The role of telephone triage nurses will evolve quickly in the coming tele health era. Telephone triage requires expert skill in pattern recognition: identifying emergencies, estimating and ruling out urgencies, and interpreting patient responses. Telenurses will also serve as knowledge workers and medical informaticists.

1. *
Telephone Triage Nurse:
Clinical Decision Maker,
Knowledge Worker,
Informaticist
Sheila Wheeler, RN, MS
TeleTriage Systems
www.teletriage.com
© 2014 TeleTriage Systems

2. *
Telenursing Defined
■ Telephone Triage is
■ Getting patients to the right level of care at
the right time and right provider.
■ “Timely Facilitation of Patient Access”
■ “The safe, effective and appropriate
disposition of health problems by phone by
clinicians”- Wheeler, 1993

3. *
Telephone Triage:
Identity Confusion
■ What Telephone Triage is not:
■ Symptom Diagnosis
■ Practicing medicine via phone
■ “Gatekeeping”
■ Health Information Hotline
■ Telemarketing Service
■ Physician Referral Service
■ Physician Message-taking/Answering Service
■ Crisis Hotline

4. *
Telephone Triage Guideline:
Evolution
■ 1970 No Protocols
■ 1980 Protocols for Adult and Pediatric
■ 1993 First Telephone Triage Training Manual
■ 1995 - Current
■ Neuro Telephone Triage Advice, Selwa et al (American Assoc of Neurology)
■ Telephone Nursing Practice in Adult Urology, Mueller et al
■ Telephone Triage for Breastfeeding, Cadwill
■ Telephone Triage for Home Care, Narayan
■ Telephone Triage for Obstetrics & Gynecology, Long & McMullen
■ Telephone Triage for Oncology Nurses, Hickey, Newton
■ Telephone Triage in an Ophthalmic A&E Department, Marsden.
■ Telephone Triage, a Manual for Orthopedic Nurses, Smith

5. *
Telephone Triage Research
■ Nurses are as safe and proficient as physicians. NEJM
1978, Perrin and Goodman
■ Nurses use pattern recognition and context, 1995,
Lephrohon & Patel.
■ Common Errors:
■ Failure to collect key info, spend enough time, no standards of practice
■ Second Guessing or Over reliance on Caller
■ Stereotyping: Clients or Symptoms
■ Acting on Assumptions: “Non Diagnostic Diagnoses”

6. *
Critical Thinking Research
■ Common Pitfalls:
■ Inadequate Assessment & “Talk Time”
■ Insufficient History Taking and Documentation
■ Inadequate Training
■ Guideline Use
■ (Often related to User Unfriendly Format)
■ Over-reliance or failure to use protocols
■ “Out of Guideline Experience”
■ Using wrong Guideline or Using Guideline Wrongly

7. *
Telephone Triage Nurse Quality
■ Clinician Deficits
■ Lack of experience
■ Lack of Confidence/Overconfidence
■ Decreased Sensitivity
■ Lack of Feedback
■ Sensory Overload
■ Decision Fatigue/Discomfort

8. *
Best Practice = Risk Reduction
■ Adequate numbers of high quality
Clinicians
■ Provide Excellent Training
■ Rotate phone work/frequent breaks
■ Pre-Triage Calls/Patient Brochure
■ Provide Feedback Mechanism

9. *
Telephone Triage:
Best Practice in Hiring
■ Schmitt’s Rule of Thumb:
■ “Lowest paid person who can safely do the job”
■ Qualifications
■ 10 year’s clinical experience
■ Life experience/Parenthood/Maturity
■ Good judgement (Critical Thinking Skills)
■ Excellent communications skills (Phone Preview)
■ “Telecharisma” (Nordstrom's, ED, “Car Talk”)

10. *
The Expert Telenurse
■ Benner’s Domains of Nursing Expertise:
■ Helping
■ Unacknowledged Case Manager
■ Diagnostic/Monitoring
■ Pattern Recognition, Urgency Estimation, Ruling out Urgent
symptoms, Interpreting patient responses.
■ Crisis Intervention: Identifying Emergencies
■ Teaching/Coaching
■ “Knowledge Worker, Medical Informaticist

11. *
Critical Thinking Skills
Nurse must determine whether
■ a problem exists
■ a potential problem exists
■ the patient is handling it well or not
■ the problem needs further evaluation
■ the problem sounds serious
■ the problem is urgent or emergent
■ Adapted from Yura and Walsh (1978)

12. *
Telephone Triage Research:
Critical Thinking Skill
Critical Thinking/Decision Making Requires
Time
■ Inadequate Time = Inadequate Data
■ “Under time pressure, people use less
information to make decisions, which are often
suboptimal.” Vimla Patel

13. *
Telephone Triage Research:
Critical Thinking Skill
Critical Thinking Requires Time
■ In the space of one call the nurse must:
■ Multi-task
■ Listen, Talk, Empathize, Write, Teach, Read, Analyze,
Problem Solve, Make Decisions
■ Manage High stakes Population
■ Veterans = High Risk Populations. Domestic Violence,
Suicide/Homicide
■ Meet Conflicting goals
■ Goals: Administrative, Patient, Provider, Own

14. *
Telephone Triage Research:
Critical Thinking Skill
■ Experts use “Rules of Thumb”
■ A method or procedure based on experience
and common sense.
■ A general principle regarded as roughly correct
but not intended to be scientifically accurate
■ Cardinal, Age, Symptom, Trauma-Based

15. *
Telephone Triage Guideline
Controversies
Philosophical Divide in Telephone Triage
Decision Support vs.. Decision-making Tool
■ Algorithms vs.. Pattern Recognition Models
■ Bottom Line: Expert Clinician Brain
■ Guidelines remind us of info we have once
known, but may have forgotten

16. *
Telephone Triage
Guideline Limitations
■ Guideline Inadequacies
■ Inflexibility (Strict Algorithms)
■ Bias (previous exposure to other guidelines)
■ Flaws (overly specific, deterministic, diagnostic)
■ Failure to train nurses to perform thorough
assessment prior to consulting guideline

17. *
Documentation:
Integrated Nursing Process
■ Assessment: Problem/Patient History
■ Diagnose: “Working Diagnosis" or
“Impression”
■ Treat: Advice per guideline name
■ Evaluate: Teach patient self evaluation

18. *
Telephone Triage Best Practice:
Disposition Clarity
■ “Duty to Terrify” (Tennenhouse, 1993 )
■ Best Practice: Five Tier Triage
■ Level of Care/Time Frame/24/7 Place of Treatment
■ Acuity Boxes
■ Overlapping, flexible
■ Conservative
■ Limit Disposition options: Keep it Simple

19. *
Telephone Triage:
General Reminders
■ TALK DIRECTLY TO THE PATIENT
■ Assess Early, Often and Aggressively
■ Use Guidelines as the finishing touch
■ Select the guideline for:
■ the most serious symptom
■ the symptom most likely to lead to appointment

20. *
General Reminders
“What people vaguely call common sense is
actually more intricate than most of the
technical expertise we admire.”
Marvin Minsky, Founder of the Artificial
Intelligence Movement