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 related terminology.
• Discuss the components of a high-quality telephone triage system.
• Summarize the essential aspects of effective 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 the use of telephone guidelines and patient disposition.
• Summarize common risk management issues in telephone triage practice.

WHAT IS TELEPHONE TRIAGE?

Telephone triage is the process by which a healthcare provider assesses presenting concerns that are relayed by a patient through a telephone encounter and determines the appropriate level of care based on the seriousness of the situation (Haddad et al., 2019). Telephone triage, however, does not involve making diagnoses—nursing or medical—by phone (ANA, 2019).

The clinician’s disposition is defined as a directive to the patient about the time, place, and reason for further evaluation and/or treatment. Safety in telephone triage is paramount and requires that dispositions 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. The term disposition in telephone triage is often used interchangeably with level of care.

Telephone triage is an integral component of ambulatory care practiced by licensed clinical professionals (most frequently nurses) and occurring within a range of practice settings, including emergency departments, primary care, pediatric practice, specialty services, and managed care environments. The American Academy of Ambulatory Care Nurses (AAACN, 2018) identifies registered nurses to be qualified to safely perform telephone triage. Similarly, most state boards of nursing identify clinical decision-making inherent in professional nursing practice.

Terminology

Naming conventions and titles for telephone triage services may be confusing and sometimes misleading. Terminology for this area of care delivery has included telephone triage, teletriage, telepractice, telenursing, telephone advice, and telehealth. Titles for telephone triage practitioners vary by settings, as there is not a standard. Some examples include 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.

Other key terms that are closely related to telephone triage are telehealth, telemedicine, and telecare. Although they are similar and often used interchangeably, their meanings are different and are defined below for clarification. It is important to note that there are not standard definitions for the following “tele-” terms.

Telehealth is commonly used as an umbrella term and is defined as the use of electronic information and telecommunication technologies to support long-distance clinical care by healthcare professionals, including but not limited to nurses, pharmacists, therapists, and social workers. It may involve patient health education, social support, and medication adherence as well as managing health issues and treatment for patients and caregivers (FCC, n.d.).

Telemedicine is a narrower term usually used by physicians and refers to the use of telecommunications technologies to support the delivery of medical, diagnostic, and treatment-related services (FCC, n.d.).

Telecare is a general term and refers to technology that includes sensors and tools that connect individuals to family members or other caregivers, health-oriented apps, digital medication reminder systems, or early-warning and detection technologies (FCC, n.d.).

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 identify telephone triage as part of the continuum of care. Phone calls often precede emergency department visits. Thus, telephone triage could be considered a form of prehospital 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.

Similarly, emergency medical dispatchers receive and manage calls for medical assistance through a “systematic interrogation” of callers using protocols to evaluate injuries and illnesses established by a medical director (IAED, 2023).

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

Telephone triage, as an inherent part of telehealth, is practiced in a variety of healthcare settings (AAACN, 2018). Some areas with a high volume of triage calls include clinical offices and group practices, clinical call centers, and emergency departments.

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 utilize computerized clinical decision support systems (CDSSs) or electronic guidelines and have access to patient demographic information via an electronic medical record (EMR). Demographic information includes patient medical history, medications, allergies, and recent procedures. The EMR software program enables 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 intended to make the process safer, the presence of CDSS and EMR does not guarantee safety or even user compliance (Sutton et al., 2020). 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 (Wheeler et al., 2015).

Telephone Triage Utilization Patterns

Although there is great variation in utilization of telephone triage services across the various practice settings, there are some patterns that have emerged, as described below.

HIGH-UTILITIZING POPULATIONS

Frequent callers are often related to high-risk age groups: infants and children, frail older adults, 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 focus on 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.