Nurses prepare for the future of telephone triage
Specialized training and good judgment are key ingredients in working telephone triage, as nurses become more and more at risk for legal action.
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Dedicating a highly skilled, experienced registered nurse to work the phone lines in a triage center is an expensive undertaking, and one that is often hard to justify to cost-cutting managers. But telephone triage experts believe good advice is worth its weight in gold-even if it is difficult to measure.”We have not done a stellar job in demonstrating our value,” said nurse consultant Carol Rutenberg, MSN, RN. “When there’s no revenue generation, it looks like money is pouring out.”But in some cases, statistics are being measured and showing that telephone triage is cost effective.At the Family Health Plan Cooperative, a Milwaukee HMO, emergency room visits average 100 per 1,000 members, compared to the national average of 146 ER visits per 1,000 members, said Margot Peters, JD, MSN, RN, a teletriage nurse and nurse consultant at the HMO.”We really do believe it’s a cost-effective way to provide care,” she said.~ Mary Ann Hellinghausen
|The front lines of health care have been spliced with fiberoptic cables. Telephone triage, where voices in need connect with medical advice, is an industry filled with busy signals as healthcare providers search for better ways to manage large numbers of patients – and help them avoid expensive, unnecessary hospital visits.Experts say nurses, who have performed teletriage over the phone since a patient first called in for medical advice, need to guide the industry so it remains dedicated to patient care as it evolves with the emergence of new technologies.”I think we’re going to see a real explosion in interactive health, and we’ll see more regional-type hubs [for triage],” said Holly Russo, RN, director of outcomes research for Advance Medtronix in Austin, Texas, and a former health telecommunications policy analyst for the U.S. Department of Commerce. “But it’s all going to twist in a different direction” as technology expands telephone triage with innovations such as sensor monitors that can relay a patient’s condition through visual displays.As the future of telephone triage emerges, a return to the basics may be the easiest way to ensure a smooth transition to new technologies. That means setting protocols that will ensure patient safety, according to telephone triage experts.Protocols firstThe risks involved in remote triage are great, highlighting the need for qualified staff and the use of protocols, according to Carol Rutenberg, MSN, RN, a telephone triage consultant in Hot Springs, Ark. “If you’re not using protocols, you’re begging for bad outcomes. And you’ll be in an indefensible position.”Rutenberg believes, however, that telephone triage nurses should be able to have the autonomy to downgrade or upgrade protocols. “If we’re not in a position to exercise judgment, why do we have RNs doing [telephone triage]?” she said.Sheila Wheeler, MS, RN, of San Anselmo, Calif., said legal action involving teletriage has escalated as “attorneys have discovered it’s an area of risk [that’s] coming back to haunt nurses.””In some cases, nurses are not using protocols intelligently, if at all,” said Wheeler, who has written books on telephone triage. “They think of protocols as security blankets, but protocols are not enough. You need to have specialized training and good judgment.”Wheeler described a case in which the mother of an infant who cried constantly said she didn’t think the baby was getting enough breast milk, so the nurse advised starting the child on rice cereal. Two days later, the baby was diagnosed with meningitis.”The mom jumped to conclusions and the nurse jumped with her,” Wheeler said, adding that the nurse should have made a more comprehensive assessment of the baby’s symptoms. “In most legal cases, if nurses had taken more time and done a better of job [of assessing the situation], the mistake wouldn’t have happened.”Off the hookBut protocols for nurses are considered useless if nurses aren’t the ones giving medical advice over the phone.”The vast majority of telephone triage is taking place in informal settings [such as a physician’s office],” that can’t afford to hire RNs who are dedicated to the phone,” Rutenberg said. “In my 30 years as a nurse, telephone triage is the most sophisticated nursing I’ve ever done.”If nursing doesn’t get organized and see telephone triage as an important emerging industry, I’m afraid it will go in the wrong direction. It’s critical for people involved in telephone triage to be verbal, visible and involved with their state boards of nursing and professional groups.”Experts maintain that highly trained, experienced nurses should handle patient care over the phone, an expensive undertaking that some triage systems avoid by using untrained – maybe even unlicensed – staff.Quality controlSo what does it take to be a highly trained triage nurse? At least five years’ experience in clinical nursing (many call centers require 10 years), and the ability to ask the right questions, Rutenberg said. Nurses also must establish trust with the patient. The use of auditory cues, such as recognizing the sound of shortness of breath, knowledge of the patient’s distance from care, and an ability to draw a mental picture of the patient’s situation, also are helpful, Rutenberg said.To promote the professionalism of telephone triage nurses, a certification exam is being designed and should be available by 2001, Wheeler said.Another issue that will benefit the advancement of technology in telephone triage is how medical advice will be offered across state lines. Many experts believe multistate licensure – which has been adopted by 11 states and allows nurses to dispense medical advice to anyone involved in the compact – is inevitable.”Multistate licensure will make telehealth safer for the consumer and provide better access to care,” said Carol Becker, MS, RN, director of clinical development and research for McKesson HBOC Access Health Group, based in San Francisco and Atlanta.”Telephone nursing is here to stay,’’ Rutenberg said. “It’s certainly a good alternative to managing large numbers of patients safely, efficiently and with high quality.”|