What is Telephone Nurse Triage?

By Sara Courson, BSN

Spring, 2004

Telephone triage is only a small part of the telehealth movement that is sweeping across the globe.  Telehealth refers to providing health administration, patient and professional education, or even long-distance clinical health care through telecommunication technology.  Technologies are improving and expanding at great speeds and are offering healthcare providers economical and efficient ways of delivering timely medical education and support to clients at home.

Telehealth technology is being used to connect several different client populations with healthcare services.  Video conferencing and home monitoring systems are just a few examples of the new technology.  Video conferencing can be done for certain patients with chronic illnesses that need frequent follow-up from their homes.  Some advanced home health systems, the more expensive ones, can monitor blood pressure readings as well as blood glucose levels from a home terminal.  In particular, rural health settings can benefit from this advanced technology.  Telehealth can extend the capabilities of a handful of healthcare professionals to reach clients over a large geographical area, which would be impractical by a more traditional method of healthcare delivery.

Telephone triage is quickly becoming one of the most common uses for telehealth technology.  Nurses have been dispensing advice over the phone as long as phones have been around but the new computer-aided systems and equipment that are available now are amazing.  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.

Telephone triage is done at many levels.  For example, many healthcare facilities have their own triage systems for their communities.  Insurance corporations are offering their clients triage services to help determine the level of healthcare intervention that is needed and where or if the client needs to seek medical attention.  Physician offices have traditionally offered nurse advice lines for patients and families who are seeking answers to medically oriented questions.  In addition, many new forms of triage are developing with the advent of new technologies.

Telephone triage is also known as demand management in the managed care arena.  Many HMO's are requiring patients to call into a triage center to discuss their symptoms before they are permitted to go to the emergency room for after-hours medical treatment.  According to some of the nurses currently working in call centers, it seems that the wave of the future may be for all medical providers and healthcare facilities to insist on triage before treatment is sought in order to ensure reimbursement.  This process is already being implemented in some organizations.

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. 

Many call centers function in a similar way to a switchboard service.  Nursing personnel are located in a central area, or in smaller "pods" containing the telecommunications equipment.  Telephone headsets are used and each 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, etc.  The algorithms are designed to assist the nurse in completely and accurately assessing the client, without jumping to conclusions given certain symptom sets. 

One of the difficulties facing inpatient nurses who do telephone triage is that they tend to assume the worst when it comes to interpreting the complaints of the client.  Triage nurses must take into consideration all the different elements that are affecting the client and his or her decision to seek medical attention.  Using the algorithms ensures that the triage nurse considers various aspects of the current complaint.  When certain symptoms are highlighted in the program, the nurse is prompted to ask further questions to guide her to the appropriate decision, taking into consideration all the various possibilities.

For example, if someone asks about a child with a fever, the nurse would be prompted to ask certain questions regarding onset, duration, the child's medical background, and any treatment currently being given.  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 on-line 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. 

Each call center has its own orientation process.  Most centers will start a new employee by having her spend a certain number of hours simply listening to the preceptors as they handle their calls throughout their shift.  A dual headset is used so that the new employee can hear how the nurse assesses the client over the phone and obtains the needed information.  The trainee then observes the nurse as she or he completes the documentation and dispenses the appropriate advice and follow-up instructions.

Computer literacy is also a major portion of the orientation.  Prior proficiency with computers, especially Windows-based applications, is a benefit to the nurse interested in becoming a triage nurse.  Those call centers using computerized programs for triage will require a new hire to spend several hours becoming comfortable with the programs.  Triage nurses must be able to easily maneuver through a computer program while talking with a patient on the phone and entering all the required data.  These skills take some time and practice to acquire.

If the call center offers both phone advice lines and telephone triage, the new hire will usually start with answering the advice line, which is more general and non-urgent in nature.  Once her skill and confidence level increases, she would then be ready to answer the more demanding calls involved with triage.  If a call comes in that the nurse feels she cannot answer, the caller is put on hold, and consultation with another nurse on staff takes place.

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 your appeal as 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.

Salary Information: Salaries depend on the institution for which one is working.  Some facilities hire on the lower end of the range for nursing jobs in the geographical area in which the position is offered.  On the other hand, other institutions offer a higher salary than outpatient nursing in their area, and comparable to inpatient staff nurses.  Most call centers provide full benefits for nursing employees including shift differential and insurance policies.  For those who are looking for a change from bedside nursing, the salary difference might be well worth it.

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.

Check with local healthcare facilities to see if they offer an advice line, Ask-A-Nurse^TM program, after-hours triage program, or physician referral program.  Many facilities offer advice lines of one form or another, depending on their resources and the needs of their communities.  Physician's offices, hospitals, long-term care facilities, clinics, veteran's hospitals, and insurance companies are all examples of institutions to research for possible employment opportunities.

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.