Tag Archives: telephone triage articles

Pairing Nurse Triage with Medical Answering Service



By Ken Bleakley

After-hours telephone services for physicians must be able to address both administrative questions and clinical concerns from patients. Both physician and patient need to be confident that all inquiries will receive a prompt, caring, and authoritative response. This requires the deployment of two different skill sets: medical answering service and registered nurse triage.

Medical Answering Services: An efficient answering service can provide superior value to its clients by conveniently servicing callers through a compassionate and accurate response, including:

  • Answering and messaging services
  • Appointment calls
  • Conference calls
  • Client satisfaction surveys
  • Initial screening for clinical concerns

The staffs who provide these services need not be medical professionals, but they do require medical knowledge. Emphasis is on speed, efficiency, and accuracy in responding to a wide variety of situations using specialized operating systems.

Nurse Triage Services: When the caller requires clinical information or advice, licensed registered nurses using established guidelines and protocols become necessary. Using a dedicated operating system and their own clinical skills and experience, they triage, record, and document clinical calls from patients. Accreditation, insurance, and rigorous quality assurance programs add to the cost and complexity of these services, but provide dependability and confidence in the end result.

Integrated Services: As each of these types of services become more developed to support the medical practice, the need for a simpler, single service to provide the complete after-hours coverage for the busy physician become increasingly desirable. The ability to contract with one unified entity with single billing and a mutually compatible functioning becomes a valuable enhancement. The search and evaluation process are simplified. The service becomes the after-hours extension for each medical practice. On nights, weekends, or whenever physicians need a break, they are able to flip incoming calls to a single number and receive:

  • A compassionate response to patient needs, answered in the practice’s name
  • Committed medical answering services
  • Accredited medical advice and triage by registered nurses when required
  • Medical encounter reports immediately and aggregated reports monthly
  • One predicable monthly bill for services
  • A dedicated representative to address any concerns
  • Optional scheduling and referral services

Meeting the Need: Medical answering services and nurse triage services have responded to the challenge in different ways. Some simply provide parallel services to medical practices that contract them separately. Others offer informal pairing arrangements with different levels of integration. A few provide both services under a single company. While there are advantages to each model, there are also disadvantages.

Parallel service models provide maximum flexibility to medical practices and frequently combine local answering with nationally accredited medical call centers. However, the handoff from one service to the other and from one operating system to the other can be problematical, as can fixing responsibility for errors or delays. Separate billing complicates the task of practice administrators.

The combined service company is automatically equipped to provide a single number to connect the patient to an integrated answering/triage service with a single bill and to assume responsibility for outcomes. However, this model may generate an incentive for the answering service to refer patients to the company’s more expensive nurse triage, even when the call may not be truly of a clinical nature. As the two different functions may not even be in the same location, it does not necessarily assure a smooth handoff between them. In addition, a nurse triage service that is also competing for medical answering business will find it difficult to build cooperative relationships with medical answering services already providing answering services to their own clients.

Optimizing the Roles of Each Service: Once it becomes clear that neither the answering service nor the nurse triage service has any interest or desire to enter the substantially different business of the other, they become natural allies. They can concentrate on providing the one call/one service/one price model desired by medical practices and patients. They can concentrate on making their respective systems as compatible as possible, while enhancing the quality of their respective services. They can also develop joint sales programs focused on mutual specialized or local markets.

The result of these alliances is better and less costly service for the patient and physician alike. More physicians will be able to afford turning over their practices after-hours to reliable professionals. The pairing of local and national capabilities also helps to maintain the personal relationship between doctor and patient during the hours when medical practices are closed. Patients are able to schedule visits to their providers and avoid unnecessary visits to over-crowded emergency rooms.

Ken Bleakley is CEO of Fonemed, whose mission is to connect people by telephone and Internet to health information, services, and products. Fonemed provides nurse advice throughout North America and the Caribbean. For more information, call 800-366 3633.

[From the February/March 2007 issue of AnswerStat magazine]

Outbreaks and Pandemics: New Roles for Triage Call Centers

By David A Thompson, M.D., with Sue Altman and Barton D Schmitt, M.D.

“My daughter is away at college and just phoned to tell me that her roommate was diagnosed with mumps today. What should she do? What symptoms should she be watching for? How can I tell if she was adequately vaccinated?”

“One of our employees just returned from a business trip in the Far East, and he called in sick because of cold symptoms. I’m in HR. Should we be concerned about ‘avian flu’ when he comes back to work? Are my other employees at risk?”

Questions regarding respiratory viruses like mumps and avian flu have recently been popping up at medical call centers across the country. Mumps is a significant clinical topic this year. Although it is generally not a serious disease, there was a real outbreak centering on college students in Iowa. Call centers that serve student health contracts or are convenient to college campuses need to have the facts ready and available to answer incoming questions.

Early this year, Drs. Barton Schmitt and David Thompson wrote a Mumps Exposure guideline. It was released to call centers that use their clinical content in July, 2006. The guideline provides background information on mumps, potential complications, the MMR vaccination, and Centers for Disease Control and Prevention (CDC) recommendations for outbreak control. In addition, the care advice section includes facts on contagiousness, symptom recognition, prevention, and isolation – responses to the common questions call center nurses would anticipate receiving.

Avian influenza is another significant clinical topic because of concerns about the possibility of a pandemic. In May of this year, the White House published a National Strategy for Pandemic Influenza: Implementation Plan. This document stated, “A system of effective home-based care would decrease the burden on health care providers and hospitals and lessen exposure of uninfected persons to persons with influenza. Telephone call centers should be established or augmented within affected communities to provide advice on whether to stay home or to seek care.”  Medical call centers can have an important role in local disaster preparedness. One area of need in particular is having a plan in place for an influenza pandemic. The Avian Flu Exposure guideline, written by Drs. David Thompson and Barton Schmitt, includes the latest public health recommendations for providing meaningful triage and advice.

Les Mortensen, president of LVM Systems, served on an advisory panel for the Agency for Healthcare Research and Quality (AHRQ), which investigated the role of community call centers in supporting outpatient healthcare and monitoring in major healthcare crises. Call centers could be instrumental in providing:

  • Triage surge capacity (extreme volumes of calls from ill, injured, and worried well)
  • Communication hubs to healthcare providers.
  • Communications to and management of those quarantined.
  • Information hotlines.

Remote workforce initiatives will be a key factor in disaster preparedness and shelter in place scenarios. In this way, all employees can work via remote connections and a core group of IT staff will shelter at the headquarters to maintain servers, phone lines and connectivity.

Mumps:  In December 2005, an outbreak of mumps began in Iowa, and as of May 2006, involved at least ten additional states. The 18-24 year old age group was most likely to be effected, with many mumps cases occurring on college campuses.

What are the symptoms of mumps? The majority of people who get mumps have general viral symptoms, such as fever, headache, muscle aches, and decreased appetite. Approximately 30-40% of people develop a swollen tender parotid gland, called parotiditis. The parotid gland is located at the angle of the jaw (in front of the ear). Generally, the symptoms of mumps last 7-10 days.

Mumps is caused by a respiratory virus. Close contact with someone with mumps is needed before a person is at risk of getting mumps. Certainly being a roommate qualifies as close contact. A more detailed description of significant exposure to mumps would include the following activities: kissing or embracing, sharing eating or drinking utensils, close conversation, and performing a physical examination (relevant to health care providers).

There is no specific anti-viral treatment for mumps. Instead, the most important part of prevention is assuring that one’s mumps vaccination is up to date. The CDC has recommended:

  • Isolation of anyone with proven mumps for 9 days after symptom onset.
  • Protection of persons at risk by being sure they receive a second MMR (if they have received only one). One MMR is 80% protective and 2 are 90% protective.

Avian Influenza: Avian influenza is an infection caused by avian (bird) influenza (flu) virus. It is also sometimes called avian flu or bird flu. This influenza virus occurs commonly in wild birds which carry it in their intestines, but usually do not get sick. There is a strain of influenza referred to as H5N1 that is easily spread to domestic birds such as chickens, ducks, and geese. In domestic birds, this strain of influenza is deadly; up to 90% of infected fowl can die.

Usually, avian influenza does not infect humans. However, since 1997, there have been about 200 cases of humans that have been infected with the H5N1 strain of influenza. The World Health Organization maintains a current list of avian influenza outbreaks worldwide. There have been no cases of human avian influenza in the United States. Some international experts worry that there is the chance that a worldwide outbreak of avian flu could occur. Such a worldwide outbreak would be termed a pandemic.

What are the symptoms? Early symptoms of avian influenza are similar to regular human influenza. Symptoms include fever, cough, sore throat, and muscle aches. However, unlike normal yearly human influenza, most people infected with avian flu have a more severe illness. Pneumonia is common.

Who is at risk of getting avian flu? Most cases of avian influenza infection have resulted from direct contact with infected poultry or contaminated surfaces with feces or body fluids from infected poultry. Avian flu in humans typically develops within 5-10 days of exposure (possibly up to 14 days).

Is there a treatment for Avian Flu? There are two anti-viral medications that are possibly helpful in treating this infection: oseltamivir (brand name Tamiflu) and zanamivir (brand name Relenza).

Whether it is a mumps outbreak or an avian flu pandemic, nurse triage call centers will play a critical role in responding to and with it. Now is the time to make sure your call center and staff are ready.

The article was collaboration by David A Thompson, M.D., FACEP with Sue Altman. Dr. Thompson is the author of the Adult Telephone Triage Protocols used internationally in medical call centers and physician practices. He is Board Certified in both Internal Medicine and Emergency Medicine. Sue Altman is the President of Call Center Consulting Network. The article references clinical protocols recently developed through the partnership of Dr. Thompson and Barton D Schmitt, M.D., FAAP, author of the Pediatric Telephone Triage Protocols.

[[From the October/November 2006 issue of AnswerStat magazine]

Triage Documentation: Setting a Best Practice

By Barton D. Schmitt, M.D., FAAP and David A. Thompson, M.D., FACEP

[Quality monitoring programs for triage include many components, one of which is documentation. When the practice of triage nurses is at the extremes, from sparse documentation to a novella of the caller’s entire health history, it is easy to identify areas for improvement. But that still begs the questions, “How much is enough?” and “What items should be present in the final call document?” The call center manager still needs to describe the best practice and coach his/her staff to that benchmark.

These questions have been posed to Drs. Barton Schmitt and David Thompson, authors of the leading telephone triage protocols. Both have actively worked with staff as Medical Directors for their own triage call centers. The following is an excerpt from their combined thinking.]

Triage is the decision process of sorting patients to the level of care that best meets their medical needs. This decision process must take into consideration the seriousness (medical acuity) of the patient’s medical complaint, the types of resources required to provide effective care, the patient’s expectations, and several other factors. Effective and concise documentation should support the decision process.   Here are some documentation examples for chronic illness, current medications, allergies, and social history.

Chronic Illness – The Active Problem List: Documentation of pertinent chronic illness is indicated in most calls. Documentation should not be a comprehensive listing of every medical and surgical problem that the patient has ever had. Instead, it should reflect current ongoing medical problems (the active problem list).

The higher the acuity of the disposition, the less documentation of chronic illness will be needed. A patient who obviously requires an EMS 911 or GO TO ED NOW disposition needs a very abbreviated documentation of chronic illness.

The Schmitt-Thompson protocols contain Initial Assessment Questions that prompt the triage nurse to inquire about key chronic illnesses for certain complaints. For example, the pediatric Hives protocol contains the following Initial Assessment Question:

RECURRENT PROBLEM: “Has your child had hives before?” If so, ask: “When was the last time?” and “What happened that time?”

The protocols contain Triage Questions that prompt the triage nurse to inquire about key chronic illnesses for certain complaints and then the protocols recommend a disposition. For example, the adult Puncture Wound protocol suggests a SEE PCP WITHIN 3 DAYS if the patient is: [1] Diabetic AND [2] puncture wound of foot

Another example from the pediatric Headache protocol is: [1] High-risk child (e.g. bleeding disorder. V-P shunt, CNS disease) AND [2] new headache

When documentation of chronic illness is indicated, the recorded information can often be very brief. For example, the triage nurse could document past medical history (PMH) and past surgical history (PSH) in the following manner: PMH – diabetes; PSH – coronary bypass surgery

Current Medications: It is reasonable and appropriate to document medications to the extent that they are pertinent to the presenting complaint and affect the disposition. Sometimes inquiring about current medications reveals a Chronic Illness that the caller had forgotten or denied. Documenting every medication that a patient takes on every call is time-consuming and not necessary.

The higher the acuity of the disposition, the less that the medications will need to be documented. A patient who requires an EMS 911 disposition rarely needs any documentation of medications. Such rare circumstances would include a life-threatening reaction to the medication, for example, anaphylaxis or profound hypoglycemia. And in such a circumstance, documentation should not delay completion of the call. A patient that requires a GO TO ED NOW disposition uncommonly needs to have medications documented.

Schmitt-Thompson’s Initial Assessment Questions prompt the nurse to inquire about key medications for certain complaints. For example, the pediatric Asthma protocol contains the following Initial Assessment Question:

MEDICATIONS (MDI or nebs): “What is your child’s asthma medicine?” and “What treatments have you given so far?” The neb or inhaler treatments listed in the triage questions refers to Albuterol or other rescue, quick-relief, beta-agonist medicines (not steroids, cromolyn, or other anti-inflammatory medicines).

The Triage Questions prompt the nurse to inquire about key medications for certain complaints, and then suggests a disposition, For example, the adult Trauma-Head protocol recommends a GO TO ED NOW (or PCP triage) disposition if the patient is:

Taking coumadin or known bleeding disorder (e.g. thrombocytopenia)

When medication documentation is appropriate, the recorded information can often be very brief:

MEDS – amoxicillin, started yesterday

Documenting the exact dosage of a medication or dosing interval is not necessary, unless either:

  1. The patient has a specific medication question, or
  2. An adverse drug reaction (dose-related side effect or overdose) is suspected by the triage nurse or caller, or
  3. The triage nurse is calling in a prescription (by physician order and per protocol) for a medication (e.g. antibiotic eye drops for purulent conjunctivitis, nystatin for oral thrush).

Medication Allergies: Medication allergies are only rarely pertinent to the presenting complaint and the triage decision-making process. Medication allergies should be documented in the following two circumstances:

  1. Presenting complaint of rash
  2. Triage nurse is calling in a new prescription (by physician order and per protocol), calling in a refill (per call center policy), or recommending an Over-the-Counter medication (per call center policy and protocol).

Social History: There are a number of social factors that may influence triage decision-making. Social history only needs to be documented if it affects the triage disposition. The triage nurse can use the acronym to remember important social factors.

The Schmitt-Thompson Initial Assessment Questions prompt the triage nurse to inquire about key chronic illnesses for certain complaints. For example, the adult Anxiety and Panic Attack protocol contains the following Initial Assessment Question:

SUBSTANCE ABUSE: “Do you use any illegal drugs or alcohol?”

The Triage Questions prompt the triage nurse to inquire about key chronic issues for certain complaints, and then the protocols recommend a disposition. For example, the pediatric Bruises protocol suggests a GO TO ED NOW (or PCP triage) if

Suspicious history for the injury (R/O: child abuse)

When social history documentation is appropriate, the recorded information can often be very brief:

SH – lives alone, has car

Copyright 2004. David Thompson MD, Barton Schmitt MD. For a copy of the full document, email Sue Altman at sue@selfcare.info.

[From the October/November 2005 issue of AnswerStat magazine]

Consistent Triage and Advice: Automated and Integrated at Each Contact Point

By Sue Altman

Patients and callers have three sources for decision support information: their physician’s office, a medical call center, or the Internet, but is the information they receive consistent between all three? Well, until recently, it probably was not.

Physician-authors Barton Schmitt, MD and David Thompson, MD recognized the need to have consistent clinical content sets for each scenario several years ago. They have authored triage protocol sets for use by physician offices, after hours and managed-care call centers, and consumers (parents, grandparents, teens, and adults). Although the clinical information sets are written for distinctly different audiences (physicians, office staff, registered nurses, and members of the public), the triage questions and care advice are consistent and drive the same actions based upon the symptoms at hand.

The clinical content has been eagerly received. More than 10,000 offices use the book by Barton Schmitt, Pediatric Telephone Protocols. Thompson’s book, Adult Telephone Protocols, was released in 2004 after years of demand for a companion to Schmitt’s work. Schmitt’s and Thompson’s After Hours Triage and Advice protocols are used by more than 300 medical call centers internationally – leading other content sources by a ratio of more than ten to one.

HouseCalls Online, the self care guides written specifically for use by consumers on the Internet, is the newest Schmitt/Thompson collaboration. It is now in use or being installed by more than 30 hospitals and health plans. HouseCalls Online has been well received by consumers of all ages. It also extends decision support to a generation that is more comfortable online than on the telephone.

For the call center aspect, LVM Systems served as the integrators. LVM has had the Schmitt/Thompson after-hours triage protocols in its medical call center software since 2000. When LVM launched WebLink, its self-service Internet product, they embedded the HouseCalls Online self-care guides. WebLink and the call center software, E-Centaurus, are fully integrated. For the call center (and sponsoring organization), this means web “hits” or visits to HouseCalls Online can be tracked and reported directly using the call center’s software. Protocol usage can be compared and contrasted between calls received via the call center and consumers accessing the organization’s website.

In 2004, LVM launched the first physician practice triage product, D.O.C., or Doctor’s Office Calls. From a content perspective, it provides an electronic version of Schmitt’s and Thompson’s office protocol books. In relation to risk management, this product standardizes the process of providing telephone advice to patients and automates documentation of each encounter. According to medical groups, it is also a conduit to getting physicians to use the same “decision system” for handling inbound patient calls. The D.O.C. product’s success has been its ability to support a fast (five minute), yet thorough triage call and automate a variety of other practice functions.

But the piece de resistance is the integration of the office product with the after hours call center. This connection after the appropriate HIPAA Business Associated agreements are in place, allows:

  • The physician office to view any after hours calls processed for their specific patient base and
  • The medical call center to view the daytime triage calls processed by the practices for which they provide after hours service.

Some healthcare organizations are choosing to host the D.O.C. product and making it available to their affiliated physician practices.

So the opportunity is here. The Schmitt/Thompson content can guide and support consistent decision-making – whether consumers access their physician office, the Internet or their healthcare organization’s medical call center. Also, the technology supports centralized management and reporting across the continuum.

[From the October/November 2005 issue of AnswerStat magazine]

Book Review: The Complete Guide Providing Telephone Triage and Advice in a Family Practice

Reviewed by Ann Maddaus

Poole, Steven. The Complete Guide Providing Telephone Triage and Advice in a Family Practice: During Office Hours and/or After Hours.

Dr. Steven Poole’s new book gives a practical approach to setting up or enhancing a telephone triage protocol. The book is laid out in an easy-to-follow format. Three items in this book that stand out: defining the roles necessary to provide a quality program, determining the ideal or model call for your specific practice, and getting paid for the service you’re providing. Dr. Poole’s lengthy experience in telephone triage gives the reader full benefit of the policies and procedures he’s revised over the years.

Defining the roles of administering a cost-effective triage program is the first step in providing your service. The book suggests three key roles: a nurse to serve as telephone manager; a physician, nurse practitioner or physician assistant to serve as medical care director; and a manager to oversee the business aspects of the practice. These roles are defined completely in the book with separate chapters of interest for each role.

The model or ideal call determines much of your practice. By defining how you want calls handled, you define training and quality control. It’s extremely important for cost-effectiveness and quality care for the phone personnel’s duties to be clearly defined and to train them to be efficient. Chapter six of this book is dedicated to the model call.

Reimbursement is essential to continued telephone care. Triage centers are becoming busier due to today’s lifestyles. Chapter sixteen is dedicated to getting paid for what you do. In order to provide great telephone service, the funding has to be there. In fact, in order to facilitate the billing, the CPT (Current Procedural Terminology) codes are provided in this chapter as well.

This book has a wealth of information from a very knowledgeable source. Both existing practices and those being developed would benefit from reading this book.

What else is new in books:

Moore, Griffith’s Instructions for Patients. Seventh Edition 2005, Elsevier Inc. ISBN: 141600364 (Included in this edition a CD-ROM that prints out patient instructions in English or Spanish)

Ann Maddaus is the Manager of Enrica Fish Books in Minneapolis, MN. Call 800-728-8398 for more information about these or other books.

[From the Fall 2004 issue of AnswerStat magazine]

What is Telephone Nurse Triage?

By Sara Courson, BSN

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-NurseTM 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.

[From the Spring 2004 issue of AnswerStat magazine]

Multistate Nurse Licensing

By Mike Wilson, J.D.

One of the most common uses of telenursing is telephone triage with centralized phone banks. However, telephone triage by a nurse can run afoul of licensing laws when calls are taken from states in which the nurse is not licensed to practice.

Licensing of professionals historically has been a state matter. Recent technological advances make it easy for professionals to provide services in other states via the phone or Internet. Nurses, under the leadership of the National Counsel of State Boards of Nursing (NCSBN), are ahead of other medical professions in addressing the legalities of multistate practice with the Nursing Licensure Compact (NLC), approved by the NCSBN in 1998. Because regulation of nurses is a state matter, the decision to join the NLC must be addressed legislatively on a state-by-state basis.

According to the NSCBN, the Nursing Licensure Compact has been adopted and implemented in the following states: Arizona, Arkansas, Delaware, Idaho, Iowa, Maine, Mississippi, Nebraska, New Mexico, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Utah, and Wisconsin. States in which the Compact has been adopted but is not yet fully implemented include Indiana, New Jersey, and Virginia.

The Compact allows for mutual recognition of state licensure among states that have adopted the Compact. A nurse who obtains a multi-state license in the state of his or her residence may practice in other states that belong to the compact. Individual states still establish their own rules and regulations related to licensure, practice, and disciplinary action while adopting their own administrative rules to implement the Compact. However, employers verify licensure through the state where the license is issued.

The multi-state license dispenses with the need to obtain a separate license in states that belong to the Compact. Nurses in compact states need not apply for multi-state licensing, but doing so has become popular. A survey by NSCBN found that 86% of nurses in Compact states have multi-state privileges. Employers report it is less cumbersome to hire nurses from a NLC state because there is no time wait for licensure. Nurses report that multi-state licensing saves them time, money, and trouble. Benefits of NLC cited by the Nurse Licensure Compact Administrators include the growing need for nursing practice to occur across state lines and the technologies nurses use that may cross state lines.

Even with a multi-state license, nurses still must obey the laws and rules of any state in which they practice. Also, each state still carries out disciplinary proceedings with reference to nursing practice in that state, whether the nurse involved is a resident or is a non-resident practicing under a multi-state license. A survey by NSCBN found that nearly 40% of employers of nurses say they do not understand the disciplinary proceedings under the NLC. Basically, only the nurse’s home state that issued the multi-state license can take action against that license. However, other states in which the nurse practices but does not reside can take action against the nurse’s privilege to practice in that state. As multi-state licensing is adopted by more states and nurses sign up for multi-state privileges, licensing concerns that arise in nurse triage by telephone should diminish.

Mike Wilson is an attorney and author. He teaches at Sullivan University in Lexington, KY.

[From the Spring 2004 issue of AnswerStat magazine]

How to Evaluate a Protocol

By Sheila Wheeler, RN, MS

Whether you are evaluating electronic or paper based protocols the same basic steps should be followed. Begin the process by obtaining paper copies of the following items: the table of contents, three representative protocols (abdominal pain; nausea and vomiting; or respiratory problems), and the documentation form.

Ask the vendor:

  • How Were They Developed And Tested? Were the protocols developed by a single RN, MD, or a Nurse Taskforce? When it comes to protocol development, four heads are better than one. A taskforce working collaboratively as a group is superior to the single developer working alone or taskforce members working independently.
  • Who is best suited to develop protocols, RNs or MDs? Nurses are best suited and more economical as protocol developers, while physicians are best suited to consult, review, and approve them.
  • What were the qualifications and experience of the taskforce members? The best candidates for protocol developers are expert level nurses or nurse practitioners with expertise in pediatric and adolescent medicine, adult, geriatric, and OB/GYN medicine as well as experience in telephone triage. Physicians who are familiar with and supportive of nurse telephone triage are the best consultants and reviewers.
  • What is the optimum development time? For a complete set of protocols (50 to 100) a development time of less than six months is suspiciously fast. Usually, one to two years is more realistic.
  • How long have the protocols been in use and where? A history of several years or more in large, busy group practice or HMO is more meaningful than a few months in a small office.
  • How Are They Designed To Be Used? There are two distinct philosophical approaches to protocols and decision-making in telephone triage. One philosophy is that the nurse’s judgment is primary and that protocols are a decision support tool. A competing philosophy is that the protocols do not require trained professionals and thus are the ultimate decision making tool. Decision support has been defined as an expert system designed to remind experienced decision makers of alternative options or issues to consider. Decision-making systems are defined as expert systems that allow non-experts to make decisions beyond their training and experience. Ask whether the protocols require an autonomous professional or whether the phone interaction is mainly “protocol driven.”

Assess the protocols:

  • Table of Contents/Title System: One quick and easy way to assess a set of protocols is to simply review the table of contents which is essentially the author’s “search engine” to find the right “tool” in the system. Remain alert to titles that are confusing, inconsistent, or redundant. For example, is lay language mixed with medical terminology? Is there a consistent, intuitive approach to titling? Are the protocols listed consistently by system, site, or symptoms, or are they a confusing mix of all three? Poorly organized titling results in a search engine that is not user friendly and slows the interaction.
  • What is the scope of the collection? Having too many or too few protocols decreases the “user friendliness” of the product. Too many protocols results in excessive page turning or screen changes, which can be confusing and time consuming. Too few protocols leads to the “out of protocol experience,” where the nurse is left without adequate protocol coverage and must “fly blind.” The optimum number of protocols is between 50 and 100, which covers about 1000 common diagnoses, including common emergencies.
  • Documentation Form: The protocols should have an accompanying documentation form. It should contain the steps of the nursing process – assessment, impression, treatment, and self-evaluation. In addition to demographic information, there should be ample space for the assessment and treatment sections. Labeled spaces for standard information to be collected, trigger words for key questions, well-developed problem/client history section, and words delineating the nursing process will facilitate complete, accurate data collection. Forms that have too much blank space or are too busy are not user-friendly.
  • Test Driving and Training: Once you have narrowed the selection down to two or three designs, have staff test them out, using scenarios. See how effective they are to use within the “real world” time of 10 minutes per call. Finally, for best results, all protocols (paper-based included) require training in their correct and safe use. Training affords the staff the opportunity to fully grasp the design, achieve buy-in, shorten the learning curve, and facilitate compliance.

Sheila Wheeler, RN, MS, is an expert in the field of telephone triage. Ms. Wheeler is the author of Telephone Triage: Theory, Practice, and Protocol Development (Delmar Publishers: 1993) and Telephone Triage Protocols for Pediatric and Adult Populations (Aspen Publishers: 1998). She is the founder and chairperson of the annual telephone triage conference, “Telephone Triage: Essentials for Expert Practice.”

[From the Winter 2004 issue of AnswerStat magazine]

Telephone Triage for the Medical Call Center

By Peter Lyle DeHaan, Ph.D.

Peter DeHaan, Publisher and Editor of AnswerStat

Of all the exciting advances in medicine, there is one that falls outside the traditional scope new drugs, innovative procedures, or revealing research. This development is in the application of telephone technology to facilitate the provision of healthcare. Lumped into the broad category called telemedicine or telehealth, the telephone is cost-effectively improving patient care while increasing patient satisfaction. The application of technology to cut costs and improve quality in any industry is noteworthy; in medicine, it is critical.

One of the most exciting developments in telemedicine is telephone or nurse triage. The history of telephone triage dates back three decades. For Dr. Barton Schmitt, arguably the father of telephone triage, it was born out of the practical necessity of ensuring consistency and accuracy among those who interacted over the phone with parents concerned about a child’s well-being. His initial telephone protocols have been refined, expanded, and validated for the past 30 years. More than 400 call centers are using computerized versions of his work and an estimated 10,000 pediatric offices refer to the printed version. Others have independently developed similar protocols.

Telephone triage will be a reoccurring theme in AnswerStat, as we believe it is an important development, not only for medical related call centers, but also for healthcare as a whole. Our goal in this issue is to introduce the subject and provide some initial resources. Look for more information and articles in upcoming issues.

Telephone Triage Call Centers: There are several call centers that provide telephone triage on an outsource basis, or for a fee, to hospitals, clients, individual practices, and medical answering services. View our current list.

Telephone Triage Vendors: Lastly, here is a list of vendors who have integrated telephone triage protocols into call center software.

Books on Telephone Triage: As a primer for learning more about telephone triage, you might want to refer to some of the many books available on the subject. Here is a list of some of them (let us know your favorites and we will add them to our list):

  • Pediatric Telephone Advice by Barton D. Schmitt (Spiral-bound)
  • Pediatric Telephone Protocols: Office Version by American Academy of Pediatrics, by Barton D. Schmitt
  • Quick Reference to Triage by Valerie G. A. Grossman, et al.
  • Telephone Health Assessment by Sandra M. Simonsen
  • Telephone Medicine: Triage and Training: A Handbook for Primary Care Health Professionals by Harvey R. Katz, Harvey P. Katz
  • Telephone Triage: Theory, Practice, and Protocol Development by Sheila Q. Wheeler, Judith Windt
  • Telephone Triage for Obstetrics and Gynecology by Vicki E. Long, Patricia C. McMullen
  • Telephone Triage of the Obstetric Patient by Deborah E. Swenson
  • Telephone Triage Protocols for Adult and School Age Populations with Women’s Health and Infant/Child Protocols by Sheila Wheeler, RN, MS
  • Tele-Nurse by Marijo Baird, Sandi Lafferty

Additional Resources: In addition to information on the websites of the preceding vendors, also consider:

Peter DeHaan is the publisher and editor-in-chief of AnswerStat magazine and a passionate wordsmith. Connect with him on his personal blogs, social media sites, and newsletter, all accessible from peterdehaan.com.

[From the Fall 2003 issue of AnswerStat magazine]

Dr. Barton Schmitt Interview: Telephone Triage Protocols

By Peter Lyle DeHaan, Ph.D.

Peter DeHaan, Publisher and Editor of AnswerStat

One of the pioneers of telephone triage protocols is Dr.Barton Schmitt. His telephone triage clinical content for pediatrics is used by McKesson, LVM Systems, Epic, Intellicare, Fonemed, and United Health Care (Optum). Together that is over 400 call centers. The book form is used in an estimated 10,000 pediatric offices. With a 30 year history behind it, we recently asked him to share his story with readers. Here is what he had to say:

How has the triage protocols changed over the last 30 years?

They have become more complete and more comprehensive including lots of background information to help nurses learn this field. They have also become more experience-based (I know 10 times more now than I knew then), and more evidence-based, thanks to research on them and the ever-expanding medical literature.

How did you get started?  Why did you write the Telephone Triage Protocols?

I’ve always enjoyed the challenge of taking parent phone calls and trying to make the correct diagnosis without seeing the patient. In 1973, while I was Medical Director of the Urgent Care Center (UCC) for children at the University

By 1975, the collection of triage protocols had grown to 100. Graduates of our program who were going into practice began to ask for them and I provided them in binders. Over the course of a few years, I’d given away over 200 of these binders. By 1978, I’d expanded the collection to over 180 topics and tried to find a publisher. I submitted to the leading medical publishers. The book received unanimous rejection letters. The main reason they gave was that “it was heresy to suggest that nurses could (or should) ever triage medical calls.”

In 1980, the book Pediatric Telephone Advice was finally published by Little, Brown & Co. in Boston, who was just breaking into the medical publishing business. Within a matter of years, it was also published in French, Portuguese, and Japanese. It has continued to be a good seller and is going into its third edition. This book has remained a self-study guide for nurses or physicians in training.

In 1990, I wrote a streamlined (telegraphic) version for use by the advanced practice telephone triage nurses who worked in our call center at The Children’s Hospital (TCH) in Denver. The new book was called Pediatric Telephone Protocols. In 1994, I self-published this book because of the demand for it by call centers at other hospitals. I updated it yearly. In 2000, the American Academy of Pediatrics (AAP) picked up the publishing and distribution rights. The 10th edition will be released in early 2004. In 1994, I also started collaborating with NHES (National Health Enhancement Systems) to produce a software version of pediatric telephone triage. Because our call center was covering for over 120 pediatricians, we needed to improve efficiency. In 1999 I became software vendor neutral. In 2000, I collaborated with David Thompson, MD.

Why did you partner with David Thompson, MD, FACEP?

David and I share similar backgrounds, and therefore we find it very easy to work together. Working in the Emergency Department (ED), David is involved with direct patient triage on a daily basis. That’s required in a setting where you have 10 patients in different rooms and you need to prioritize exactly who you’re going to see next, who gets a procedure, who gets an x-ray, and who can safely wait. I worked in an emergency department for five years, and know how important it is to have razor-sharp decision-making. At the present time, David is on the American College of Emergency Physicians (ACEP) and Emergency Nurse Association (ENA) National Triage Task Force that’s attempting to standardize emergency department triage.

The advantage of us working together is that the adult triage protocols and the pediatric triage protocols share parallel layouts, dispositions, and logic. This makes it easy for the nurse in a full age range call center to move back and forth from pediatrics to women’s health to adult health to geriatric decision making. Nurses appreciate the seamless flow between protocols. Having two people responsible for keeping the protocols compatible is an attainable goal. We have developed over 100 rules that we follow closely to achieve and preserve clarity and consistency. David is my best critic. We spur each other on to producing a better triage product.

How important is feedback from others?

It’s the lifeblood of the fine-tuning process. I’ve been medical director of the Children’s Hospital After-Hours Call Center since its inception in 1988. It is the crucible in which I test my protocols. I have the privilege of working with 40 pediatric telephone nurses who have specialized in this field. Their critiques and feedback are invaluable.

In addition, I work with 30 ED physicians who see the patients our call center refers in, and they have no hesitation in questioning my triage guidelines or judgment if we over refer to them. If their concern makes sense, I make changes in the protocol. I also have over 400 primary care physicians (PCPs) throughout Colorado, half of whom have trained here, that give me feedback if they think we have over referred or under referred one of their patients. For any under referral, we always do a complete review of the complaint, including listening to the phone encounter which is automatically recorded on all calls.

I also receive unexpected communications from nurse managers, medical directors and triage nurses in various call centers throughout the country. I value these questions and critiques. I respond to them directly and make appropriate changes in the protocols when indicated. In summary, I welcome input from anyone who uses my clinical content.

What are some of the health care goals behind your triage protocols?

  • Prevent all under referrals of emergent or urgent conditions (safe care).
  • Minimize over referrals (unnecessary ED and office visits) (cost-effective care and family-focused convenient care).
  • Help triage nurses use the most appropriate protocol through optimal search words and cross-linkages.
  • Provide the caller with targeted, current health care information/education.
  • Educate callers about misconceptions that lead to frequent unnecessary calls (e.g. fever, phobia, green nasal discharge, or productive coughs).
  • Achieve more than 98% triage nurse satisfaction with clinical content.
  • Achieve more than 95% caller satisfaction with service provided.
  • Achieve more than 90% primary care physician concurrence with decision-making.
  • Continuously improve clinical content by incorporating user feedback, reviewer feedback, quality improvement outcomes, research outcomes, and the current medical literature.

How do the philosophies of the three versions differ?

  • All versions use the same criteria for recognizing 911 symptoms or conditions.
  • All versions have similar triage questions and care advice. This helps with consistency of care. Mainly, the dispositions within each set are different.
  • The After-Hours version is for evening, weekend, and holiday coverage by call centers or physicians. Approximately 20% of patients are referred in to the ED or UCC. Whenever it is safe to do so, patients are referred to the physicians’ office on the following day.
  • The Office-Hours version is for triage when the office is open. No one is sent to the ED without the PCP prior approval. Approximately 50% of callers are brought to the office. Anyone who wants to be seen is worked into the office schedule. The remaining callers are provided with specific home care and self-care advice. The software version of office-hours triage is an expanded version of the book the AAP distributes to office pediatricians. This has the advantage of having the parent hear the same advice from the call center and their PCP’s office.
  • The managed care version is for health insurance companies. If a caller needs to be seen and doesn’t need to go to an ED, they are re-directed to call their PCP for further triage. Those who can safely be treated at home are advised similarly to the other versions.

Tell us about HouseCalls Online.

HouseCalls Online are Internet-based self-care guidelines. There is both a pediatric and an adult version. They are available in English and Spanish. Over 20 hospitals currently have them on their website and most report frequent use and a lowered call volume; in essence, they are off-loading some of their low-acuity calls to the web. An exit survey to one website documented 100% of parents thought both the triage and advice they received were understandable and easy to use and 60% said it prevented a call to their doctor’s office. An added benefit is that the content is compatible with Schmitt/Thompson nurse triage guidelines. Some call centers have launched marketing campaigns to redirect unnecessary calls to this resource.

Tell us about the after-hours call center program at The Children’s Hospital (TCH).

It is in Denver, Colorado and was established 1988. It is a statewide system in Colorado and Wyoming.

Will you highlight the stats for the call center?

  • Volume: 10,300 calls per month (2002)
  • Total: 123,000 calls/year (2002)
  • Provided for 477 physicians
    • Private physicians: 337 (324 pediatricians and 13 family physician)
      (includes 98% of metro Denver pediatricians)
    • Kaiser Permanente physicians: 140 (50% pediatricians)
  • Provided by 40 Pediatric RNs (both full-time and part-time)
    • 1 RN can cover 15 pediatricians
    • 1 RN can take 6 calls per hour or 42 calls per shift
  • Disposition of TCH Nurse-Triaged Calls
    • See patient after hours: 20% (admission rate 1:88 calls or 1.1%)
    • See patient within 24 hours: 30% (usually in physician’s office)
    • Telephone advice for home care only: 50%
    • Excludes: advice-only calls 6%
      • Clinical Nurse Manager: Kris Light RN
      • Software Systems Coordinator: Teresa Hegarty RN
      • Medical Director: Barton Schmitt MD

Thank you for taking time to share with our readers.

Thank you

Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat. He’s a passionate wordsmith whose goal is to change the world one word at a time.


[From the Fall 2003 issue of AnswerStat magazine]