By Sheila Quiler Wheeler
Broadly speaking, telephone triage is a form of pre-hospital clinical care, albeit by phone. All clinical care implies a standardized approach and system components, similar to any other clinical subspecialty.
Telephone Triage Decision-Making Safety Research
The task of telephone triage involves assessing symptoms of invisible patients with a range of emergent to non-acute symptoms. As telephone triage clinicians we must insure the safe, timely assessment, and disposition of patient symptoms via the phone. Our challenge is to get the patient to the right place, at the right time, for the right reason.
In 2013, I authored a review of literature on telephone triage with a team of experts. We found that patient safety is a persistent topic in telephone triage research. Reviews of past research did not differentiate between clinicians’ and non-clinicians’ respective safety.
For example, four groups of decision makers—both clinician and non-clinician—perform aspects of telephone triage: physicians (clinician), nurses (clinician), emergency medical dispatchers/EMD (non-clinician), and clerical staff (non-clinician). We compared the four groups, reviewing studies between 2002 and 2012, looking for evidence of safety: complete systems and safe dispositions—that is, timely access to appointments.
Safety is likely related to the clinical expertise of the decision maker. While clerical staff and EMDs were not found to be safe, nurses had the highest percentage of safe dispositions, followed by physicians. While telephone triage nurses have minimal systems, traditionally, physicians have little or no training, telephone triage guidelines, or standards; frequently they do not document calls.
When compared to nurses, physicians’ practices appear to not have significantly evolved since the 1950s. Many experts believe that physicians’ practices will not likely change soon. Yet, telephone triage is rapidly growing, requiring expanded patient access and increased formalization. Thus, we believe the best approach is to focus research exclusively on nurse-staffed clinical call centers and to explore ways to improve their systems.
Telephone Triage System Research
In 2016, I conducted an informal online survey of RNs visiting teletriage.com. The survey explored RNs general perceptions of the quality and safety of system components: standards, training, guidelines, and EMR. Respondents to this anonymous survey were encouraged to be candid. Results of the 132 respondents are combined (36 were managers/administrators and 96 were staff nurses).
My purpose was to get a general idea about clinicians’ perceptions of safety and quality of telephone triage system components. Although the survey was informal and small, there were some interesting results, discussed below. Clearly, after fifty years, there is still a need for improved system components and training in telephone triage.
Type of Facility: The largest number of respondents worked in clinics and offices. It was surprising that hospitals were ranked second, followed by clinical call centers. It is unclear where exactly in hospitals telephone triage is taking place.
Populations Served: Most nurses served both pediatric and adult ages. A small number served pediatric populations exclusively.
Standards Usage: Most respondents had standards for telephone triage; the quality is unknown.
Type of Training: Most respondents had some training, with the majority having on-the-job training, and thirty-six having on-site training. Six respondents had no training. Training appears to be variable in content and quality.
Training Quality: Respondents ranked training quality as excellent: 29; above average, 43; average, 44; fair, 7; or poor, 3. Training content is unknown—whether in clinical decision-making or operation of electronic software—the first being a clinical skill and the second a technological skill.
Type of Guidelines: Respondents use electronic only, 59; both paper and electronic, 32; paper only, 33; or no guidelines at all, 8. Minimally, every facility should have at least paper guidelines.
Consistent Use of Electronic Guidelines: Respondents used electronic guidelines all the time, 49; most of the time, 36; half the time, 3; or rarely, 3.
Electronic Guideline User Friendliness: Respondents ranked electronic guidelines user friendly all the time, 15; most of the time, 66; half of the time, 7; occasionally, 2; or never, none.
EHR User Friendliness: Respondents found the EHR as user friendly all the time, 13; most of the time, 61; and half the time, 9.
Telephone Triage Outcomes
Given the conditions of uncertainty and urgency in our practice, it is concerning that malpractice cases still often involve the following failures and system error:
- Use of clinically unqualified staff to assess symptoms
- Failure to speak directly to the patient
- Inadequate preliminary assessments
- Inadequate documentation
- Inadequate training
The survey summarized above presents rudimentary evidence of existing system failures, which is defined as “Failures of systems, processes, or conditions—intended to prevent errors from occurring—that might lead people to make mistakes.” Identified system errors include “wrong person, wrong task,” “Wrong match of plan to problem,” or “Failure to use any plan” to prevent error (Institute of Medicine). What’s needed is to provide quality guidelines, quality training, or complete system components.
It is reasonable to assume that, at a minimum, safety (good outcomes) begins with using qualified staff that is supported by a complete system: What is a system? A set of detailed methods, procedures, and routines formulated to carry out a specific activity or solve a problem. Donabedian defines quality as structure and process that results in safe, quality outcomes.
Structure: Quality System Components
- Qualified staff in adequate numbers
- Training program
The Nursing Process
- Working Diagnosis
Outcomes: Safe outcomes are timely, that is, coming early or at the right time.
- At the right time
- In the right place
- For the right reason (See 5-Tier Triage)
Right Staff and Right Stuff
If a malpractice lawsuit occurs due to patient death or harm, telephone triage expert witnesses will request to review the following components of your system:
- Training materials
- Job qualifications and description
- Standards (policies and procedures)
- Call documentation (EMR)
Two initial recommendations based on these research projects are:
- Clinicians should manage symptom-based calls: Using non-clinicians to manage symptom-based calls may produce an unintended consequence of error. In the interest of safety, we recommend that nurses or other clinicians take symptom-based calls directly.
- Improve current nurse-staffed clinical call centers: While more complete, clinical call centers still need improvement: formal standardized training and improved call center and practice standards. To date, no independent peer-reviewed research has shown electronic decision support software to be reliable or valid. Some researchers have found that nurses are not actually using the electronic guidelines as instructed. The study indicated that, even when using guidelines, nurses still under referred 10 percent of patients.
Since 1984, Sheila Quilter Wheeler, RN, MS has pioneered the field of telephone triage through guideline development, conference development, research, expert witness, and consulting work. Her company, TeleTriage Systems, is located in San Anselmo, CA