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
• Clinical practice guidelines (protocols)
• Documentation forms
• Standards

Researchers have not yet determined which clinical practice 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. Clinical practice guidelines “optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” (IOM, 2011, p. 4).

Telephone triage guidelines based on the nursing process and related research offer decision 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.

Telephone Triage Nurse

Telephone triage services are performed by specially trained, licensed registered nurses. Ideally, telenurses should have a minimum of three to five years of decision-making experience in direct patient care.

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
• Competency in nursing process
• Effective written and verbal communication skills
• Knowledge of basic pathophysiology
• Knowledge of basic and current pharmacology
• Ability to make clinical decisions autonomously
• Ability to problem solve
• Understanding of scope of practice
• Cultural sensitivity

Personal characteristics of 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

Core competencies are defined as “the essential minimal set of a combination of attributes, such as applied knowledge, skills, and attitudes, that enable an individual to perform a set of tasks to an appropriate standard efficiently and effectively” (Albarqouni et al., 2018, p. 2). The Association of American Medical Colleges (AAMC) and the American Academy of Ambulatory Care Nursing (AAACN) have both developed telehealth competencies.

The AAMC (2021) established a Telehealth Advisory Committee to identify the skills clinicians need to provide high-quality telehealth care. The competencies can be used to develop outcome-based cross-continuum education focused on telehealth. The competencies are organized into six domains:

1. Patient safety and appropriate use of telehealth: Clinicians will understand the timing and purpose of telehealth and demonstrate the ability to assess patient readiness, patient safety, practice readiness, and end-user readiness.
2. Access and equity in telehealth: Clinicians will understand telehealth delivery that addresses and mitigates cultural biases as well as clinician bias for or against telehealth and that accounts for physical and mental disabilities and non-health-related individual and community needs and limitations.
3. Communication via telehealth: Clinicians will effectively communicate with patients, families, caregivers, and healthcare team members using telehealth modalities.
4. Data collection and assessment via telehealth: Clinicians will obtain and manage clinical information via telehealth to ensure appropriate high-quality care.
5. Technology for telehealth: Clinicians will have basic knowledge of technology needed for the delivery of high-quality telehealth service.
6. Ethical practices and legal requirements for telehealth: Clinicians will understand practice requirements to meet the minimal standards to deliver health care via telehealth. Privacy will be maintained while minimizing risk to the clinician and patient during telehealth encounters, putting the patient’s interest first.

The AAACN Scope and Standards of Practice for Professional Telehealth Nursing (2018) contains 16 standards. The first six are “Clinical Practice Standards,” and 7 through 16 are “Professional Performance Standards.” The AAACN telehealth standards are “authoritative statements that describe the responsibilities for which telehealth nurses are accountable.”

1. Assessment
2. Nursing diagnosis
3. Outcomes identification
4. Planning
5. Implementation (care coordination/transition management, health teaching and health promotion, consultation)
6. Evaluation
7. Ethics
8. Professional development
9. Research and evidence-based practice
10. Performance improvement
11. Communication
12. Leadership
13. Collaboration
14. Professional practice evaluation
15. Resource utilization
16. Environment

Training

A training program should address the most needed topics: pathophysiology, medications, and decision-making.

Formal standardized training is inconsistent in telephone triage systems. While the American Association of the Colleges of Nursing (AACN) and the AAACN have both developed telehealth competencies, telehealth content remains low at both undergraduate and advanced practice levels (Eckhoff et al., 2022). Although the AAACN offers an annual conference and online training resources, training occurs on the job and is not formal or standardized. Nurses receive training from another staff member. There are some organizations that provide formal in-house training, have preceptor programs, or use online training.

Similarly, physicians receive limited or no formalized education focusing on telephone triage. In recent years, the number of medical schools offering telemedicine education has increased to nearly 90%, but the approaches vary and are not supported by data on effectiveness. Medical schools cite a lack of faculty experience in telemedicine and the lack of a “gold standard” for training as significant barriers to developing education (Bajra et al., 2022).

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 role: 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 management function: Nowhere else is the instant grasp of rapidly changing situations more vital than in crisis intervention by phone. To manage a call with potentially life-threatening symptoms, the telenurse will 1) assess/triage the patient’s emergency and 2) facilitate, orchestrate, and coordinate access to care as needed (Benner et al., 2011). Because some rural communities lack resources such as 911, suicide prevention, or rape crisis hotline systems, telenurses may be the first responder as they field calls regarding imminent births, trauma, suicide, and ingestions.
• Teaching-coaching 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.

The Process of Telephone Triage

In the management of symptom-based calls, nurses must use the nursing process, which is the core of practice for the registered nurse to deliver holistic, patient-focused care in any setting. The five steps in the nursing process include assessment, diagnosis, outcomes identification/planning, implementation, and evaluation (ANA, n.d.).

• 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, guidelines, and patients as their proxy to self-evaluate.
• The diagnosis process consists of formulating a provisional/working diagnosis, or impression.
• The nurse identifies outcomes based on the patient’s values and preferences; their situational environment; current evidence; and telehealth best practices.
• The nurse collaboratively develops a plan with the patient that is based on the nurse’s clinical judgment, the selected guideline disposition, and the caller’s preferences.
• The implementation of the collaborative plan is determined by the nurse and patient or caregiver.
• Evaluation is completed by the nurse through evaluation of progress toward the ability to implement the plan or achieve the desired outcomes.
  (AAACN, 2018)

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.

It is essential to start the assessment process by asking questions, aided by a specific template or 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 misinterpreting or focusing on the incorrect symptoms 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 patient who is experiencing a myocardial infarction may present with one symptom (like chest pain), or a few generalized or more unique symptoms (ear pain, arm tingling, nausea, vomiting, sweating), or the 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 (e.g., 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: OUTCOMES EVALUATION

Once the assessment is complete and the working diagnosis or impression is formulated, the nurse collaborates with the patient to determine the desired outcome. Factors such as the patient’s values and preferences; spiritual, cultural, and ethical considerations; age-related implications; situational environment; current scientific evidence; and best practices may contribute to the plan.

STEP 4: DISPOSITION AND ADVICE (PLANNING)

Planning 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 referring to the guideline disposition (level of care) and care advice.

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

• Disposition (level of care) requires that the nurse advise the patient when and where to go for treatment in addition to why the patient must go as advised, i.e., that the symptoms appear emergent, urgent, acute, or nonacute.
• Appropriate referral (AR): A timely, safe disposition (“right place, right time, and right person”) that avoids a delay in care, evaluation, or treatment
• Over-referral (OR): A referral deemed by some to be unnecessary at the time and place initially recommended; judged to be safe but not cost effective
• Under-referral (UR): A referral to a lower level of care than required, often resulting in a delay in care and causing (or with potential to cause) patient harm; may also be a type of error that can result in a delay in care
• Home treatment advice often includes first aid instructions related to over-the-counter medications and common self-care strategies.

STEP 5: IMPLEMENTATION

In a telephone encounter, the nurse and caller do not share the same physical space, so the patient or family member takes responsibility for carrying out the interventions. When the nurse relays the plan, there is an assessment of whether the caller is able to carry out the plan. Patient education may be completed during this step to validate that there is an understanding of the advice and plan. The nurse verifies that the determined plan with be operationalized.

STEP 6: EVALUATION

Evaluation is the last step in the nursing process. In a telehealth encounter, the nurse evaluates progress toward the expected outcomes and collaborative plan of care. This is achieved prior to the conclusion of the encounter. The nurse confirms that the plan will be carried out and that the caller verifies understanding of worsening symptoms and/or changing condition.

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 changes 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.

(AAACN, 2018; Rutenburg & Greenberg, 2012)