Telephone triage

Overview
Telephone triage is defined as the management of patient health concerns and symptoms via a telephone interaction (telecommunications) by “advice nurses”.

Telephone triage utilizes an older form of technology (telephone lines) and thus, preceded telemedicine and telehealth. Telehealth is defined as the delivery of health related services and information via telecommunications technologies and is now the umbrella term describing all the possible variations of healthcare services using telecommunications.

Uses of Telephone Triage
Triage means a sorting out. Telephone triage nurses utilize protocols or guidelines, in paper or electronic format to help sort symptoms, from “chest pain to chicken pox”. Telephone triage involves ranking clients' health problems according to their urgency, educating and advising clients, and making safe, effective, and appropriate dispositions--all by telephone. It may include everything from disease management, AIDS counseling and child abuse hotlines to 911 and telemetry monitoring, and takes place in settings as diverse as emergency rooms, large call centers and hospices.

Telenursing
Telephone triage nurses have a range of titles: “advice nurses”, “telepractitioners”, “telenurses”, “telepractice nurses” or “consulting nurses”. In one 8-hour shift, a telenurse may field 60-80 telephone calls--one every 6 - 10 minutes--painstakingly assessing headaches, newborn rashes, chest pain, possible allergic reactions, medication questions, and seasonal flu and fevers. Nurses may also direct clients to obtain a second medical opinion, or advise them where to find relevant, current health information. They might counsel or perform crisis intervention for a threatened suicide. What was traditionally done informally in emergency rooms, clinics, and physicians' offices for years has evolved into a new nursing subspecialty called telephone triage.

Telepractice Settings
Telenurses practice in a range of settings, from large medical call centers, physician’s offices, clinics, hospices, college health centers, disease management call centers, poison centers, and emergency departments.

Research on Telenurse Decision-making
Telephone triage — the safe, effective and appropriate disposition of health related problems by RNs — always involves “decision-making under conditions of uncertainty and urgency.” (Patel, 1996) “Uncertainty” because decisions are often made based on partial or inaccurate information; “urgency” because calls must be processed within a brief time frame — usually 6-10 minutes average. In new research, telephone triage has been compared to the work of air traffic controllers, EMDs and firefighters — all high stakes activities. Vimla Patel, Ph.D., described how a group of RNs working in an emergency department setting made “real world” decisions in telephone triage. She discovered that these nurses used pattern recognition, rules of thumb and context as major strategies to make decisions.

Protocols
Protocols or guidelines are essentially“ standing orders” for nurses for the assessment and management of a range of symptoms. Protocols may be in paper or electronic format. Some developers see protocols as decision-making tools; others as decision support tools. This is an area of controversy in this new field.

The research on nurse decision-making by Patel and other experts has important implications for protocol design. The strategies of pattern recognition, rules of thumb and context should be incorporated into all elements of any decision support system as well as telenurse training and forms. The goal should be to mimic how the brain naturally solves problems in "real world" situations.

Protocols vs. Training
Telephone triage is a high-risk area of practice, primarily because nurses cannot see the patient with whom they are speaking. Thus, training and guidelines are essential to support the nurse. Relying on protocols to take the place of formal instruction can be a mistake, and over reliance on a decision-making tool can lead to mistriage.

Generally, experience and specialized training combined with strong decision support tools are the best approach to telepractice. Potential problems and misunderstandings can be averted through instruction in the correct and safe operation of the protocols and documentation form.

Brief History
Informal telephone triage is as old as the telephone itself. In fact, one of the first calls made by Alexander Graham Bell was for assistance following a battery acid burn (Grumet, 1979). In the early days, physicians were quick to install telephones in their offices, seeing that these new tools could help their practices. Initially, physicians performed telephone advice. Telephone management has always comprised a large percentage of several physicians' practices – pediatrics, Women’s Health and Family Practice specialties.

In the 1970’s, several health maintenance organizations began utilizing nurses to give telephone advice -- in the role that physicians once served. A wide variety of similar systems have sprung up over the last decade. In 1990, the term "telephone triage" appeared on Medline indexes--a formal acknowledgement of this new subspecialty.

Telepractice Formalization
In the early 70’s, telephone triage had few job qualifications -- most nurses were felt to be qualified. As the field evolved into a recognized subspecialty, managers discovered that the high-stakes, high stress work required seasoned RNs with many years of “bedside” decision-making experience. Thus, new graduates were not considered the best candidates for the task of telephone triage.

Certainly, there are exceptions to this rule. However, we know that less experience results in over triage (Patel, 1996), while increased experience results in more appropriate decisions. The new RN, with little or no bedside decision-making experience will require time to build up these skills. Whether in the clinic, office, hospital or in the emergency department setting, five to ten year’s experience provides the foundation necessary for good decision making by phone -- a considerably more difficult task.

RNs are considered the best choice not only because they are autonomous professionals, but they are also “the lowest paid person who can safely do the job” (Schmitt, 1980). Telephone triage requires excellence in interpersonal skill or “telephone charisma”  (articulate, personable, resourceful, dedication to service). There must be a good match between the work -- high volume, high-pressure decision making under conditions of uncertainty and urgent-- and the practitioner’s temperament -- calm, mature and patient. Computer literacy is desirable.

Since the 70’s most training was “on the job”, essentially “see one, do one, teach one”. Each new advice nurse had to learn through trial and error, essentially “reinventing the training wheel” with each new employee. In the 90’s, formal training programs emerged. Currently, the best training programs have a minimum of 40 hours. Orientation addresses an overview of the field and the nursing role, the nursing process, communication aspects, history taking, interview and documentation skills, protocol use and medical legal aspects.

Two types of training and education currently exist -- in-house and national conferences. In house trainers employ a variety of training methodologies, since research demonstrates that individuals learn differently and learning happens best when all senses are utilized. In-house training techniques include reading, lecture, discussion, “shadowing”, written exercises in interview and documentation, audiotapes analysis/critique, preceptor programs and role-play of mock calls. Role-play is an excellent method to cumulatively integrate the new skills and tools (protocols and documentation form) and to simulate the actual task. Preceptors can support and counsel the new advice nurse in the first three to six months.

National conferences provide a broad perspective and opportunity to network and problem solves. Since 1994, conferences on telephone triage have provided a national forum for manager and practitioner alike to network and share experience and expertise. The final step in formal education will be accreditation -- not yet a reality -- but anticipated within the next five to ten years.

The Future of Telepractice
The future job description of a telenurse might read: “Part-time positions in high volume high tech, 24 hour, integrated telemedicine call center. RN or NP with minimum of ten years nursing and five or more year’s telephone triage experience. Eligible candidates must be computer literate, culturally sensitive and possess excellent communication skills. Requires expert level decision-making, communications and negotiating skills. Experience with telemedicine and/or telemetry required. 80-Hour full-time orientation required. Bilingual nurses (esp. Spanish) highly desired. BS/MS in Psychology or Sociology a plus. Desired specialties: Pediatric, Adult/Geriatric, OB/GYN, Crisis Intervention, Behavioral Health, or Case Management.”

Already, some nurses work from home-based systems. However, in the future, many will practice from large national call centers. In these “mega call centers”, nurses may serve as the coordinator from the “hub” of an integrated computer and phone system -- a network of phone-based health care services, calls ranging from crisis level to information-based and from telemedicine and internet based service to “POTs” -- “plain old telephone” lines.

As coordinators, nurses may manage and triage calls to Poison Control, 911, Suicide Prevention, the emergency department, office, home health, case managers and community hot lines. Rotation through these crisis level call centers will be commonplace as nurses learn how these agencies operate and manage calls. As part of the “community sentinel system” advice nurses will both monitor the community and alert appropriate agencies, such as 911, public health agencies or EDs, during community-wide seasonal health threats, such as heat waves, disease outbreaks and related media scares.

As case managers, they may routinely perform disease management by phone, pro actively managing populations of callers with CHF, asthma, and diabetes. All staff will be cross trained, as nurses monitor blood pressures and weights for home health clients, uterine activity for high risk mothers and intermittent cardiac arrhythmias to identify, diagnose and treat some cardiac problems.

Telehealth will subsume telephone triage, with the addition of visual display of patients from home, telemonitoring and internet access by both nurse and patient. For example, home health assessment will include heart, lung, and bowel sounds, blood pressure and pulse readings, gait, neuro exams and mood assessment.

Training programs will be a minimum of 40 hours and will include online training based on “real life” problems. Sophisticated training programs will provide patient call simulations from off site and nurses utilizing telemonitoring and electronic protocols.

Because telephone triage is an international phenomenon, conferences of the future will be international. Soon, experts from the Europe, the United Kingdom, Australia and South America will converge to network and share solutions and expertise from a multi-national and multicultural perspective.

Accreditation in the future will likely be 80 hours of formal training through a regulatory agency, like AAACN. Core content will include telemedicine and telemetry, competency training, medical decision-making theory, legal aspects, specialized communication and negotiation training, psychology, community health systems and cultural sensitivity. Advice nurses will be experts in chronobiology, the science of how the biorhythm affects our health, prompting predictable seasonal, diurnal and nocturnal “surges” of such conditions as allergic reactions, heart attacks and strokes. Certified trainers from 911, suicide prevention, poison control and sexual assault response teams will provide specialized training as part of this program.

Resources

 * Teletriage consulting site by Sheila Wheeler
 * Teletriage consulting site by Carol Rutenberg
 * Association of Telehealth Service Providers
 * American Academy of Ambulatory Care Nursing (AAACN)
 * Nurse Triage site specializing in personalized health information and support