Err on the Side of Caution

I mentioned in a previous post about as RNs, we should exercise critical, independent thinking skills and use protocols as a guidance in helping us do that. The following is an example of how one of our nurse's did just that.
The nurse received the call on a weekend morning from a worried mother regarding her 14 year old son who had been experiencing right sided lower abdominal pain for 24 hours. The only other symptom the child had was abdominal pain on urination. The mom called because the pain appeared to be getting worse, and the child did not sleep well the night before. He had been drinking fluids well, but a had a decreased appetite. He had no other symptoms classic of appendicitis. There was no fever, no vomiting, no pain on palpation, nothing.
One might interpret the symptoms as possible a kidney or bladder stone or maybe even a UTI since there was pain on urination. However, the nurse used the protocol as a guide, and erring on the side of caution, sent the child to the ED for evaluation as the protocol recommended. The child was subsequently diagnosed with acute appendicitis and had an appendectomy later that afternoon.
Often, I find nurses wanting to read too much into the problem and try to second guess or diagnose what they think the problem is. That is not within our scope of practice to diagnose. Our position as effective triage nurses is to recognize there is a potential problem and to determine what needs to be done to get the patient safely to the next level of care, doing so with caution and being intuitive that there could be a potentially worse situation than what we even realize.
Does this mean send all patients to the ED? Of course not. It means using good listening skills, being an excellent critical thinker, and "going with your gut". Just because all the symptoms are not present to give a disposition of ED does not mean that is the best decision to make. If your instinct is telling you that the patient needs a higher level of care, it is best to seek that option for them, and what is the worst that could happen? The patient is seen unnecessarily in the ED. That sure beats the alternative of hearing later that the they suffered undo harm because the nurse did not pick up on the subtle symptoms. Remember, all patients are individuals and do not always present with textbook signs.

Recommended Reading!

I commented on my last post that I am reading the new book written by Carol Rutenberg and Liz Greenberg, The Art and Science of Telephone Triage. This is a brand new resource that was released this year by Anthony J.Janetti, Inc, and endorsed by the AAACN!
So far, I have found this book to be enjoyable and educational. It takes you from how telephone triage came into being, where it is now, and where it is going. Along the way, they have included how to correctly run a successful triage program, whether it be in an office or a call center, the legal aspects of telephone triage nursing across state lines, and my personal favorite, true triage stories to learn by.
So far, I have used some of these stories in our staff monthly newsletter as a training tool, and our nurses have commented on how much they too have learned and how interesting they are.
This resource has been needed for a long time. There are several telephone triage books and resources available, but none puts the pearls and perils into the same perspective as this book does. I would encourage anyone to read it and use it as a valuable resource for their telephone triaging. I also think it would be a great book for someone who is interesting in entering this specialty area, and a valuable training resource for those new to the field as well.
I am encouraging our nurses to read it!

Real Telephone Triage

There are so many telephone triage companies now that it would be impossible to name them all, and I am definitely not here to say there is any one program that is better than another. However, has telephone triage gotten so complex that many have lost focus on what it really is?
I have seen complex programs, and have spoken with many experienced telephone triage nurses that tell me they feel like robots reading from computer screens. Systems have gotten so complex that they are not given the ability to actually use what they were trained to do, and that is be independent critical thinkers and use the nursing judgment skills they were trained with. Many of these nurses are now expected to be secretaries among other duties and track waiting times in urgent cares for instance. Is that really providing patient focused care?
What is wrong with being able to follow a protocol for questions to ask, to get the information needed to make a sound judgement of if the patient needs immediate treatment, or can it wait until the office opens? And, if there is not a protocol that fits, to be able to use nursing judgment to give sound advice? I know that I have spoken with patients who are grateful to be able to get appropriate advice from someone who can think independently from a computer screen, and I know the patients can tell when that advice is being read to them vs actually coming from a voice of experience and reassurance. Offices have verbalized that they appreciate personalized attention given to their patients from experienced telephone triage nurses.
Alot of money can be spent in some elaborate systems, and they sure look attractive, but I am proud to say that we ARE what telephone triage nursing is...Quality telephone advice given following standardized protocols, by caring, experienced triage nurses who go the extra mile to educate, advocate and direct the caller to the most appropriate next step of care. All completed without the complexities of navigating among many screens for one symptom.
Our nurses care about their callers, and many will tell you they will take patient focused care and the freedom to be a real nurse any day!!
It would be interesting to see how many other triage nurses feel the same.