ASSESSMENT

The telephone triage process often begins with a rapid assessment to determine and prioritize how urgently the patient should be seen. Expert nurses quickly build the clinical scenario through gathering (or noting on the EMR) key chunks of information: the patient’s age, gender, chief complaint, literacy or language level, emotional state (determined via the words, tone, pacing of voice), and previous medical history (Raheja, 2016).

This key contextual information can quickly identify high-risk patients or problems. This process, while appearing superficial, yields valuable information and often takes as little as 60 seconds.

Using critical-thinking skills, the nurse must quickly recognize when collection of more data is appropriate. Whereas in the case of chest pain, the nurse may quickly elicit key data and make a decision, a case of vague abdominal pain requires gathering larger quantities of detailed information.

Rapid assessment and prioritization is referred to as a global assessment, intended to quickly recognize an emergent situation that requires aborting the formal assessment process and directing the caller to the emergency department (see “SAVED” below). However, most calls are not emergent and require eliciting an adequate symptom and patient history.

The history-taking process begins by verifying the patient’s contact information (address and phone number). The nurse should remind the patient that this information is important in case the call is disconnected (especially since many patients’ only or primary phone is a cell phone, which can disconnect at a critical moment).

SAVED: Identifying High-Risk Patients and Symptoms

Quickly identifying and prioritizing high-risk situations is a critical skill in telephone triage. Research has identified several broad categories of high-risk (red flag) patients and symptoms, signified here by the mnemonic SAVED.

SAVED

S	Severe, strange, or suspicious symptoms
A	Age
V	Veracity
E	Emotional state
D	Debilitation and distance

These are “red flag” symptoms and populations that should raise suspicions and that all clinicians should remain aware of (Wheeler, 2009, 2013, 2017a).

Using this broad, global approach has several advantages. It supports clinical prioritization of patients and symptoms that are at high risk as a quick “first pass” in the assessment process. It expedites data collection and decision-making and quickly establishes acuity. In general, high-risk symptoms and patients with several risk factors must be treated more conservatively (i.e., by appointment rather than advice).

SEVERE, STRANGE, OR SUSPICIOUS SYMPTOMS

Severe pain (9 on scale of 10), severe bleeding (spurting, bright red), or severe trauma (falls from a height over 15 feet) are all conditions that the average layperson could identify as urgent. Strange symptoms include ill-structured, vague, atypical, or unusual presentations—symptoms that astute professionals typically recognize as urgent.

Sudden, unexpected, or new symptoms; recurrent symptoms; or a marked change in the patient’s condition all qualify as suspicious or strange. Also included as strange are symptoms that are atypical, novel, or silent presentations—often present in persons with compromised immune systems, such as the older adult or young children.

Three descriptive methods can help establish acuity:

• Compare current symptoms to normal ADLs (see also “ADLs” later in this course).
• Quantify symptom severity. Measure symptoms in terms of numbers, frequency, size, or duration. For example, pain described as an 8, 9, or 10 on a scale of 1 to 10 (10 being the worst pain ever experienced) is quantitatively severe. Other examples of severe are:
  • Vaginal bleeding of more than one pad per hour (females)
  • Urine output less than one scantily wet diaper per eight hours (infants)
  • More than six to eight large, watery stools in eight hours
  • Swelling of wrist that is twice the size of a normal wrist
• Qualify symptom severity. Qualitative severity refers to descriptive terms or characteristics that indicate extreme symptoms. A headache described as sudden, splitting, throbbing, blinding, or “the worst headache I’ve ever had” is considered qualitatively severe. Other examples are:
  • Crushing chest pain
  • Sudden, localized, sharp abdominal pain
  • Sudden onset, widespread, unusual rash
  • Intense itching, sudden onset
  • Severe difficulty breathing

The “big six”—head, abdomen, chest, respiratory, dizziness, and flu symptoms—are regarded as suspicious. They always require thorough investigation for two reasons: 1) many of these symptoms have been found to be serious when subsequently evaluated in the ED; and 2) they may represent potentially serious conditions such as ectopic pregnancy, myocardial infarction, or appendicitis—conditions that often end in malpractice lawsuits due to underdiagnosis.

Suspicious symptoms also apply to situations where the nurse has a “gut feeling” or a hunch about a problem. In such situations, if the nurse is uncomfortable with the guideline disposition, it is important to upgrade a problem or bring the patient in sooner.

S = SEVERE / STRANGE / SUSPICIOUS SYMPTOMS (INCLUDING SEPSIS)

(Wheeler, 2009, 2013, 2017a.)

Severe pain, bleeding, trauma, diarrhea, vomiting, rash, etc. In older adults, severe diarrhea or dehydration Novel, atypical, unusual presentations (worst, new, sudden, unexpected, recurrent, silent) “Big six” (head, chest, respiratory, abdominal, “flu,” dizziness); often missed/delayed diagnosis of stroke, myocardial infarction, pulmonary embolus, appendicitis, ectopic pregnancy

AGE

Age is one of the most important pieces of data obtained. The very young, very old, and women of childbearing age are typically regarded as high-risk populations. Due to immature immune systems, premature infants and those under 3 months of age are at highest risk. The “frail elderly” (anyone over 75 years of age or suffering from multiple or chronic diseases, functional disability, or psychosocial problems) are vulnerable due to failing immune responses. The childbearing years—always a high-risk period—may extend from age 11 to 60+ years.

Age information is typically readily available in the EMR. If the EMR is unavailable, always elicit and document the age; for infants and newborns, indicate in days, weeks, or months.

Some diseases are age-related. For example, women of reproductive age have a higher incidence of ectopic pregnancy, birth control side effects, and sexually transmitted infections. Extremes of age increase vulnerability to “routine” illnesses. All infants under 6 months (especially newborn and premature infants) as well as frail elderly are more vulnerable to infections and risks of sepsis.

A = AGE (HIGH-RISK POPULATIONS)

(Wheeler, 2009, 2013, 2017a)

All children, especially newborns; then under 3 months; then under 6 years All older adults, especially frail elderly Men over 35, women over 45 (in relation to cardiac symptoms) All women of childbearing age Teenagers who may be depressed (in relation to risk for suicide attempts) Developmentally disabled (typically age prematurely)

VERACITY

Veracity refers to the ability to describe facts of the situation accurately. In the context of telephone triage, impaired veracity refers to the compromised ability to communicate accurately. Typical populations who have obstacles to communication include children under age 8, poor historians, extremely young or very inexperienced mothers, or caregivers unfamiliar with the patient.

Information relayed through second or third parties (as with calls about children) may be incomplete or erroneous. A cardinal rule of thumb is “to speak directly with the patient,” but this is not always possible. Third-party calls may occur when a working parent receives a report of the child’s condition from the onsite caregiver and then phones the telenurse. In the case of language barriers, using certified medical interpreters may improve communications but will double the length of the call.

These patients will likely require an appointment because communications are impaired. A prudent policy is to see the patient in a timely fashion rather than to attempt to evaluate symptoms by phone. However, in all cases, it is important to attempt to ascertain if any emergency exists by performing a basic “rule-out” of urgency before advising an appointment.

V = VERACITY (IMPAIRED COMMUNICATION)

(Wheeler, 2009, 2013, 2017a)

Second- or third-party calls Child under the age of 8 Extremely young or very inexperienced mother Low literacy Language barrier (best practice is to use a certified medical interpreter to translate rather than a family member) In older adults: Suspected adverse drug reaction / substance abuse / overmedication by caregiver (“chemical restraints”) Incoherent or slurred speech in patient/caregiver Caregiver unfamiliar with patient

EMOTIONAL STATE

Emotional status is a major factor in assessing acuity. Research on calls to emergency medical dispatchers found that when callers were extremely emotionally distraught and individuals were 50 years of age or older, 96% of the individuals were having a cardiac arrest (Clawson & Democoeur, 2020).

Nurses can discern subtle cues through careful attention to the words, tone, and pacing of the caller’s voice. There may be hysteria or denial, inappropriate affect in the caretaker or parent, confusion, or a history of psychiatric problems or substance abuse. Anxiety is always a red flag. When possible, telenurses attempt to gauge whether emotions are a temporary reaction to the current illness or long-standing emotional patterns. Call acuity is upgraded when extreme emotional reactions are present.

It is important to ask how often and when the patient has called in the recent past. Frequent calls in a brief period of time are an indicator of both caller anxiety and may be an indicator of symptom urgency. Frequent calls are a red flag and indicate the patient should be seen urgently. Malpractice cases often involve encounters in which multiple phone calls were ignored, causing a delay in care (Wheeler, 2016, 2017a).

Documentation should include patient hostility or legal threats, inappropriate or extremes of affect, confusion, multiple phone calls, and patient statements of emotional state, to assure that calls are placed within the proper context and not disregarded.

E = EMOTIONAL STATE

(Wheeler, 2009, 2013, 2017a)

Multiple calls, anxiety Hysteria or denial Inappropriate affect in caretaker Emotional distress Parent or caretaker with history of abuse (e.g., physical, sexual, financial, emotional), psychiatric problems, or substance abuse

DEBILITATION AND DISTANCE

Generally, the term debilitation refers to chronic illness. Chronic illnesses may include (but are not limited to) cancer, diabetes, heart disease, hypertension, mental disorders, asthma, or COPD. For the immunocompromised, debilitation may involve lack of adequate immunizations, chemotherapy, HIV, splenectomy, steroid therapy, transplants, or nephrotic syndrome. Debilitation is also related to risk of sepsis.

D = DEBILITATION AND DISTANCE

(Wheeler, 2009, 2013, 2017a)

Chronic illnesses (asthma, depression, diabetes, cancer, cardiac symptoms, CHF, COPD, dementia, hypertension, inflammatory bowel disease, kidney disease, liver disease, neurologic symptoms, rheumatologic disease, Sickle cell disease) Smoking, substance abuse Immunocompromised (chemotherapy, HIV/AIDS, nephritic syndrome, splenectomy, steroid therapy, transplant history) Developmentally disabled (typically age prematurely) Frail elderly (over 75 years; over 65 years with functional impairments, with physical or mental disabilities) Parent/caretaker calling from remote location over one hour from hospital Reliance on public transportation that is sporadic or nonexistent at certain hours In emergent situation, patient unable to reach care within one hour due to traffic or lack of available transportation

Medically complex patients are defined as those with comorbidity of several medical conditions that significantly compromise the ability to function (IOM, 2015). Medically complex patients may require upgraded acuity. For example, “flu symptoms” might represent early sepsis symptoms in patients with HIV, cancer, hemophilia, congenital defects, alcoholism, drug abuse, or multiple surgeries. Homeless and mentally ill (including PTSD) patients may have higher rates of chronic illness, as will those who are immunocompromised and frail elderly.

Telephone triage is “time sensitive”; time to treatment (distance) influences triage disposition and can affect continuity and result in a delay in care. A patient/caregiver calling from a remote location several hours from a hospital or patients who depend on public transportation to travel may be at risk for delays in care. Delays may be typical of rural areas but may also apply to urban settings where rush-hour gridlock may impede arrival. Upgrading by calling paramedic transport can have the advantage of bringing access to the patient, thereby reducing a delay in care.

To summarize:

• Quickly prioritize by using the high-risk categories within SAVED on the documentation form.
• Ask questions in any order, or simply let the caller tell their story at first.
• Use open-ended questions where possible.

Elicit the Problem and Patient History

When a problem does not appear urgent, the telenurse performs a more detailed assessment of symptom and patient history. This begins by eliciting the patient’s primary reason for calling. A patient’s first utterances are very important, and the patient’s first few descriptions can be key to zeroing in on the heart of the problem. Information can be collected in any order that seems appropriate to the patient and the situation.

By the same token, obtaining a brief patient history creates context and an immediate sense of patient risk. It includes verifying recent injury or illness, chronic illness, current daily medications, pregnancy status, and drug allergies.

It is not necessary to let a standard data collection form dictate the order of collection. In real-world situations, people volunteer information initially. It is important to find a safe balance between listening to a patient’s explanation and communicating the need to gather information in a timely fashion. Data is recorded into the appropriate field as the patient volunteers information; any information gaps are filled in later with follow-up questions from the guideline.

Patients often present symptoms in erratic and disorganized ways. They may focus on one symptom to the exclusion of other, more important ones. An example might be the parent who is concerned about a child losing a tooth due to trauma, when the more serious problem is possible head injury. A critical step in data collection is to avoid being caught up in the patient’s perception and to start the triage process with assessment questions and the documentation form. The rationale is to quickly sketch an outline of the problem.

Do not select a protocol too quickly. Perform thorough assessments as a “first pass” to reduce the risk of jumping to conclusions. As uncomfortable as uncertainty may be, choosing a guideline prematurely may lead down the wrong path.

SCHOLAR and RAMP: Problem and Patient Histories

Researchers have consistently pointed out the need to collect essential information related to the problem and patient histories. The mnemonic SCHOLAR lists key questions to elicit data on the problem history, and the mnemonic RAMP lists key information about the patient history. While other well-known nursing mnemonics, such as PQRST or SOAP, may work well for face-to-face assessment, more detail is needed in telephone triage interactions.

USING SCHOLAR FOR ELICITING PROBLEM HISTORY

(Wheeler, 2009, 2013, 2017a)
S	Symptoms and associated symptoms	Is it an isolated symptom or complex of symptoms? Course of symptoms: Is it better? Worse? The same?
C	Characteristics (aids in precise description)	Quantitative (e.g., scale from 1–10) Qualitative (e.g., sharp, dull, pounding)
H	History of complaint	In the past, what was done? By whom? When? What were the results?
O	Onset of symptoms	When did they start? How long have they been present? Was the onset sudden or gradual? (sudden = higher acuity)
L	Location of symptoms (strive for precision, e.g., RUQ, LLQ, etc.)	Localized? Generalized? Radiation?
A	Aggravating factors	What activity, foods, positions, etc., make it worse?
R	Relieving factors	What activity, foods, home treatment, positions, etc., make it better?

USING RAMP FOR ELICITING PATIENT HISTORY

(Wheeler, 2009, 2013, 2017a)
R	Recent	Injury Infection Illness Invasive (post-procedure, postoperative, postpartum) Implant International travel Immunocompromised (chemotherapy, HIV/AIDS, nephrotic syndrome, splenectomy, steroid therapy, transplant) Ingestion (accidental or intentional ingestion/exposure, adverse drug reaction, new medication, drug-disease / drug-drug / drug-food interaction)
A	Allergies	Any exposure to foods, chemicals, drugs, insect bites, cosmetics, or other substance (new or existing)?
M	Medications	Current or new over-the-counter, prescription, birth control, or recreational drugs?
P	Pregnancy / breastfeeding	For all women 12 to 50 years of age, any possibility of pregnancy or unprotected intercourse?

ADLs: Poor Historians, Children, and Disabled

Sometimes, symptom presentations are vague, ill-structured, or nearly absent, as may be the case with children, some older adults, and poor historians. Gathering adequate information is made more difficult because the patient is a poor historian. In these cases, SCHOLAR and RAMP may be unworkable. Instead, the tool of choice is activities of daily living (ADLs), assessed to elicit and compare the patient’s current state with their baseline state.

Comparing current ADLs with baseline ADLs provides a mental image of how ill a patient might be now. This includes asking how the patient is functioning compared to their normal routines in the areas of eating, drinking, sleeping, playing, working, eliminating (urine output and bowel movements), general appearance, and demeanor. A second party (such as a parent or caregiver) can also evaluate this baseline state. Activities of daily living provide a surprisingly concrete picture of the patient when other data are sketchy.

USING ADLs FOR BASELINE COMPARISON

(Wheeler, 2013, 2009, 2017a)
Intake	Fluids, food
Output	Urine, emesis, BM, diaphoresis (quantity and quality)
Sleeping	Too much, too little
Activity level	Compared to normal activity levels or routines
Mood	Marked change (any)
Color	Pale, red, blue, grey, ashen
Skin	Turgor; lips/tongue

For newborns, infants, older adults, aphasic, extremely poor historians, or severely disabled patients, the mnemonic A DEMERIT can also be used to assess demeanor/mood.

USING A DEMERIT TO ASSESS DEMEANOR/MOOD

(Wheeler, 2013, 2009, 2017a)
A	Any extreme behavior (irritability, inactivity, disengagement, inconsolable crying)
D	Difficult to awaken or keep awake
E	Expression (decreased)
M	Movement (little or no spontaneous movement on own)
E	Eye contact/focus decreased
R	Recognition of caregiver/parent (decreased)
I	Interactivity (decreased)
T	Talking (decreased)

Pain Assessment

Pain—a common presenting symptom—usually requires patient self-assessment. The telenurse instructs patients how to use landmarks to identify the location of pain (e.g., in relation to nipples, sternum, umbilicus, and pelvic bones). The analogy of a clock is helpful to estimate the location of a foreign body in the eye, abdominal pain, or lump in the breast. Pain may be diffuse or localized. If the patient can point with one finger to the location, it may indicate localized pain (thought to be more serious), whereas if they cannot, it may indicate diffuse pain (thought to be less serious). Sudden onset of pain is thought to be more serious than gradual onset.

If patients cannot adequately relate the severity of their pain, another way to estimate pain intensity is to systematically ask about its effect on their ability to function as normal or ADLs. If pain is moderately impactful, it will require a same-day appointment.

Sepsis Recognition

With high-risk or any sick patient, the clinician remains suspicious for the often subtle symptoms of sepsis. This includes performing early sepsis recognition by taking into account contextual details that are associated with sepsis—previous (any chronic illness) and recent medical history (recent injury, infection, invasive procedure, implant, immunocompromised, international travel). This information can be combined with age and current symptoms to form a pattern of risk.

Early sepsis recognition can be made using the mnemonics SAVED, RAMP, and SEPSIS.

(See also “Pediatric Sepsis and Dehydration Guidelines” below.)

USING SEPSIS

(Bradford, 2016)
S	Shivering, fever, or feeling very cold
E	Extreme pain or general discomfort
P	Pale or discolored skin
S	Sleepy, difficult to rouse, confused
I	“I feel like I might die”
S	Shortness of breath

Assessing by Proxy

Unless telehealth and biotelemetry (measuring physiologic functions from a distance by telemeter) are available, telephone triage clinicians must enlist the aid of patients to assess by proxy. Traditionally, clinicians use vision, touch, hearing, and smell to assess symptoms. In telephone triage, the patient must serve as eyes, ears, nose, and hands to the clinician, who elicits data. (Auscultation by phone—gross respirations, emotional tenor, speech patterns, background sounds—is sometimes feasible.)

Methods available to gather information by proxy include:

• A visual assessment of a possible fracture can include comparing extremities (fingers, hands, feet, ankles) for swelling, discoloration, or deformity (e.g., “How do your two wrists compare to each other?”).
• Tactile information can be elicited (e.g., “Touch the area and tell me what happens. Is there tenderness in one particular area?”).
• In the case of a possible chemical ingestion, olfactory data can be elicited (e.g., “What does the child’s breath smell like?”).

With some exceptions, patients are subject to many of the same cognitive errors as clinicians: stereotyping, inadequate data collection, erroneous self-diagnosis, over-reacting, under-reacting, and fatigue. It is important to alert patients to these possibilities (e.g., “Is there a chance that you might be underestimating your symptoms?”).