When it comes to documenting triage calls, there’s always a fine balance between effective communications and liability risk. Nurses want to—and need to—effectively communicate information and directions to patients and those who may see their notes after the call. However, triage nurses must also cover themselves when it comes to liability.
So, what elements make good call documentation? Here are three tips to make sure your calls are well documented.
Read your notes out loud and ask yourself, would this make sense to anyone else who reads it? Have I used the appropriate words? Does it have a definitive beginning and end?
2. Make Your Communication Concise
Think about what your narrative will look like to others. This applies not only to the next caregiver but six months or a year later when your instructions may face review. Are your communications direct and to the point?
3. Make Your Communication Credible
Use appropriate terminology, punctuation, and abbreviations. Make sure that others would view your documentation as written by someone who is knowledgeable. Always stick to the facts. Avoid jargon or slang. If a patient says she has a tummy ache, put that information in quotes so it’s known these were the patient’s words. Nurse triage documentation is not the place for personal views.
Every nurse wants to provide the best care, perfect care. But perfect care is not what the law requires. The law requires that a triage nurse provide reasonable care. Clear, concise, and credible documentation is always a best practice.
Heather Jarvis is the communications and client engagement specialist at Triage Logic.
Telephone triage processes are proven to improve access to care professionals, lower patient anxiety, save on ER costs, and prevent unnecessary health complications. The primary goal of the telephone triage process is to deliver safe, quality-oriented telephone triage partnered with outstanding customer service. The health, safety, and wellbeing of the patient is at the forefront of every telephone encounter.
The purpose of the telephone triage process is to assess the patient’s current signs and symptoms, concurrently evaluating their past medical history and current medications. It performs the patient assessment in accordance with protocols which guide the nurse to determine the proper triage disposition to direct care to the safest, most cost-effective solution available at that time.
To accomplish the goals of the telephone triage process, an organization needs to recruit, hire, train, and retain experienced telephone triage nurses. Two valued components that will result in quality patient outcomes are providing comprehensive, detailed orientation, as well as equipping the nursing staff with needed tools: gold-standard telephone triage protocols.
However, the final determining factor of quality phone triage lies in the training of nurses to utilize the protocol tool properly. Anyone can read a protocol. It is the knowledgeable triage nurse who applies the following attributes of enhanced assessment skills, superior judgment, prior nursing experience, and exceptional decision-making abilities to the protocol tool that results in safe, quality outcomes and cost-effective patient care.
Performing hands-on patient assessment allows the healthcare provider to visualize cyanosis, smell foul drainage, palpate an abdomen, and use a stethoscope to assess patients’ lung sounds. Telephone triage nurses don’t have such luxuries to assess patient needs. They’re limited to their ability to query and listen intently to the caller to obtain the necessary details of the patient’s medical symptoms and then direct medical care accordingly.
Successful triage nurses live by the following golden rules of the telephone triage process:
Every call is life threatening until proven otherwise.
Complete an ABCD assessment with every telephone encounter: Airway, Breathing, Circulation, Deficit (Neuro).
Assessing patients over the phone is high risk; therefore, take the callers word as truth.
Follow your sixth sense: protocols are decision support tools; nursing judgment determines outcomes.
Know your patients’ medical history and current medications.
Assess your callers as well as your patients. Be a patient advocate.
Never provide a dosage of a medication without a complete patient assessment.
Always confirm labeled dosage of a medication as well as the means in which the caretaker plans to administer the drug.
Always assess the caller’s level of comfort with the established plan of care before ending the call:
“Are you comfortable with these recommendations?”
“Now tell me what you plan to do next.”
If it isn’t documented, it didn’t happen. Use defensive documentation. Paint a picture.
Regardless of the reason for the call, always obtain a rectal temperature on an infant under the age of three months.
Document the exact mechanism of injury.
Be alert for red flags. Any time a caller uses or implies one of the following phrases be sure to clarify the underlying meaning. Carefully analyze your disposition and recommendation for follow-up care:
Grunting or moaning
Lethargic or listless
Sleeping more than usual
Just doesn’t look right, act right, or is fussy
Sleeps through a rectal temperature
High pitched cry or unusual, funny cry
History of sickle cell or immune deficiency
Caller that expresses anxiousness or numerous questions after discussing a plan of care
Patient symptoms of headache, dizziness, disorientation, nausea, fatigue, or irritability; flu versus carbon dioxide exposure
At the conclusion of the patient telephone encounter, instruct callers to call back or seek medical evaluation if current symptoms become worse or additional signs and symptoms of concern develop.
Triage nurses don’t always have to be right; we just can’t afford to be wrong. Always err on the side of caution.
Learn more about telephone nurse triage and how to implement successful triage nurse centers by downloading the free e-book: Telephone Nurse Triage Handbook
Telephone triage nurses have a more important role than ever
before. Nearly one in five U.S. adults lives with a mental illness (44.7
million in 2016), which is why many adults with mental illnesses go untreated
(60 percent according to a report from USA Today). This article addresses the
growing concerns for mental health awareness and education.
Telephone triage nurses are often the first point of contact for
those struggling with a mental illness and can help a patient recognize the
need for intervention. So, what can telephone triage nurses do to help?
Provide Accurate and Timely Triage
Telephone triage nurses are often the first point of contact for a
patient with mental health symptoms and as a result, nurses should be patient,
flexible, and have great communication and listening skills. The nurse must
combine both clinical judgment and emotional connections to assess the patient’s
situation to identify possible mental health issues. The telephone triage nurse’s
role is to obtain the most accurate medical history and assessment to rule out
medical symptoms that require immediate attention.
Remove Biases That Can Impact the Triage Process
Good telephone triage nurses always remove any biases and
stereotypes. Having preconceived notions and distinctive sets of thinking can
lead to error in the treatment of patients.
Assess the Environment
The Emergency Nurses Association recommends treating patient
agitation as if it’s “the chest pain of behavioral emergencies.” Key phrases
such as “I understand” can help place a patient at ease and give them the space
to talk to the nurse. Throughout the call, the nurse should assess the patient’s
environment and resources available to determine the most appropriate care
Not all patients will be able to accurately describe their
condition, history, medical conditions, or other pertinent information. It is up
to the nurse to decipher this uncertainty.
Assess the situation: How is the patient presenting? Is his or her speech coherent? Are
they answering questions appropriately? Hallucinating? Delusional? Rambling?
Address the whole patient: One common occurrence within
mental health care is “diagnostic overshadowing.” This happens when the focus
on a patient’s mental health diagnosis overshadows their physical health needs.
Be an advocate: Triage nurses are the first to communicate with, provide support
to, and manage patients with psychiatric or mental health issues. Acting as a
patient’s initial advocate can be life-changing for that patient
Triage nurses always have the callers’ safety in mind. They
combine both clinical judgment and emotional connections to assess the patient’s
situation and to identify possible mental health issues. Nurses need to know
the local emergency assistance numbers in case they need to reach out for more
assistance. Just talking about their problems for a length of time can help a
great deal for many callers who might be suffering from a mental illness.
Ravi K. Raheja, MD is the COO and medical director of the
TriageLogic Group. Founded in 2005, TriageLogic is
a URAC accredited, physician-led provider of high-quality telehealth services,
nurse triage, triage education, and software for telephone medicine. Their
comprehensive triage solution includes integrated mobile access and two-way
video capability. The TriageLogic group serves over 7,000 physicians and covers
over 18 million lives nationwide. For more information visit www.triagelogic.com and www.continuwell.com.
New technologies are transforming how clinicians deliver healthcare. At the same time, digital solutions alone are not enough to help patients. Incorporating some human component increases patient compliance and education, further reducing healthcare costs. Medical call centers should be adopting software and increasing the role of triage nurses to complement traditional care settings, such as the VA.
For example, digital diabetes prevention and treatment platforms connect users with support communities and health coaches who can remotely monitor chronic conditions such as weight, blood sugar, diet, and medicine intake. Thresholds and alerts can be set up to alert healthcare providers about abnormal and potentially abnormal or dangerous values. While the devices can collect and transmit data and even have a certain threshold, a medical professional still needs to interpret the data and then direct patients about the next steps based on the data and in the context of their symptoms and current health status.
Telephone triage nurses play a vital role in interpreting the data and providing appropriate follow up for patients who use these technologies. They act as the first line of screening when an alert or abnormal value is reported. They have the training to talk to patients, assess their symptoms, and determine the next best steps based on combining the data with the full patient assessment over the phone.
To assess patients and direct
them appropriately, the nurses need triage protocols. Most medical call centers
use the gold standard protocols from Schmitt-Thompson to assess symptoms. Call
centers should also incorporate robust protocol builders, a technology that enables
an organization to modify existing protocols to meet their needs and create new
protocols when required.
By using custom-developed protocols, triage nurses can assess a patient using the data received from devices with appropriate next steps for medical care. As a result, triage nurses play a significant role in this new digital era, driven by value-based care. By combining the data from devices and other sources with innovative triage technology, triage nurses can act as the bridge between patients and providers. This creates a viable monitoring solution that provides cost-effective care.
In conjunction with the custom protocols, organizations should use platforms to put in custom workflows. As an example, once a nurse has determined the appropriate level of care, they can now further direct the patient to specific care locations, referral numbers, or provide handouts via text or email. This allows the triage nurse to serve as an effective first point of contact and get the patients to the appropriate next steps on the first call.
Finally, look for companies that can provide an optional mobile app to enable patients to take advantage of increased self-service, access to customized resources, and insight into their own information.
Technology is changing the access, monitoring and delivery of healthcare. Value-based solutions are now possible to optimize patient care and decrease healthcare expenses.
Call center solutions that incorporate effective communication using telephone triage nurses, coupled with valuable wearable device data, will be able to greatly improve the level of VA healthcare services for veterans and their families.
Ravi K. Raheja, MD is the COO and medical director of the TriageLogic Group. Founded in 2005, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, nurse triage, triage education, and software for telephone medicine. Their comprehensive triage solution includes integrated mobile access and two-way video capability. The TriageLogic group serves over 7,000 physicians and covers over 18 million lives nationwide. For more information visit www.triagelogic.com and www.continuwell.com.
Telephone triage nurses play a
critical role in suicide prevention and serve as the first point of contact for
callers in need of immediate assistance. According to the CDC, 123 Americans
die by suicide every day, and for every person who dies from suicide every
year, another 278 people think seriously about it but don’t kill themselves.
As the demand for mental health
services grows, practices are turning to outsourced telephone triage call
centers to support their practices. Call center triage nurses trained in
treating patients with mental illnesses are better prepared to intervene and
often alleviate lengthy interruptions to the normal call flow of a practice.
In moments of crisis, connecting
with a trained triage nurse can deescalate the suicidal crisis and provide
immediate help. It is never easy to talk about suicide, but it is crucial for
triage nurses to be comfortable talking about suicide in the same way they talk
about chest pain. How they handle each call can be life-changing for the
Triage nurses need to find a connection with the patient,
find the patients local emergency assistance numbers, and be ready to involve
all resources available to help prevent this patient from harming him/herself.
It is essential for the triage nurse to be sympathetic,
non-judgmental, and accepting. The caller has done the right thing by getting
in touch with another person. No matter how negative the call seems, the fact
that it exists is a positive sign, a cry for help.
Triage nurses always have the caller’s safety in mind. They
combine both clinical judgment and emotional connections to assess the
patient’s situation to identify possible mental health issues.
Even though remote triage nurses typically can’t see their
patient, they must develop that all-important trust quickly and by means other
than visualization for the caller to open up and be honest with the nurse. Not
all patients can accurately describe their condition, history, medical
conditions, or other pertinent information. The telephone triage nurse must decipher
Sometimes the patient needs emergency treatment, while other
times they are reaching out for someone to talk with and work thru difficult
situations like substance abuse, economic worries, relationships, sexual
identity, getting over abuse, depression, mental and physical illness, and
Just talking about their problems for a length of time gives
some suicidal caller’s relief from loneliness and pent up feelings, an
awareness that another person cares, and a sense of someone understanding them.
Also, as they talk, they get tired and their body chemistry changes. These
things take the edge off their agitated state and help them get through a bad
night. Suicide calls can be difficult, but with proper training, protocols, and
disposition, telephone triage nurses save lives, one call at a time.
Ravi K. Raheja, MD is the CTO and medical director fo the TriageLogic Group. Founded in 2005, the TriageLogic Group is a URAC accredited, physician-lead provider of high quality telehealth services, nurse triage, triage education, and software for telephone medicine. Their comprehensive triage solution includes integrated mobile access and two-way video capability. The TriageLogic group assists their clients with value based care and serves over 7,000 physicians and covers over 18 million lives nationwide. For more information visit www.triagelogic.com. and www.continuwell.com.
Emergency Room (ER) overcrowding
is widespread in hospitals, creating delays and diversion from those who need care
the most. According to a recent article, “Compounding the problem is the alarming
trend of a decreasing number of ERs and an increasing number of ER visits.”
All too often, injury or illness appears without warning for patients. For hospitals trying to control overcrowding, the obvious solution is to redirect patients who don’t need to be in the ER to more appropriate paths for care. Who then determines if it’s necessary for a patient to go the ER? Most people aren’t trained medical professionals, and as a result, they worry and end up in the ER for non-urgent symptoms.
Patients faced with uncertainty
about where to go, all too often, end up calling the ER department and receive a
standard response: “We are not allowed to give advice over the phone. If you think
you have an emergency, please hang up and call 911. If you think you need to see
someone, you can come to the emergency room or call your doctor.”
So, who do you call?
One hospital in Oklahoma, with a similar issue, wanted to change this process. What if they provided a nurse triage line that would be available to receive calls from the patients calling the ER? Having the reassurance of a triage nurse could help decrease the number of people in the ER for non-emergency reasons.
This would provide patients with
quick and easy access to a trained medical professional to assist in determining
the appropriate next steps based on their symptoms and medical history. Also, since
the nurses work independently from the hospital system, the nurses would provide an objective opinion increasing
The results were inspiring. The nurses significantly decreased unnecessary emergency room visits. A random survey of about 520 patients uncovered their plans before talking to a nurse. This helped determine the effectiveness of the system.
Out of 240 patients who were planning to go to the ER, 42 percent of them were diverted to a lower level of care, including 17 percent that received home care needing no additional follow up actions. This translated into a savings of at least 215,000 dollars in unnecessary ER visits, not to mention providing peace of mind for patients being able to stay home and rest.
Better Health Outcomes
The benefits didn’t just stop at ER costs savings. Consider the patients who called into the nurse triage line and were not intending to go to the ER. Some medical conditions are considered emergencies because they require rapid or advanced treatments.
Surprisingly, close to 20 percent of the patients who called into the nurse triage line had symptoms that were serious enough to warrant a visit to the ER. Without the nurse line, the outcomes for these patients could have been life threatening or fatal.
While nurse triage has shown significant
effectiveness in an outpatient setting, this preliminary data shows even greater
promise to expand this model to emergency rooms around the country.
Providing local communities with a nurse triage program not only prevents unnecessary ER visits and saves on healthcare costs, but it also ensures patients get appropriate care when a serious symptom arises. For the hospital, this increases goodwill in the community while addressing the overcrowding of the ER: a win-win all around.
Dr. Charu Raheja is the co-founder and CEO of the Triage Logic Group. Charu’s personal struggles and triumphs with her health define both her personal and her professional mission. Most recently, her experience in overcoming a life-threatening health event led her to launch the Continuwell brand. The TriageLogic Group provides telehealth software, mobile communication solutions, and services to large medical centers and businesses around the country. It is part of the Women’s Business Enterprise National Council (WBENC), and it covers over 25 million lives nationwide. Visit www.TriageLogic.com or contact Amy Smith at 888-TEAMTLC for more information.
While job burnout may not seem like a serious issue, it can produce critical circumstances when it involves a physician. Reports claim doctors experiencing burnout have higher levels of divorce, depression, alcohol and drug addiction, and suicide.
Additionally, they have lower levels of clinical care quality and patient satisfaction and higher levels of medical errors and malpractice risk. Medical errors are estimated to be the number 3 cause of death in the United States and annual costs for medical mistakes are estimated to be between 17 and 30 billion dollars. The U.S. healthcare system cannot afford the financial effects of physician burnout.
Better Work-Life Balance
When a physician is on call after office hours or during the weekend, they often receive patient calls interrupting personal time with family or getting needed rest. It would be easier to manage if these calls were rare, but the reality is, patients need access to healthcare professionals 24/7 to avoid unnecessary ER visits. Many of these patient calls regularly result in advice that could have been given by a nurse.
Technology can help minimize the burden. Utilizing telephone nurse triage, physicians can ensure that patients are receiving prompt, quality care based on standardized protocols combined with custom orders. As a result, many physicians who use telephone nurse triage find that their phone doesn’t ring as often after hours, they’re able to spend more time focusing on their patients during office visits, and they can be confident everything is properly recorded in the computer for efficient billing.
There is no single solution to eliminate physician burnout. Providing work-life balance education early in their careers and offering continuing education and assistance for stress management can help many doctors. Additionally, telephone nurse triage provides a flexibility that allows physicians to adjust their schedule more easily to create a better work-life balance and avoid burn-out.
Dr. Ravi Raheja is the medical director at TriageLogic, which is a leader in telehealth technology and services. The company’s goal is to improve access to healthcare and reduce costs by developing technology for providers and patients, backed by high-quality nurses and doctors. The TriageLogic group serves over 9,000 physicians and covers over 18 million lives nationwide.
Telemedicine has been a medical buzzword for several years, and the variety and depth of services provided have grown dramatically during this time. There is little argument that telemedicine is a great way to supplement traditional medical practices.
One of the biggest hurdles for doctors is that their time with patients is limited. In a traditional office setting, doctors have a nurse start a patient visit before the doctor comes in. Nurses take vitals, talk to patients, and evaluate their needs before a doctor walks in the room. The same type of process needs to be designed for telephone medicine, with the difference being that the nurse will do her job over telemedicine, just like the doctor.
First, some practices have nurses in their office taking patient calls and scheduling visits with a doctor. When managing these calls, the nurse needs to perform two tasks. First, the nurse must evaluate whether or not the patient needs the doctor at all or whether the nurse can help the patient over the phone with home care advice. Second, the nurse must document patient symptom information before making the appointment for the patient to speak with a doctor.
This is where having a good platform to document patient calls and ensure standard protocols comes in. This can ensure patient safety and help make the process efficient. Medical protocols such as Dr. Schmitt and Dr. Thompson’s protocols ensure a standard care every time a nurse takes a call. These protocols are also available electronically, making them easier to use as compared to textbooks. The electronic protocols can also allow the care advice to be documented directly on the patient chart for review by the physician during the telehealth visit.
However, not all doctors offering telehealth services have their own nurses always available to answer patient calls when they first come in. An alternative for these doctors is to hire a telephone nurse triage service. A nurse triage service can serve as an extension of the office by providing patients with a trained nurse to evaluate patient symptoms and determine what actions to take.
What sets a high-quality telephone nurse triage service apart is the ability for the physician to have custom orders and preferences built into the system so that the nurses can act as a true extension of the physician. A high-quality nurse triage nurse service is also able to schedule the patient appointments for those patients who need an appointment.
Providing patients with access to triage nurses can also be helpful for those doctors who don’t have the ability to provide telehealth services 24/7. If given the appropriate instructions, triage nurses are typically able to resolve over 50 percent of the callers’ issues without the need of a doctor.
Figure 1 comes from a survey of over 35,000 patient phone calls. In over 50 percent of the cases, the nurses were able to resolve the caller’s medical symptoms by giving them home care advice. These nurses were also able to determine which callers required a physical visit to an urgent care or an ER (in an event of an emergency, such as symptoms of a potential heart attack).
Telephone nurse triage allows a practice’s telemedicine program to work seamlessly, whether the office is open or closed. Setting up a nurse triage system where nurses use standardized protocols to answer patient questions increases the productivity and profits for your practice.
When your nurses use triage protocols, you can have the confidence that they are asking the right questions and not missing anything. The basic patient information, the protocols used, and the nurse notes can also be used as a quick reference for the physician prior to the telehealth visit similarly to the notes that the doctors receive when their nurses see a patient before them during a physical office visit.
Charu Raheja, Ph.D., is the CEO of TriageLogic a leading provider of quality, affordable triage solutions, including comprehensive after-hours medical call center software, day time triage protocol software, and nurse triage on call. Customers include both institutional and private practices. If your hospital or practice is looking for information on setting up a nurse triage service, contact TriageLogic to get a quote or set up a demo.
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.
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
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
The Nursing Process
Outcomes: Safe outcomes are timely, that is, coming early or at the right time.
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:
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
Being a “digital immigrant,” whose knowledge and comfort with mobile apps is admittedly deficient, over the past thirty years I have championed the value of a traditional, phone-based nurse triage call center. If I need clinical help (or vendor assistance, for that matter), I still prefer a phone call to interact with a person.
To me, texting, emailing, tweeting, or communicating by any other non-voice-to-voice method, not only can be cold, impersonal, and incomplete, it is often intimidating. Despite claims to the contrary, the developers of many mobile apps have compromised ease-of-use for faster programming and meeting product release deadlines.
The Triage Nurse Callback Queue: The follow-up call queue is of weighty value especially when new patients call and all of the call center nurses are busy speaking with other patients. Here, assuming the call is of a non-critical, low-acuity nature, a non-clinical staff member could advise the patient that no nurse is currently available and he or she would gladly add the patient to the nurses’ callback queue once some initial information is gathered.
Web or Mobile App Requests for a Nurse Follow-up Call: For some, enabling the patient to send a summary of their conditions via a smartphone app would be the logical starting place for a phone app interface. Many hospital call centers have begun accepting this kind of communication.
Using the triage nurse callback queue for outbound calls to the patient enables the nurse to review the text sent via the mobile app. Once reviewed, the nurse calls the patient back to engage in a more in-depth conversation regarding the details of the patient’s symptoms.
As always, if the patient is experiencing critical symptoms, they should always be instructed to hang-up and dial 9-1-1 or proceed to the nearest emergency department.
Prioritizing Calls in the Callback Queue by Acuity: The best way to verify that each call added into the nurse callback queue has been assigned an appropriate acuity level would be to have all calls reviewed, assessed and, if needed, adjusted by acuity. To facilitate this, many sites have a charge nurse responsible for managing the queue throughout the day, making sure the highest acuity requests remain listed at the top of the “requests received for nurse call-back” queue.
But this is an article on mobile apps. Isn’t there a way to review and assign an appropriate acuity level with a technological solution instead of needing to manually review each request using a process that requires the addition of more staff?
Natural Language Processing: A more technologically advanced option would be to utilize one of the industry’s natural language processing (NLP) mobile apps. An NLP system can read, at the time of the initial call, the notes captured by the non-clinical, front-end intake person or directly by a call center nurse. The NLP can then interpret the notes into their clinical equivalents, assess the acuity of the call, and send the call to the follow-up queue or make it available to the nurse, in both cases with the appropriate acuity level.
There are systems that can automatically assign an acuity ranking to each call before adding it to the nurse callback queue. If the call is being handled directly by the call center nurse, this same information can be provided directly to the triage call center nurse to help direct her guideline selection. Doing so substantially reduces the time needed to manage the queue. Instead, the charge nurse could be used to provide greater value to patients by handling additional live triage calls.
Again, if needed, these calls could be assigned a higher or lower acuity level by the charge nurse monitoring the queue. When functioning correctly, the auto-feed, queue-sorting algorithm should take into consideration newly added calls every two to three minutes. Generally, callbacks should be made within thirty to forty minutes of receipt of the initial request.
Live Chat Technology: Another option traditional nurse triage call centers are beginning to embrace is utilizing live chat technology to enable the patient to directly interact with a triage nurse within just a couple of minutes of the initial inquiry. Here, via the chat function on most computers and smartphones, the patient can simply enter a brief description of his or her symptoms and send it to the call center. A triage nurse opens the chat, reads the patient’s notes, and then enters an educational or directive note back to the patient again in the chat window.
The nurse’s reply, along with the patient’s initial message, is returned to the patient for further review. If the patient is satisfied with the nurse’s response, he or she simply closes the open chat link. Otherwise, the chat can continue. Once the final message is sent, click to close the chat window. Be sure to follow organizational HIPAA privacy rules.
Using the chat function can be a great productivity benefit because a single nurse can manage multiple chats simultaneously. Just be sure, if chat is implemented in the call center, clearly segment each caller’s or patient’s data from all others to avoid inappropriately sharing personnel health information (PHI) with the wrong individual.
Self-Assessment via Guided Questions: Another mobile app gaining popularity in the telephone triage world is often referred to as a symptom checker. This app provides patients with the ability to self-assess their symptoms using a web or phone-based app. These programs typically begin by providing instructions for using the app and the site’s privacy rules.
When the patient is ready to begin, two diagrams appear, one male and one female, with several body regions defined (such as upper right leg, lower left leg, neck, etc.). The patient can rotate the body to indicate the concern has something to do with an area on the back. Once the body region is identified, the patient clicks on it to display a list of symptoms from which to choose (for example, muscle ache, sunburn, laceration, etc.).
Typically, these programs present a user-friendly interface with self-triage guidelines or some other healthcare information pertaining to the issue the patient is having. If the patient prefers to speak with a nurse, some of the more advanced symptom checker apps will enable the patient to request a follow-up call from a call center nurse.
The patient’s request is added to the nurses’ follow-up call queue. The process continues from there, processing the request much like the steps for chat follow-up interactions, except that the subsequent contacts take the form of phone calls instead of chat texts.
Photo of Wound: This is a surprisingly simple, yet significant feature of many remote apps tied to triage call centers. One of the greatest challenges of performing remote patient triage is the inability to see the patient’s symptoms or problem visually. By adding the ability to share a photo with the call center nurse, the patient can greatly enhance the nurse’s ability to successfully triage the issue.
It is true. A picture is worth a thousand words. These photos are typically shared as jpg files and are stored as part of the patient’s overall triage encounter record.
Video of Patient Behavior: Another visual tool available from some vendors is the ability to send and store a video of the patient’s behavior. Describing lethargic or manic behavior or the uncontrollable crying or hysterics of a toddler is often difficult for a highly stressed parent. Enabling the nurse to watch a brief video of the patient’s current activities can greatly improve the nurses’ ability to correctly assess the patient’s health issues.
Video-Based Doctor Visits: The last application is a rapidly growing phenomenon that spawned an entire new industry to address what many believe to be one of the greatest challenges of Obamacare: providing insurance coverage to twenty million Americans, while struggling with a major shortage of primary care physicians throughout much of the country.
Through governmental action such as the ACA, millions more Americans were provided government subsidized healthcare. Unfortunately, the vast majority of individuals who initially enrolled in the new programs were those of greatest ill health and costliest conditions. These individuals were also largely without a primary care provider. Consequently, the over-crowded, already backed up emergency departments across the country became even more congested with individuals who had nowhere else to go to receive the healthcare they needed to stay alive. Video-based doctor visits provided a partial solution.
The sharpest players in the healthcare triage call center niche will be those who devise a strategy to integrate with these video-based physician practices, performing both pre and post-visit calls and doing follow-up case management calls to these individuals.
The future is here. Either embrace it or miss this current wave—or might it be a tsunami?
Mark Dwyeris a 30-year veteran of the healthcare call center industry. Mark is in his sixteenth year at LVM Systems where he serves as COO. LVM Systems provides healthcare call center software. For more information or a demonstration of LVM’s call center solutions contact Carol Zeek, regional VP, sales, at 480-633-8200 x279 or Leann Delaney, regional VP, sales at 480-633-8200 x286