingling, nausea, vomiting, sweating); or the full-blown, classic picture (crushing chest pain accompanied by shortness of breath, nausea, vomiting, dizziness, sweating, anxiety). It is the role of the telenurse to determine what constitutes a match.

The nurse documents the impression using the patient’s own words (eg., headache, nosebleed, vaginal bleeding) to describe the problem, then adds modifiers or qualifiers to designate the level of acuity. For example, using a pain scale of 1–10, the nurse might document as follows: “abdominal pain, 9/10, sudden onset” or “ankle pain, 4/10, trauma history.”

(See also “Selecting the Correct Guideline” later in this course.)

STEP 3: DISPOSITION AND ADVICE (PLANNING AND INTERVENTION)

Planning/intervention is determined after pattern recognition and matching. Patterns (symptom complexes) are classified according to the level of acuity, or disposition: emergent, urgent, acute, and nonacute levels. The nurse prevents, reduces, or resolves potential or identified problems by employing the guideline disposition and directives.

The treatment plan is composed of two parts: the disposition and the advice. This step helps ensure patient informed consent.

• Disposition requires that the nurse advise the patient when and where to go for treatment in addition to why the patient must come as advised, i.e., that the symptoms appear emergent, urgent, acute, or nonacute.
• Home treatment advice often includes first aid instructions related to over-the-counter  medications and common self-care strategies.

STEP 4: PATIENT SELF-EVALUATION INSTRUCTIONS (EVALUATION)

In telephone triage, evaluations that would normally be performed by the nurse in face-to-face encounters must be carried out by the patient (as instructed by the nurse). Thus, “evaluation” is modified to become “patient self-evaluation instructions.” The nurse may also choose to monitor progress and self-care activities via follow-up calls to determine if home treatment is effective or if upgrading is needed. The nurse reviews as appropriate any emergent, urgent, or acute symptoms that the patient must continue to observe.

• Follow-up instructions: In addition to the disposition and treatment plan, it is important to always include standard follow-up instructions and a disclaimer in the instructions to the caller.
• Patient call-back: Telenurses always advise callers to call back if the symptoms worsen, new symptoms arise, or there are marked changed in activities of daily living because, “If your symptoms change, my advice will change.”
• Nurse follow-up calls: Policies should address the use of routine proactive follow-up calls, especially for high-risk callers.