SELECTING THE CORRECT GUIDELINE
Patients rarely present with the classic picture of any disease. Patients’ disease presentations vary due to immune response, medical history, age, and the timing of the call in relation to the disease process. Thus, telenurses must carefully navigate the multitude of possible presentations. A myocardial infarction may present as one key symptom (like chest pain), a few generalized symptoms (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 nurse to determine what constitutes a match to a given guideline.
Once the nurse has elicited adequate information utilizing assessment tools, the next step is to select a specific guideline. One expert recommends choosing the guideline that matches the most serious-sounding symptom or the one that most likely will require an appointment (Schmitt, 2018).
After consulting a guideline, a nurse can formulate a provisional or working diagnosis (impression). Use the patient’s chief complaint in their own words (headache, nosebleed, vaginal bleeding) to describe the problem. Add 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.”
Universal Guideline
Problems arise when patients present with symptoms that do not match a given guideline. This situation requires a type of “standard” or “universal” guideline. A universal guideline represents a standards-integrated tool. Encompassed in it are built-in provisions for thorough assessment, communication, patient continuity, and improved decision-making for all presenting symptoms—life-threatening to nonacute.
Symptom assessment precedes the triage process. Assessment is based on the nursing process; guidelines operationalize the symptom sorting (acuity-level selection) or triage function. When both are robust processes, it helps to reduce human cognitive error and bias through both structure and process.
A universal guideline serves several functions as a:
- Contingency (fallback) guideline, when no guideline seems to apply
- Preemptive (go-to) guideline prior to selecting a specific guideline
- Training tool for new staff to introduce broad assessment and triage rules
- Symptom sorter into several acuity levels
- Standard-integrated structure and process (i.e., a nursing process tool with built-in standards for assessment, communication, continuity, and improved decision-making)
(Wheeler, 2017a)
| Acuity Level with Assessment Questions | Disposition/Advice |
|---|---|
| (Wheeler, 2017a. Used with permission.) | |
| Emergent Symptoms | 911 or ED in 0 minutes to 1 hour |
|
|
| Urgent Symptoms | ED/UCC/Office in 1 to 8 hours |
|
|
| Acute Symptoms | ED/UCC/Office in 8 to 24 hours |
|
|
| Nonacute Symptoms | Home treatment w/ or w/o appointment in 24+ hours |
|
|
DECISION-MAKING VS. DECISION SUPPORT
Are guidelines decision-making or decision support tools?
Some telephone triage designers have developed decision-making tools, maintaining that nurses should generally adhere to deterministic algorithms. Others see the nurse as the true decision maker, with guidelines serving as decision support tools. Decision-making tools are designed to allow unqualified operators to make decisions that are beyond their level of training and experience, whereas decision support systems contain prompts to remind experienced decision makers of clinical information they once knew but may have forgotten.
Decision-making tools are designed with yes/no questions and are used to make differential diagnoses. They are not recommended for safe use in telephone triage.
Decision support tools, based on pattern recognition, support the telenurse to use the nursing process and pattern recognition to estimate urgency. This approach mimics the way the brain solves problems by providing general descriptions to compare with the patient presentation. (The examples presented in this course are based on a decision support approach.)
The clinician must rely on clinical experience, training, and common sense to identify urgencies, estimate symptom urgency, rule out urgency, interpret patient responses, and determine a course of appropriate action. Decision support guidelines—whether on paper or electronic—are an adjunct to the decision-making process.
Pediatric Sepsis and Dehydration Guidelines
There are two key guidelines that no pediatric telephone triage manual should be without: sepsis and dehydration. While older adults and debilitated persons are also at risk, children are especially vulnerable to these two serious conditions. Because symptoms may be subtle, generalized, or atypical, both guidelines describe alterations in key behavioral patterns related to these conditions based on the parameters outlined in activities of daily living. A good rule of thumb is: All sick children should be assessed for possible dehydration or possible toxicity (sepsis).
For example, with possible toxicity or possible sepsis, the child may exhibit extremes of behavior: extremely irritable, crying inconsolably, unable to be comforted. At the other end of the spectrum, a child who is quiet, not moving, very withdrawn, and difficult to engage presents another pattern of severe illness. Refusal to eat, drink, or breastfeed nearly always indicates patterns of extreme illness in children.
With dehydration, the nurse should elicit and be alert to the context and combined effect of conditions that can worsen dehydration. These include extreme heat or humidity, exercise, fever, nausea and vomiting, diarrhea, low or no fluid intake, as well as age, chronic disease, degree and duration of fever, patient medical history, depressed thirst response, and medications.
| Acuity Level with Assessment Questions | Disposition/Advice |
|---|---|
| (Wheeler, 2013. Used with permission.) | |
| Emergent Symptoms (severe dehydration) | 911 or ED in 0 minutes to 1 hour |
|
|
| Urgent Symptoms (moderate dehydration) | ED/UCC/Office in 1 to 8 hours |
|
|
| Acute/nonacute Symptoms (mild dehydration) | ED/UCC/Office in 8+ hours and home treatment |
|
|
| Acuity Level with Assessment Questions | Disposition/Advice |
|---|---|
| (Wheeler, 2013. Used with permission.) | |
| Emergent Symptoms (severe toxicity) | 911 or ED in 0 minutes to 1 hour |
|
|
| Urgent Symptoms (moderate toxicity) | ED/UCC/Office in 1 to 8 hours |
|
|
| Acute/nonacute Symptoms (mild toxicity) | ED/UCC/Office in 8+ hours and home treatment |
|
|
DISPOSITION: A TIERED APPROACH
Telephone triage implies a tiered approach that requires nurses to identify the symptom acuity level. The example below has several tiered categories with flexible timeframes within which the nurse determines a safe, prudent, and reasonable disposition. The following four tiers are adapted from definitions and descriptions used by the American Board of Emergency Medicine (Beeson et al., 2020).
- Emergent Level: All emergent-level symptoms will require ED services. Life-threatening symptoms will always require paramedic transport to ED within minutes. Patients must be kept NPO. Remain on the line with the caller. Whenever possible, institute a three-way conference call with both patient and EMS services, suicide prevention, rape crisis, poison center, etc., according to facility policies.
- Some patients with emergent (but non-life-threatening) symptoms may be brought by car by a person who can safely drive the patient within the appropriate time frame (0 to 1 hour). When applicable, always notify labor and delivery or ED of pending arrivals of any patient coming via car.
- Urgent Level: Urgent symptoms typically require evaluation within 1 to 8 hours (i.e., same-day appointment). Some patients may require evaluation within the hour and are instructed by guideline to “come in now.” Depending on the time of day and day of the week, some patients may be directed, as appropriate, to ED, urgent care, or office settings for further evaluation.
- Some patients in the urgent category may also require paramedic transport due to transportation problems. Some may require other reliable, timely transport as is practical (e.g., cabs, ride-share, etc.) if there is no readily available car or if loved ones are too anxious to drive them in. When applicable, always notify labor and delivery or ED of pending arrivals of any patient coming via car.
- Acute Level: Acute symptoms typically require evaluation within an 8- to 24-hour timeframe or a next day appointment. Depending on the time of day and day of the week, some patients may be directed, as appropriate, to ED, urgent care, or office settings for further evaluation. Always notify labor and delivery or ED of pending arrivals of any patient arriving via car.
- Nonacute Level: Nonacute symptoms may require evaluation within a 24-plus-hour timeframe or future appointment or advice only. Depending on the time of day and day of the week (available access), these patients may also be directed to ED, urgent care, or office settings for further evaluation, as appropriate.
UPGRADING A DISPOSITION
“When in doubt, always err on the side of caution” is a cardinal rule in telephone triage. Telephone triage nurses must rely on their best professional judgment and use every means at their disposal to ensure that patients are treated in a timely manner. Timeframes provided in a guideline are intended as a general guide. If a nurse has doubts about the severity of symptoms and condition, safety dictates the patient come in sooner rather than later, erring on the side of caution.
Telephone triage nurses may upgrade dispositions as appropriate (e.g., from urgent to emergent, nonacute to acute). Downgrading a disposition or level of care occurs if a nurse recommends or approves of a lower level of care. Downgrading can be risky.
Examples:
- The nurse has identified a life-threatening symptom, and the patient requests to remain at home and “wait it out.” The nurse cannot support this unsafe decision. Instead, the nurse provides the patient with compelling rationale to convince them to follow the advice. If there is still resistance, collaborating with the physician on-call is an option.
- A patient contacts a nurse, who determines that the symptoms require an appointment within 24 hours. The patient declines an appointment and states that they will implement home care advice for 24 hours and then return a call to the nurse within 24 hours to provide an update related to progress. Although the guideline required an appointment within 24 hours, the nurse agrees that a follow-up phone call is acceptable.
In both of these situations, the patient did not follow the timeframe that was advised. There could be significant implications in the first example, and so more actions were taken to address the patient’s nonadherence. In both cases, it is necessary for the nurse to document comprehensively to ensure that the situation is reflected accurately and to demonstrate that the standard of care and due diligence was met.
Improper Use of Guidelines
A common pitfall is when nurses make improper use of guidelines. Even though guidelines may be well-designed and comprehensive, there are several ways in which the nurse can misuse them, including:
- Failure to use a guideline. This is obviously risky but easily occurs when the nurse finds that no guideline seems to apply to the presenting problem. It is commonly referred to as the “out of guideline” experience.
- Selecting the wrong guideline. Failure to collect enough information can lead to selecting the wrong guideline, which may in turn lead to an inaccurate referral and/or disposition for the patient.
- Applying a guideline improperly. Nurses may choose the correct guideline but fail to follow it correctly. This can be remedied by providing comprehensive user’s guide instructions and guideline competency training.
- Over-reliance on a guideline. When guidelines are given too significant a role, nurses may become passive, and this can lead to errors in triage. A balance between nursing judgment and the use of the guideline is required.
- Using one guideline when there are multiple symptoms. Although a patient may be experiencing many symptoms, the nurse chooses only one guideline. This may be done in an effort to reduce call time. Or the nurse decides what symptom is the most apparent. Or the patient may have called numerous times, and the nurse picks a guideline only for the new symptom. Whatever the case, this is risky because each guideline will result in a level of care, and unless all guidelines are used, the highest level of care may not be determined.
In addition, there is the possibility of “guideline bias.” This may occur when nurses who have become used to one type of guideline must change to a new, different type of guideline. They often have difficulty adjusting to the new design.
Telephone triage managers should also be aware of the pitfall of relying on guidelines to take the place of formal training and instruction in critical thinking, history taking, communication, assessment, and decision-making.
Disposition Closure
The nurse’s disposition includes ending each call with the final question, “Is anything else worrying you?” or “Do you have any additional questions?” This step may reveal that a patient has an entirely different motivation and may even open the door to a new triage process.
Documenting a closing statement helps ensure that the patient has given informed consent. In other words, they comprehend the provisional diagnosis and any proposed treatment, with the following understanding:
- This is an impression, not a medical diagnosis.
- The advice or home treatment is based on the impression.
- If a patient disagrees with the impression, they may have an appointment.
- If symptoms worsen or fail to respond to the home treatment, the patient agrees to call back or come in.
- The patient agrees to the plan.
A key element of documentation is to elicit and document what the patient plans to do at the end of the call. This will demonstrate that there was agreement to a certain plan of action. Further, it ensures that the patient understands what to do and under what conditions they may need to ask for further help. The chain of command may also be used; nurses should not be afraid to go to the next higher level.