How Telehealth Nurses Can Use Triage Protocols to Address All Three

By Ravi K. Raheja, MD

Since COVID-19 restrictions have been eased, this fall is already experiencing a surprising surge of respiratory syncytial virus (RSV) in conjunction with flu and the common cold. Telehealth nurses have experienced a roughly 20 percent increase in patient call volumes and winter hasn’t even started.

While RSV symptoms are typically cold-like in appearance, the virus can be detrimental to infants, older adults, and those with medical conditions that put them at higher risk for serious, life-threatening complications. Symptoms for all three of these ailments can be similar, and because health systems are already being taxed with cases of RSV, it’s important that call centers and telephone triage nurses have the tools to accurately evaluate them.

Up-to-date nurse triage protocols developed by Drs. Barton Schmitt and David Thompson can help determine which ailments patients may have and direct them to the appropriate care. These protocols aren’t a substitute for the medical knowledge of a nursing staff; rather, they serve as a guide for their patient interactions to standardize care and avoid potential diagnoses.

First, let’s review the common symptoms and complications for colds, flu, and RSV, and then explore how protocols can address all three.

Colds

Although common, colds are typically mild. They usually begin slowly, starting with a sore throat before leading to nasal congestion and drainage. Common symptoms a few days after infection include coughing, sneezing, as well as a slight fever that usually doesn’t exceed 101 degrees.

As symptoms progress, nasal drainage can change from clear to dark, and become thicker. Many patients who come down with colds find it difficult to perform activities of daily living (ADL) compared to their normal energy levels. It’s also possible that colds will lead to other complications, like sinus congestion and ear infections.

Flu

A case of the flu is more severe than a cold and has faster onset symptoms. Because sore throats and fevers are common with both ailments, they can sometimes be confused. That said, coughing and congestion are more likely to be worse with the flu, and are usually accompanied by headaches, muscle aches, general soreness, and even severe exhaustion.

In layman’s terms, a bout of the flu usually makes patients “feel rundown” for a week or longer. Complications can also be harder on the body, including sinusitis, bronchitis, ear infections, and pneumonia.

RSV

The Centers for Disease Control and Prevention (CDC) notes that, as a respiratory illness, “RSV is the most common cause of bronchiolitis (inflammation of the small airways in the lung) and pneumonia (infection of the lungs) in children younger than one year of age in the United States,” and that the vast majority of all children have experienced it by the time they turn two.

Initial symptoms are usually in the form of runny noses, decreased appetites, and coughs that may evolve into wheezing and trouble breathing. Infants may also be irritable and experience apnea. Older adults with heart or lung disease, or those who have weakened immune systems, are also at risk.

Similar to colds, there is no vaccine that can prevent an RSV infection, although palivizumab is a commonly prescribed medicine for young children who are more susceptible to extreme illness, including bronchiolitis or pneumonia.

There were already expectations that flu and COVID would both see higher case counts as we continued into the fall and winter months. But many health systems are now seeing a surge in RSV cases, and MassLive notes how this has pushed some of them to delay elective procedures for children to conserve available beds.

One doctor said that you typically have “hand-foot-mouth in the summer, RSV in the winter, [and] flu in the winter,” but that de-masking has now allowed all of them to spread sooner, and “with a vengeance.”

With RSV season here early, it can be difficult for parents (especially new ones) to evaluate potential cases in their children—not simply because the symptoms are similar to other respiratory viruses, but because their children aren’t able to verbalize what hurts.

Telephone and telehealth triage nurses—who are trained on how to obtain information about physical symptoms that they can’t see—rely on Schmitt-Thompson protocols to evaluate these symptoms and select the best dispositions for care.

Protocols

These protocols are considered the gold standard for telephone triage because they cover symptoms for infants, children, and adults, including concerns about colds, the flu, and RSV. They do this by offering a decision-tree to nurses to identify and evaluate patient symptoms, which then determines where those patients should receive care—either from themselves at home, from a primary care physician, or a medical professional at an urgent care or emergency room.

These protocols are ideal for several reasons:

• All calls are standardized and treated with the same procedures.
• Patient needs are evaluated in the appropriate windows of time.
• Patients are guided to the correct care providers, which means less chance for delayed care, potential health complications, or overcrowded ERs.

When selecting the appropriate protocol for cold, flu, or RSV, the best triage nurses know that you always give the highest acuity—or the safest outcome—for the patient.

Ravi K. Raheja, MD is the CTO and medical director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. They have both daytime and after-hours versions available and offer intuitive telehealth and telephone nurse triage software that uses these protocols to document all patient interactions and share that information securely with providers.

By Ravi K. Raheja, MD

How do you ensure patient care quality when it comes to nurse telehealth triage? Whether you use an outsourced nurse triage service or want to license software and use your own team, follow this checklist when addressing every patient caller.

Not only do these important items minimize liability with remote care, but they also ensure a high quality of care for patients and a decrease in overall healthcare costs. We’ve seen firsthand how successful these items have been in our own nurse triage call center, which is why we want to share them with you to improve your own patient health outcomes.

Develop Detailed Nurse Triage Training

To be effective at telehealth triage, nurses must remain focused on each patient’s needs, obtain the appropriate information about their symptoms, know how to handle difficult calls, and document all information thoroughly.

At TriageLogic, we use a 10-step approach to training nurses, which can be found in our learning center course: “Critical Steps to a Triage Call.” You can also read a related article on training triage nurses.

Broadly speaking, when it comes to triaging patients over the phone, nurses must remember to smile, show empathy, and remain calm and confident while they are addressing patient questions and concerns. They must also use three types of listening—active, reflective, and empathetic—to fully understand each patient’s symptoms and guide them to the appropriate care.

Along with the potential for angry or distressed callers, triage nurses must also know how to handle patients whose symptoms call for emergency services.

Use National, Standardized Protocols

Nurse triage protocols developed by Drs. Schmitt and Thompson are the gold standard for patient care quality. When integrated with nurse triage software, they provide the most intuitive means of establishing caller dispositions by using yes/no questions to determine symptom severity.

A group of independent medical professions review these protocols annually and update them during important health-related events (like the COVID pandemic).

Give Answering Service Operators Their Own Protocols

Answering service operators (ASOs) are the first people to interact with callers on a nurse triage line. Their purpose is to greet patients and ask them about why they’re calling.

This helps identify urgent versus non-urgent issues and passes each caller’s request along to the right triage nurse. However, it’s become clear that ASOs also need their own protocols to avoid delays in patient care.

Why?

ASOs don’t always ask detailed questions. For example, if a patient calls for a medication refill, the ASO should verify if the patient has also started to experience any withdrawal symptoms, rather than simply assume the request is non-urgent.

Establish Average Patient Callback Times

When a call comes into an ASO, they will pass those caller requests along as emergent, urgent, or non-urgent. Each of these groups come with different requirements on how soon triage nurses should call them back.

A quality nurse triage program should have established time limits. Sticking to these time limits is vital to patient care quality.

For emergent, that’s five minutes or less. Urgent requires fifteen minutes or under. And non-urgent should be within thirty to sixty minutes.

Staggering calls in this manner not only prioritizes patients based on severity, but it also avoids overwhelming your triage line depending on how many nurses you have scheduled.

Record Calls for Quality Assurance

Recording your nurse triage calls is an important part of any quality assurance program. Doing so keeps your nurses accountable and less likely to deviate from using the Schmitt-Thompson protocols.

It also mitigates liability against your nurses. In case of a poor health outcome, these records corroborate the actions a nurse took, the reasons why, and whether those were correct.

Finally, recorded calls provide oversight and identify potential training needs. Evaluating them will indicate whether a nurse is struggling in a particular part of the triage process and allow managers to create opportunities for improvement.

Implement Secure Texting

Secure texting is an HIPAA-compliant option that allows nurses to chat with doctors without having to download an app or additional software. Nurses send messages to doctors’ phones over browser encryption, and doctors are required to click a link to acknowledge each message before accessing patient data.

This ensures patient confidentiality and speeds up responses from doctors depending on the severity of each patient’s symptoms—all of which leads to greater patient care quality. All messages are then documented in the patient’s file for reference.

Ravi K. Raheja, MD is the CTO and medical director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. Their comprehensive solutions include integrated mobile access and two-way video capability.

Contact them if you have questions regarding any of the items from the above checklist or you’d like to discuss how to implement them within your own nurse triage.

By Ravi K. Raheja, MD

Patient phone calls, and questions about whether symptoms require an office or emergency visit, are part of every busy medical practice. However, how do you train nurses to ensure that they give the appropriate care advice every time, while documenting caller information, symptoms, and dispositions?

If your team wants to decrease liability on these calls, implement software with medical protocols that document all this information. Choose a solution that employs time-tested protocols. This helps ensure each patient caller is directed to the appropriate level of care in an appropriate window of time, regardless of when they call.

Effective triage software is an easy-to-use solution for nurses that includes standardized protocols to address any patient symptom. It also includes thorough documentation with timestamps and the ability to customize triage and care instructions based on the needs of the practice. The information should be integrated with your EMR or able to be simply copied to an EMR file, ensuring continuity of care.

Documentation

When it comes to avoiding liability as a triage nurse or healthcare provider, documentation is everything. Consider the following example of a doctor who took a patient’s call while out of the office. He couldn’t notate his care advice to the patient in their chart. In fact, the only option available to him was to scribble his notes on a napkin.

That patient went on to experience a medical complication, then subsequently sued the doctor by disputing what the actual care instructions were during their call. Thanks to that napkin though, the doctor had proof of what he’d said. Thankfully, nurse triage software is far more thorough.

Standardized Care

Seek a solution with protocols that are easy to follow, are updated regularly as new healthcare issues develop, and can be customized with instructions specifically for your practice.

In turn, this ensures that nurses are prompted with the best questions to ask patients based on the severity of their symptoms and allow those nurses to document their thought processes as they triage each call. With this, all their interactions are recorded and easily accessible for reference.

The results? Nurses can shift their attention to their patients, and patients receive the correct outcomes, no matter which nurses they speak with. Another advantage is that all incoming calls receive the same quality of care or advice regardless of which nurses answer them.

Patient History

Along with symptom severity, effective triage software allows nurses to record relevant patient history so that their dispositions for care are based on all their potential health factors. Nurses must be mindful of addressing callers objectively, avoiding stereotypes, and using their listening skills to evaluate symptoms in their entirety.

Timestamps

Triage software should include timestamps for pivotal moments recorded on nurse calls. These include when calls are received, when they’re returned, and when they’re completed.

Consider that the biggest threat to nurse triage is delayed patient care. As such, it’s critical that your nurses correctly address patients’ symptoms in a timely manner, advise them to seek care from the appropriate medical professionals, and have the documentation to back up their work.

Clear Dispositions

Part of the nurse triage process is providing clear dispositions and follow-up instructions. If a patient’s condition suddenly changes, a nurse’s notes should reflect this change, as well as the triage advice they offered.

When patients are referred to providers, this documentation should also be easy to share with them. If it is, those providers can address those patients immediately and maintain a continuity of care, especially when their patients’ needs are urgent.

If a patient’s health begins to deteriorate, triage software should have instructions for the responding nurse to know how to expedite assistance from a referred provider. This should include a secure texting and chat option that lets nurses contact physicians, update them on the conditions of their patients, and close the loop on care.

Conclusion

Triage software can help ensure patients are directed to the appropriate level of care in an appropriate window of time. This decreases provider liability and improves patient care.

Ravi K. Raheja, MD is the CTO and medical director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. The TriageLogic group serves over 9,000 physicians and covers over 25 million lives nationwide.

Contact them to schedule a demo and see how TriageLogic’s MyTriageChecklist solution can benefit your patient callers and their dispositions.

By Ravi K. Raheja, MD

Much like the holidays that precede them, the winter months usually see an uptick in reported mental illness. These include seasonal affective disorder (SAD), depression, and suicide, reflected in the types of patient calls received through nurse triage. Because these mental health cases demonstrate similar symptoms, it’s important that telehealth triage nurses have the tools to properly address each.

SAD

Although cases of seasonal affective disorder are known to happen in warmer months, most tend to manifest and peak during winter. Symptoms can range from mild—increased appetite, weight gain, low energy, and oversleeping—to more severe, like feelings of hopelessness and worthlessness, problems sleeping, and thoughts of suicide, reportsNIH.

Recommendations: In milder cases, being active and getting more sunlight (at least ten minutes in the morning and ten minutes in the afternoon) may be all that’s needed to improve a person’s mood, but severe symptoms warrant guidance by the appropriate mental health professional. Nurse triage protocols provide nurses with the right questions to glean information from patient callers and guide them to the appropriate care.

Depression

According to NIH, roughly 7.8 percent of US adults ages 18 and above experienced at least one major depressive episode in 2019. Unsurprisingly, depression rates were exacerbated at the start of the COVID-19 pandemic—nearly three-fold, notes Vox—leading up to our current days of “pandemic fatigue.”

Recommendations: Triage nurses recognize that there will be times that require them to act as emotional counselors before they’re able to ask patients about their symptoms. Start by training nurses on the 10 Critical Steps to Taking a Triage Call that include methods for coaxing callers into the proper states of mind to obtain the information they need.

Suicide

Perhaps surprisingly, overall suicide rates reportedly dropped over the last couple of years. It’s worth noting that these statistics do not take into consideration unintentional drug overdoses, or the disproportionate suicide rates based on race and ethnicity. Furthermore, this shouldn’t diminish the fact that suicide remains one of the leading causes of death in younger adults, both in the 15-24 and 24-35 age brackets.

Recommendations: Telehealth triage nurses can assist callers who are contemplating suicide by establishing connections with them, as this serves as the best means of de-escalation. Pulling again from the 10 Critical Steps, nurses offer sympathetic, non-judgmental assistance, acting as a positive force for these callers in order to understand what they’re experiencing.

It’s important to note that any caller who says they’re contemplating suicide is still actively seeking help.

Example

A telehealth triage nurse received a call from a retired firefighter who stated that they were planning to end their life. By acknowledging and listening to the patient, the nurse learned they were a cancer survivor, had recently been diagnosed with metastasis, and were given three months to live.

The nurse’s solution was to keep the patient calm and talking while simultaneously alerting their manager on duty, who contacted local police to perform a safety check on the patient. Thankfully, that patient was found in their car and transported to a hospital for care.

Additional Recommendations

While professional healthcare providers are necessary when it comes to severe mental illness, telehealth triage nurses still can offer simple solutions to patients with milder symptoms to help them improve their mood, boost their energy levels, and sharpen their mental focus. These can include exercising, improved diet, and reduction or elimination of alcohol.

Ravi K. Raheja, MD is the CTO and Medical Director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. Their comprehensive solutions include integrated mobile access and two-way video capability. The TriageLogic group serves over 9,000 physicians and covers over 25 million lives nationwide. Contact them today to find out more.

By Ravi K. Raheja, MD

During trying times it isn’t surprising for telehealth triage nurses to see an increase in difficult calls. When we say difficult, we refer to those that are either: about cases of abuse or neglect; from unauthorized callers; about chronic ailments or repeat callers; about complicated medical or psychosocial issues; from callers who are excessively worried, anxious, or angry; and from callers who are hard to understand or communicate with. 

Like all areas of effective nurse triage, there are ways to handle each of these calls effectively so that patients receive the proper dispositions for care. Here’s a breakdown of each type, and the best ways for triage nurses to handle them. 

1. Abuse and Neglect

When telehealth triage nurses receive calls about these concerns, they must gather as much information as possible, often using open-ended questions, especially when these calls are about children. In the US alone, approximately five children die a day because of abuse and neglect. 

Nurses must remain professional and empathetic, as this will improve their chances of obtaining that information and determining if anyone is in immediate danger. If the call is about a child, nurses will also determine whether the patient’s physician should be informed to provide additional instructions, both for the child’s immediate care and for the next steps regarding their situation.

2. Unauthorized Callers            

Some individuals call a triage line to ask about a patient whom they are neither directly related to nor have received permission by that patient to receive information about their health. How a triage nurse responds will depend on the specifics of the call.

For instance, friends and relatives who are taking care of a pediatric patient may be treated the same as though they are the patient’s guardians. But if someone calls to ask only for information about that child’s health, that caller must be referred to the patient’s actual parents.

In some cases, it may be a child who phones the triage line directly. If this is the case, the best way to handle this call is to encourage the child to hand the phone over to an adult for further discussion.

3. Chronic Ailments and Repeat Callers

There will be times when callers need extra reassurance about their medical concerns. Others may have medical conditions that are not easy to identify. Each deserves the appropriate level of empathy and attention.

For example, patients who call back about the same concern within twenty-four hours are often known as acute callers. In such cases, it is imperative that nurses make sure to use reflexive listening to talk about those health concerns and encourage the patient to seek the most appropriate level of care—whether that care is at home, from their physician, or at the ER. If no serious issue presents itself based on reported symptoms, the nurse should console the patient and encourage them to make an appointment with their doctor.

4. Medical and Psychosocial Concerns

Calls that fall into this area of healthcare often rely on three solutions.

If they’re found to be minor or acute medical concerns, triage nurses rely on the appropriate protocols. If the caller’s concerns are chronic, nurses must follow specific guidelines from the physician’s practice or the applicable protocols.

In situations where guidelines or protocols are either not available or do not cover the issue at hand, the nurse must contact the physician directly to get further instruction. If that physician is not available, the nurse may determine that the best course of action is to encourage the caller to seek advice and care from the closest ER.

5. Excessively Anxious or Angry Callers

People are at their worst when they’re scared, sick, tired, or hungry, so it’s no surprise when their health influences one or all these factors. That’s why triage nurses must always use compassion to diffuse any heightened tension from an angry caller, gain the caller’s trust and understanding, and encourage the caller to follow their instructions. Effective telehealth triage nurses should:

Listen: They focus on what the caller is saying, don’t talk over the caller, and ask them to clarify when necessary.

Relate. They show empathy to the caller’s situation. A caller wants to feel heard and understood, so nurses can offer condolences about the confusion the caller may be experiencing, the situation the caller is in, or the caller’s feelings about it.

6. Propose an Action Plan

The triage nurse should lay out instructions on what type of care the caller should seek, whether customized instructions from a physician’s practice or based on triage protocols. Nurses should use comforting terminology to remind the caller that they are there to help. 

Some examples include:

• “Based on what you describe, I’m going to assist you by following the protocols set by your doctor.”
• “I’m concerned about your symptoms, so please hang up and call 911. I’ll call back in five minutes to make sure you’re okay.”
• “I’ve noted your concerns and symptoms and will have your physician contact you to review them. I’ll ask them to call you at their earliest convenience.”

There will also be times when the patient is either not responsive to the nurse’s guidance or is verbally abusive. Don’t expect triage nurses to tolerate inappropriate behavior directed at them from a patient caller. 

In these instances, they should inform the caller that they want to help them, but that if they do not cease the abuse and calm down, the nurse will not be able to assist them any further. If the caller persists after a second warning, the triage nurse should inform them that they are hanging up and that the caller’s physician will contact them.

7. Callers Who Are Difficult to Understand

The holidays also tend to see increases in alcohol and drug use, which can influence how well telehealth nurses may or may not be able to understand patient callers who are under the influence. If those nurses can’t establish a dialogue, their best course of action—like the example above—is to ask their supervisor first, then contact the caller’s physician. If their physician is not available, the nurse should instruct the caller to go to the ER.

This may also be the case if nurses do not understand the patient’s language or if the patient has a speech or hearing impairment.

In Summary

Telehealth triage nurses will meet a wide range of patient callers, personalities, and symptoms that can influence how well they’re able to arrive at the best dispositions for care. With the right training, triage software, and triage protocols, their services will be even more effective at improving health outcomes. 

Ravi K. Raheja, MD is the CTO and Medical Director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. Their comprehensive solutions include integrated mobile access and two-way video capability. The TriageLogic group serves over 9,000 physicians and covers over twenty-five million lives nationwide.

By Ravi K. Raheja, MD

Healthcare organizations benefit greatly when their nurse triage and telehealth services use triage protocol software. This has been shown to decrease unnecessary provider spend and substantially improve patient health outcomes. 

Many prefer the Schmitt-Thompson protocols as the best method for dispositions on patient symptoms. Here’s why:

Developed by Doctors

As a pediatrician, Barton Schmitt, MD contributes to office-hours and after-hours protocols focused on child symptoms and severity. He wrote the first book on pediatric telephone triage in 1980, and currently serves as Professor of Pediatrics at the University of Colorado School of Medicine. He was also the previous medical director for the after-hours call center at Children’s Hospital Colorado.

Specializing in internal and emergency medicine, David Thompson, MD contributes to those same protocols by addressing adult symptoms. He’s published several medical articles that focus on patient satisfaction and chief complaint coding. He currently serves part-time with the faculty at Northwestern Memorial Hospital’s emergency department.

Updated in Real-Time

Schmitt-Thompson protocols receive regular updates for accuracy and relevance. Typically done by a board of medical professionals on a yearly basis, doctors can submit periodic recommendations for changes as they use them.

Protocols may also undergo updates or additions when an immediate need arises. For instance, some were developed at the start of the COVID-19 pandemic and are now on their seventh revision. When these changes go into effect, nurse call centers have access to them and can utilize them in conjunction with their triage software.

Daytime and Nighttime Protocols

Schmitt-Thompson protocols have two versions: one to employ during office hours and one for after when there is not an option to send the patient to see their doctor. 

Integration

Protocols are meant to be used in combination with a nurse’s own expertise. The software with the protocols can be integrated easily with electronic health records (EHR) or other health cloud systems such as Salesforce. This allows telehealth or triage nurses to fully document all patient interactions and synchronize that information directly to a provider’s in-house EHR. The result is a digital paper trail and stronger continuity of care.

Ravi K. Raheja, MD is the CTO and medical director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. Their comprehensive solutions include integrated mobile access and two-way video capability. The TriageLogic group serves over 9,000 physicians and covers over twenty-five million lives nationwide.