What is Telephone Nurse Triage?

By Sara Courson, BSN

Telephone triage is more than answering health questions. Telephone triage nurses must be able to assess a client’s health concerns without the advantage of visual inspection or face-to-face interaction. Nurses must rely on their communication skills, knowledge of disease processes, and normal growth and development for all age groups in order to ascertain an accurate understanding of the client’s symptoms. Triage nurses must have impeccable listening skills to notice the non-verbal clues the client is giving regarding pain, anxiety, fear, and level of comprehension.

There is a difference between health advice lines and triage lines. Health advice lines are usually a community-based information service that offers answers to general healthcare questions. Triage services are typically offered by healthcare facilities and are used in association with a physician’s office. They take calls from patients who are attempting to contact the physician or other healthcare provider after usual office hours, for specific health concerns, or urgent medical needs. The triage nurse must assess the severity of the patient’s symptoms and then guide the patient to the appropriate level of care.

Triage nurses do not diagnose clients over the phone. The function of the telephone triage nurse is to determine the severity of the caller’s complaint using a series of algorithms developed by a coordinated effort of physicians and nurses, direct the caller to the appropriate emergency services if necessary, recommend the suggested medical follow-up based on their assessments and established triage protocols, and provide health information. This process is called the “disposition” in triage settings.

In addition to addressing specific caller complaints, many tele-nurse programs also book appointments for the physicians’ offices with which they are associated, both during and after office hours. Furthermore, some programs review and triage the lab/x-ray results received in the office and notify the medical practitioner of critical values. Making follow-up calls to high-risk patients may also involve allowing the triage nurse to assess changes of status or to ensure that the patient sought the appropriate treatment. In addition, there are interpretation services offered for non-English speaking and hearing-impaired clients.

Each triage nurse has a computer that is programmed with triage algorithms or the algorithms may be in a manual. The algorithms are programs that provide the nurse with pathways to follow as she or he investigates the patient’s complaint. Demographic data is assessed also, such as age, gender, height, weight, and so forth. The algorithms are designed to assist the nurse in completely and accurately assessing the client, without jumping to conclusions given certain symptom sets. Symptoms are assessed by asking questions starting with the most acute and working down in severity to the least acute, in order to determine the need for emergency intervention. Depending on the answers to these questions, the program then guides the nurse through specific pathways to obtain the needed information and help the nurse to determine the course of action, based on the various possible causes for the current problem. Thorough documentation is part of the process and must be completed just as diligently as charting on bedside procedures.

Most computerized systems make use of an electronic chart, which may be an ongoing record for each patient entered into the system. When a patient calls, his or her chart is electronically retrieved and the medical history, diagnoses, and previous records are displayed. Approaches vary by vendor, but the capabilities are increasing every day. Some systems have the ability to incorporate x-ray and lab results with the electronic record as well as notifying the patient’s primary physician, via email, of the nature of the call and the recommendations given by the nurse in order to expedite continuity of care and ease of follow-up.

The computerized programs used within triage centers are purchased from an independent vendor or established by the management of the center. Protocols must be carefully developed in order to ensure accurate and timely information, corresponding with the philosophies of the medical practitioners that are being supported in the community. Even programs purchased through a vendor must be tailored to reflect the advice of the local physician groups. Standing orders for medications or specific instructions for various patient complaints can be built into the system according to physician preference. The protocols are carefully developed from established standards and documented interventions. Associations such as the Emergency Nurses Association and American Nurses Association have recommendations for use of triage and stress the use of researched standards in order to deliver safe and prudent advice.

Educational Requirements: Registered nurses at all educational levels are able to do telephone triage. Experience is the major requirement, but there are classes available to enhance telephone triage skills. Seminars are offered nationally by experts within the triage field as well as online continuing education courses. Many of the vendors who provide the computerized programs for facilities also have educational offerings to help nurses stay current and increase their working knowledge of the system’s capabilities.

Specialty Certification: Certification is not usually required for working as a telephone triage nurse. However, many employers see this as a reflection of competency and professionalism that then increases the appeal of a job candidate. The National Certification Corporation now offers certification in Telephone Triage. As with most other certifications, there are certain eligibility requirements, such as current licensure, 2000 hours of specialty experience, and recent employment in the specialty. The tests are offered by pen and paper, or computer.

Entry Advice: Nurses who enter the triage field must have excellent communication skills, critical thinking skills, the ability to handle stressful situations, the capacity to function independently, have varied clinical experience, and the ability to document meticulously. There is no one clinical background that prepares nurses for a position as a triage nurse.

Most sources state that a minimum of five years clinical experience is needed as well as a current staff position. Occasionally, call centers may require that nurses have specialty certification for the areas in which they will be working, such as pediatrics, geriatrics, obstetrics, and so forth.

Not every nurse will thrive in the telephone triage setting. Nurses who are used to being on their feet, having face-to-face interactions with patients and peers, using technical nursing procedures and skills, as well as those with little or no computer usage, might find it difficult to adjust to the triage environment. A typical shift at the call center will involve mostly sitting, looking at the computer, talking, making independent decisions, and documenting electronically. This is a prime example of a non-traditional use of nursing skills. Don’t be fooled into thinking that triage nursing is an undemanding job. On the contrary, a shift at the phone on a triage line can be more demanding than a day running up and down the medical/surgical floors. The major difference is that the delivery of top-notch nursing care must come without the advantage of seeing or touching the patient. Skills rest on the ability to listen, process information mentally, and communicate effectively with the client.

Sara Courson has 15 years experience in Obstetrical nursing. She wishes to inform and inspire nurses to learn more about the various employment opportunities within the nursing profession, in addition to the traditional roles nurses have been involved in over the years.


Telephone Triage Vendors:

Here is a list of vendors who have integrated telephone triage protocols into call center software.

Epic Systems Corporation
5301 Tokay Blvd
Madison, WI 53711-1027
608-271-9000
www.epic.com
Nurse triage helps users deliver care advice over the telephone. Access to medical records, practice management tools, and popular clinical protocols (e.g., Dr. Barton D. Schmitt’s pediatric telephone triage protocols and Dr. David A. Thompson’s adult triage guidelines) guide nurses efficiently through the triage process. As users assist patients, the system automatically creates the appropriate documentation, generating context-specific alerts and offering access to scheduling information along the way.

HealthLine Systems, Inc.
17085 Camino San Bernardo
San Diego, CA 92127
Richard D. Stier, Vice President
800-733-8737
RStier@healthlinesystems.com
The Sharp Focus Personal Health Management System incorporates adult, pediatric, and women’s health symptom-based nurse assessment protocols. The Cleveland Clinic Foundation protocols are structured, text-based protocols, founded upon the principles of emergency nursing medicine, to facilitate the assessment of patient symptoms, and to determine the appropriate course of care. The protocols allow RNs to screen for priority and emergent symptoms, utilizing a nurse’s clinical judgment, as they progress through care choices spanning options from immediate emergency room referral to home care instruction.

LVM Systems
4262 E Florian Ave
Mesa, AZ  85206
480-633-8200
info@lvmsystems.com
The triage module in LVM’s E-Centaurus software uses the protocols authored by Drs. Barton Schmitt and David Thompson. The software fully supports triage nurses – making their jobs easier and more efficient. Advantages include customization, frequently used protocols, medication/dosage calculator, quick-entry screens, question or advice-specific comments, on-call schedule automation and analysis and QA reports

McKesson
CareEnhance Systems
Phoenix, AZ 85012
800-345-3342 x1230
Ask-A-Nurse is a licensed program of McKesson Health Solutions. Healthcare providers can license Ask-A-Nurse and provide nurse call center services in their community. This includes telephone triage, nurse advice, and physician and service referrals. Organizations choose to have exclusive or non-exclusive use of the Ask-A-Nurse name within their licensed service area.


Telephone Triage Service Bureaus:

There are several call centers which provide telephone triage on an outsource basis or for a fee to hospitals, clients, individual practices, and medical answering services.

Carenet
11845 IH-10 West Ste 400
San Antonio, TX 78230
800-226-620
www.callcarenet.com
info@callcarenet.com
Carenet provides telephone triage service, shared decision support, advocacy, pharma, and remote device monitoring support services 24/7 from its state-of-the-art medical call center facility in San Antonio, Texas.

Fonemed, LLC.
2975 Broadmoor Valley Rd, Suite 201
Colorado Springs, CO 80906
888-366-3633
info@fonemed.com

McKesson
CareEnhance Services
Broomfield, CO 80021
800-829-2550 x6361

Team Health
1431 Centerpoint Blvd Ste 110
Knoxville, TN 37932, USA
888-203-1118
“Our services are customizable and are delivered with a timely, cost-effective, and patient-focused approach, enabling us to offer our clients a 24/7 extension of their healthcare services.”

The Beryl Companies
3600 Harwood Road
Bedford, TX 76021
800-833-2000

[From Connection Magazine November 2005]

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