The Nurse Telephone Triage Blog

The Angry Caller

2011-12-13T17:55:00.000-08:00

A co-worker the other day, about 3 hours into her shift commented that so far she had been told she was stupid, that she needed to go back to school, and was hung up on twice. I have felt her frustration many times, but I could not help but wonder what her approach was.
Granted, we have all dealt with those kinds of callers, and I have had my share of them, but at least 95 percent of the time, the call starts that way and ends with the caller thanking you for your help if you chose your words carefully.
The first thing to remember is...deep breath. The caller does not know you at all, and they are not mad at you. They could be frustrated with chronic illness, the medical system, the pharmacy or their physician. You just happen to be the cat to kick out of the way at the moment.
The second step is close your mouth and listen...really listen. Acknowledge their frustrations and feelings. Tell them you hear their frustration and concerns and would love to help them, and do, if you can. If you cannot, give them a logical explanation why, and instruct them instead on what they need to do to solve their problem.
Lastly, thank them for calling, even if you were not able to solve their concerns. Reassure them that you are there to help, and encourage them to call again if further questions or concerns arise.
Many times the caller knows you may not be able to fix their issue, and they just want to know there is a friendly voice on the other end of the phone that they can talk to night or day. Remember, what you say to them in that conversation can make a lasting impression, and word travels back to their physician's office of what kind of impression that was.

Scared of Rashes

2011-10-19T08:38:00.000-07:00

So many times, I hear nurses say they hate rash calls. It is because they are afraid of what they cannot see, and I find myself saying, "Let your ears be your eyes".
When you receive a rash call, the first thing you must do is assess if there are associated signs with it. This helps you decide which protocol to use. One of the first questions I ask with a rash is, "Is there a fever?". The questions that follow should determine if the patient is on any medications, presence of itching, and/or has had any new exposures. Common new exposures that cause rashes are new unlaundered clothes; new soaps and laundry detergents; new beauty supplies, including lotions and sunscreen; new pets; new hobbies; and outdoor plant contact. Inflammation should be assessed by asking if the rash is tender to touch.
The location of the rash is easy to determine. Locations are either described as focal, patchy, or diffuse. A focal rash is specific to a specific body part. If the rash is only on a specific body part, it is still considered focal (eg, the hands, cheeks, or lower extremities). A patchy rash is considered on more than one body part but not on all body parts. For example, the rash could be all on exposed body parts only, or only on covered body parts. A diffuse rash covers multiple body parts, usually the entire body.
If a rash cannot be felt, or is not raised, it is said to be macular or consist of macules. If a rash can be felt and is raised, then it is papular or consists of papules. A lesion that contains clear fluid is a vesicle, and a rash that contains cloudy fluid or purulent material is a pustule. Some rashes can be macular and papular, with some areas being palpable and others not.
Describing the color is simple. Just ask the caller the color of the rash. If the do not volunteer an answer, give them the choice of skin colored, pink, red, purple, hypo- or hyper-pigmented.
One of the most important characteristics of a rash that is also the hardest to determine over the phone, and is so important to determine, is if the rash is blanching or non-blanching. If it is non-blanching, it could indicate the presence of blood outside of the blood vessels as occurs with petechiae or purpura. One method to determine this is have the caller apply pressure to the rash with a finger and then quickly remove the finger and look and see if the color changes. The caller needs to be told to look quickly if the rash loses its color then changes back.
The shape of the rash can be described as annular (circular), linear, or irregular. If a rash is confluent, then it covers the entire region without large areas of normal skin. If it is patchy, then areas of normal skin are interspersed with rash areas. A rash with central clearing has normal skin encircled with a rash.
The last characteristic is the appearance of the rash as dry, wet (weeping), scaly or crusted.
It can be overwhelming to attempt to decide which rash protocol to use. You have to consider what other factors are present, not just the rash. Is there a fever? Presence of fever can indicate many childhood illnesses such has Chicken Pox or Hand, Foot and Mouth Disease, but it could also be something indicative of a more serious illness such as Meningitis can also sometimes have the presence of rash.
What is the location of the rash? If it is widespread, is the patient on any new medications, especially antibiotics? If it is a child, have they been exposed to viruses? If it is a localized rash, and all else fails, ask the caller if they have any idea where the rash came from. Of course, you cannot just assume that is the cause without ruling out other possibilities, but often, the caller may know.
Rashes should not scare the triage nurse. They are challenging that is for sure, but keep in mind, it is not the rash that is often the most troubling, but other symptoms that the patient may have will often lead you to determining the protocol to use.

Who Said This Is All Cut and Dried?

2011-08-15T20:18:00.000-07:00

How do you begin to tell someone what a telephone triage nurse's job description entails? My advice is you just have to watch one work a shift to know. I really don't know there are enough words that could describe everything that goes on during that shift. In speaking with a colleague the other day, I described it as the hardest job I have ever done in my 20 years of nursing, and I meant every word of it. It is hard because it is very mentally demanding.
A lot of people have a preconceived notion that being a triage nurse means getting to chat on the phone and give advice. This could not be farther from the truth. You have to rely strongly on your ability to ask questions, and your ability to listen. Along with these traits, you must have excellent assessment skills, and most important of all, experience. You rely heavily on this alot.
You hope the calls you get are simple like colds or fever but the reality is, very few are like that. Many times, you make the call, thinking it is going to be something like this, and suddenly have to shift gears. The call has suddenly turned into acute croup, meaning you have to find that protocol quickly, because the ones you thought you were going to use suddenly do not pertain anymore.
You cannot physically assess the patient, and therefore, you have to be skilled in asking the appropriate questions to get the answers you need. And, if you are not listening closely, you may miss that one piece of information that could decide what disposition you chose.
So many times I hear, "This is not cut and dried as it should be. There are too many exceptions." But is not every patient different, and their symptoms different? So, how can anyone expect it to be cut and dried?
Along with the patient, each office has their own preferences on how to handle certain calls, so you must always be familiar with them, and if you make appointments, where do you make them and when? Still, along with all this, you have to have the ability to type, listen and talk. Don't forget there is the ability to control the call, and resolve the patient's problem in a timely manner, and move on because you have what seems like another hundred calls waiting.
So, in conclusion, if you are looking for something that is cut and dried, telephone triage nursing is far from it. Each day, brings new experiences and challenges, but when you hang up the phone knowing the caller on the other end is appreciative of your help, it makes each day worth it.

Unraveling The Mystery

2011-07-14T18:32:00.000-07:00

Anyone who knows me knows that I eat, sleep and breathe triage, but especially documentation. That, after all, is a huge part of a triage nurse's life. Or, at least it should be.
Every time I think of documentation, I remember a nursing school school instructor's words ringing in my ears, "If it isn't written, it wasn't done". And so many times, when you examine a note, it appears it wasn't done, because the nurse forgot to add it. This is so easily done in our fast paced environment, but that one little sentence you forgot to add could be your down fall in court.
I like to compare notes to reading a mystery novel. You should be able to pick it up, not knowing anything about the patient, and it give you a story from beginning to end. If it does not, something is missing.
The story should begin with the concern that the caller is reporting, and related symptoms. Details are the adjectives, who, what, when, where, and to what extent. Descriptions should be as complete as possible and paint a picture of the problem.
The body should include treatment that has been tried for the problem, if any, and the outcome.
The ending should include your advice to the caller, including protocols referenced that were followed. If any advice is given that is not included in the protocol, then it must be spelled out in the notes. If it is not, you cannot prove it was done. This is where so many nurses make their mistakes, and the story leaves you hanging. You do not know the ending, and no one likes being left at the end of a mystery with no conclusion.
So, strive to give all your stories an ending, and leave the reader satisfied that they got the complete story.

What The Caller Really Means To Say

2011-05-23T10:43:00.000-07:00

Often, you may get calls where the caller does not really understand the medical terminology they use. Many times, this is a lack of education or fear of what is really wrong with the patient. It is the telephone triage nurse's job to interpret and clarify what the caller is really trying to say. The nurse many times cannot take the caller's description verbatim and should document the difference between the caller's words, and what they are really trying to say. Let's look at some of the terms the caller may say, and what they may actually mean.

Lethargic means a serious change in activity where a patient is too weak or exhausted to move or interact, but to the caller, this may just mean a decrease in activity level. Ask what the patient has been specifically doing. Have they been been getting up to the bathroom, eating, walking or watching television? If so, they are not lethargic. The term lethargic should not appear in the nurse's documentation unless the disposition is call 911. If the patient is not getting up as often, or the child is not getting up and playing with toys but may be lying on the couch watching TV, then an alternate description would be decreased activity.

Limp means a loss of tone, and can be serious. Many times this means decreased activity and lying down most of the day, when the caller uses this term. Again, decreased activity would be an alternate description.

When a caller uses the term "coughing nonstop", they may mean the cough has been occurring hourly or daily. However, a continuous cough is one that prevents the patient from eating, drinking, sleeping, or participating in normal activities. If possible, the nurse needs to listen to the patient to determine if it is occurring frequently enough to interfere with activities. An alternative description would be frequent cough, but able to perform normal activities.

Never accept the caller's diagnosis of a rash unless their description is consistent with that of the definition in the guideline or the patient has already been diagnosed by a healthcare professional who has seen the patient. Often patients or parents will diagnose insect bites, impetigo, viral rashes and contact dermatitis as chickenpox, measles, welts, or hives. The best thing to do is describe the rash than using a diagnosis as a label.

It is important to differentiate between decreased urine output and no output. If the caller says no urine output, they may mean the output is greatly decreased or they have not witnessed any output by the patient. For patients who wear diapers, it is important to ask if the diaper is completely dry or slightly damp. Any urine in the diaper is reassuring. It is best to ask how often the patient is voiding and when was the last time, and note output is decreased.

It is obviously a red flag if the caller says the patient is having trouble breathing. Assessment is based on the patient's age. If an infant, the ability to drink a bottle normally and breathing through the nose is reassuring. If older children are able to sing, play and talk, then their respiratory distress is not severe. Often, callers will use trouble breathing to say their children are congested or breathing fast. A better term to use would be nasal congestion or upper airway congestion.

Constant abdominal pain, if significant, will leave the patient with impairment in activities. Most likely, the patient will not be active, probably not have an appetite, and have trouble sleeping. Intermittent pain is different and often represents pain associated with intestinal motility. A better description would be to use intermittent abdominal pain.

Diarrhea is often used to describe loose stools. One or two stools does not indicate diarrhea. Diarrhea refers to increased frequency, amount, and looseness of bowel movements. The best description to use is loose stools.

Constipation does not necessarily mean the patient is having trouble having a bowel movement. Constipation refers to infrequent stools that are usually hard and, in infants, pellet-like. If the feces are soft and the bowel movements are regular then it is not constipation. Regular bowel movements could range from several a day to one every 2 to 3 days. An alternative description would be trouble having bowel movement, but soft and regular.

Vomiting must be distinguished from spitting up to normal reflux of gastric contents. The difference is spitting up is usually not forceful and dribbles out of the mouth without effort. Spitting up is usually consistent of formula and not bile. Both can come out of the nose. Vomiting requires contraction of the abdominal muscles and takes effort. Spitting up is effortless. An alternate description would be spitting up.

Nurse's Week 2011

2011-04-27T19:30:00.000-07:00

Another year has gone by...Wow, where did it go? As National Nurse's Week approaches again, I have been reflecting on our business and the great nurses I am so blessed to know.
Who would think that working in a virtual environment that you would really get to know your co-workers? Most people have a perception of working in a virtual environment as being for those who do not enjoy the socialization of others, but I believe we truly have our own Utopia.
So many of us have known each other for a while now, and have developed some close bonds. Who would think that some great friendships would come from sitting in front of a computer day after day, and be built over thousands of miles. But, here at NTTS, that is what has happened. In fact, we have developed our own little "family".
Wikipedia defines family as those that are transplanted via migration to flourish in their new societies. Science classifies family as being groups that are closely related. That is what has happened within our organization. Nurses, who are closely related in what we do, have flourished in our little society. I have had the privilege of watching this first hand, and it is amazing to see what we can accomplish together.
So, to my fellow nurses, Happy Nurse's Week! You do a great job at taking care of the patients we serve! I am so proud to know all of you, and thank you for making this a great place to be!

Protocols Are Not the Gospel

2011-03-26T20:21:00.000-07:00

As telephone triage nurses, sometimes we get tunnel vision. By that, I mean, all we see are the protocols and not the rest of the picture. We forget that first, we are RNs, meaning we have the ability to work independently and make independent decisions.
Protocols are a guideline and only that. They give us the minimum action that should be taken and guidelines for advice, but we should be using our nursing judgment and assessment skills to complete the picture. Too many times I hear nurses say, "But the protocol calls for them to be seen in the ED" when the child is screaming with an earache.
Yes, it does say that, but other factors have to be taken into consideration as well. Is the correct dose of medication being given for the child's weight? If I were a betting girl, I would bet 50 percent of parents are under dosing their children when it comes to giving OTC pain relievers and fever reducers. Also, keep in mind each child is different, one medication make work more effectively for some children than others. Nothing wrong with suggesting to try Ibuprofen if Acetaminophen is not working, unless of course the child has an allergy or has been previously instructed not to use by the primary physician.
Read the protocol! Lots of helpful information in there on how to get the parent through the night until the office opens in the morning. Has the parent tried heat or ice for 20 min? Is the child's head elevated? What about a humidifier running? If there are co-existing cold symptoms, maybe relieving those symptoms will help with the ear pain and pressure.
Also, never forget, kids are real little drama kings and queens. With some children, they will scream over a hang nail. And, the best judge of that is the parent. Ask them how well the child tolerates pain.
Finally, once all of these measures have been tried and exhausted, then of course, follow your protocol guidelines. Remember, we are here to give the best advice possible, and if that means we can go the extra mile to keep the patient out of the ED when it is not necessary, then our job has been well done.
Learn to use what we were trained to do friends! Take those blinders off and be the independent decision maker you were trained to be, follow your guidelines, but take all factors into consideration before giving your disposition.

All In The Approach

2011-02-16T13:05:00.000-08:00

As telephone triage nurses, our job is to educate. When patients are calling after hours, they are worried and seeking reassurance or they would not be calling. Many times, they think medication is going to cure the problem, they feel they need to hear the advice from the physician to make it real to them, or they are afraid the nurse will not communicate to their physician that they called or that their child is sick.
The first thing to keep in mind is you must sound reassuring and confident, even if you are new to this field and feel like you don't have any idea what you are talking about. Now, we know that is not the case, but you feel that way when you step out of familiar territory into something new. Every organization and/or facility has a training program that they have moved you through before you began, and you have protocols to follow, but until you have made it through those first few calls, you do feel very unsure.
If your voice is hesitant,or you have alot of pauses in your advice and conversation with the caller, of course, they next thing they are going to do is ask you to page the physician on call.
How do you prevent this? The best advice I can give, is know your protocols. Take some time to read through them, and familiarize yourself with the information they contain. If you know the material you are talking about, it reinforces what you are saying to the caller, because you are confident in what you are advising them of, and you are much more equipped to answer their questions.
Be prepared to give them an explanation for why you are advising them to do what you are instructing. If they have explanations, they will feel more reassured. If you advise that medications are not called in after hours, tell them why. If that pt with the UTI symptoms is asking why they cannot get an antibiotic called in, tell them that a culture must be done in order to prescribe an effective treatment plan. One antibiotic does not cure all bugs.
The next thing is to reassure the caller that you are in close contact with the physician, and that the physician gets a record of every time they call and what that call entailed, including advice that was given.
Sometimes, despite all education attempts and reassurance, the caller still will want you to page the physician, and that is ok too, but if they feel you are knowledgeable and confident, most of the time you can end the call with ease and the caller will be pleased.

Mentoring

2011-01-24T20:35:00.000-08:00

Mentoring....Traditionally, mentoring might have been described as the activities conducted by a person (the mentor) for another person (the mentee) in order to help that other person to do a job more effectively and/or to progress in their career. The mentor was probably someone who had "been there, done that" before. A mentor might use a variety of approaches, eg, coaching, training, discussion, counseling, etc.
One thing I have learned, is that to be an effective mentor, you have to have the same level of interest, commitment, and confidence in your own abilities as the person you are teaching. And, you truly have to be interested in seeing someone else grow in their abilities. It is hard work, but you get the satisfaction of seeing someone else grow and become successful in their endeavors, and that is satisfaction that you cannot put a price tag on.
Telephone triage nursing is a highly specialized field that too many nurses do not succeed in if they do not have a mentor to nurture them and see them through the learning process. And, really, you need someone who is not just a preceptor, but someone who truly fits the mentoring role.
When searching for that perfect mentor to teach you the ins and outs of Triage Nursing, look for the following qualities:
1. Experience- how can they teach you, if they have not "been there and done that"?
2. Character- your mentor should be a person that you respect and admire.
3. Similar Goals- it helps when your mentor has already gone through similar work that you have in front of you.
4. Availability- your mentor should be available for interaction.
5. Open-minded- your mentor should allow you to progress in ways you need to progress, not necessarily like them.
6. Caring- a mentor needs to care about your success as much as you do.
7. Positive- you need a mentor to be positive to keep you positive. If you spend enough time around them, it rubs off.
8. Focus- you need a mentor who is not only able to focus on you and what you would like to achieve, but also helps you focus.
9. Believes in you- a mentor believes in your potential. If they are not sold on you, they are not going to put all their efforts into your success.
10. Open and Honest- builds credibility and trust. It is beneficial when you both can share bits and pieces about yourself that others may not know.

This is only a guide in what to look for to get you through this learning process. You can add and subtract from these qualities when looking for someone to mold you into becoming a real "telephone triage nurse".

The Benefits of Nursing Triage Services

2011-01-02T17:08:00.000-08:00

What is a Nurse Telephone Triage?

Author:

Kurt Duncan

A nurse telephone triage service is a feature offered in some clinics or hospitals that let patients ask certain medical questions of experienced nurses. However, a triage is about more than just a general Q&A. These nurses have to be experienced and educated enough to make a cautious recommendation without seeing the patient in person. Therefore, nurses must rely on their communication skills. They may be asked to determine disease symptoms, or make treatment recommendations, provided the matter doesn’t immediately require a physician. In addition to having good conversation qualities, a triage nurse must also have good listening skills so that she can ascertain any non-verbal communication that may be happening in a given call.

A nurse telephone triage is usually offered by healthcare facilities and perhaps by a physician\'s office directly. Ideally, the patient would like to contact the doctor, but may be content to share information with the nurse. These phone lines are often kept open “after hours” in the event of an emergency. It should be noted that while nurses have to be perceptive about individual cases, they cannot diagnose clients over the phone. Basically, the nurse telephone triage has the obligation to determine the severity of the caller’s complaint and then direct the caller to the appropriate emergency service.

Have you ever considered starting a nurse telephone triage line for your practice? It may help tremendously, especially if you have patients that can never seem to “relax” and find it necessary to call you ten times a day. Not that you devalue their business; but some patients may worry to an excessive degree. If this is true of many of your clientele then you can certainly see the advantage in starting a nurse telephone triage line.

Instead of hiring three or four staff members for a nurse telephone triage, you can always outsource the work to a medical call center. Medical call centers are a step above the ordinary call center; these operators are trained in the medical field and meet HIPAA requirements. This option allows you to delegate some of your authority to a qualified nurse—and without having to pay an additional salary. You simply pay for the service.

You do owe your patients a great deal. Sure, it would be nice to be “on call” 24 hours a day for their needs. You can’t provide that on your own. However, working with an outsourced nurse telephone triage does provide your patients with additional care.

Will Your Note Hold Up in Court?

2010-11-16T19:03:00.000-08:00

One of the details of my daily routine is to read over nurses' documentation. Many times as I read notes, so much information is missing, and I cannot help but think, "Would this nurse remember this conversation a year from now, and how would she prove she gave accurate and complete advice?"
Let's look at what an accurate note consists of. The easiest way to remember what to include in an accurate note is to put it this way:
Analytical
Concise
Chronological
Unambiguous
Risk-Focused
Accountability
Timely
Explanation
Analytical: The difference between telephone triage assessment and assessing a patient face to face is that you cannot visualize the patient. Your listening skills must be sharp, and you not only are you listening to what the caller is telling you, but you are also listening for sounds that helps with your assessment of the patient. These might include a cough, breathing, crying, anxiety, pain, and fear. Taking into account all of these things, the nurse must determine an accurate assessment.
Concise: Every note must be as brief as possible, but must include every pertinent detail of the call including symptoms, measurements, complaints and/or concerns.
Chronological: While painting the complete picture of the problem at hand, it is best that the events be given in chronological order from when the symptoms started until the time of the call to the triage nurse.
Unambiguous: The note must give clear details of the call. It is best to answer the 5 W's to avoid leaving out any details. These include what, when, where, why, how and to what extent.
Risk-Focused: No one wants to think that they might sometime be a party to a law suit, but realistically, at some point, that could be a very real possibility. Therefore, you must document defensively. Make sure that all documentation includes a complete assessment, and if possible include the patient's own words. Do not be judgmental, but give facts. When giving advice, adhere strictly with the protocol, and thoroughly document any advice given that is beyond what the protocol states. Contact with physicians should be documented and any new orders received should be documented as well.
Accountability: Not only are nurses accountable for their actions, but some accountability falls on the patient or caregiver as well. It is important to document that they understand instructions given and their intent to comply. If they choose not to comply, then the note should reflect documentation of such, and that they were advised of any risks of not complying. If the nurse feels the patient's life could be compromised by not complying, then the nurse should notify the physician on call.
Timely: The nurse is accountable to give timely advice and/or instructions. If the call is determined to be life threatening in nature, the call should cease with the nurse instructing the caller to call 911 for further assistance. Every second counts, and the nurse should follow-up within a few minutes to be sure the patient is receiving the life saving assistance they are entitled to.
Explanation: The caller deserves an explanation of why they are being given the advice or instructions that they have received from the nurse. They are much more likely to comply if they understand why, and they will be reassured that they are being given knowledgeable advice. In return, the caller will be pleased, and will be less likely to call back for reassurance.

Telephone triage nursing is so different than bedside nursing, because the senses of touch, sight, and smell cannot be used. This means that listening skills have to be so much sharper, and in return requires quick thinking and decision skills by the nurse.

Flu Season Nightmares

2010-10-20T17:17:00.000-07:00

As the 2010-2011 Flu Season quickly approaches, my mind wanders back to last year, and I feel my heart racing, weakness comes over me, a fine, cold sweat breaks out on my forehead, and I get a nauseous feeling in the pit of my stomach. Anyone who is a telephone triage nurse and survived last year's flu season deserves a combat medal of honor, and the biggest reason is the dear old media. Anytime they put something in the headlines, people panic, and suddenly every ache and pain that they experience is what the media is talking about.
Hopefully, with all fingers and toes crossed, I am praying this year will be different. Here is some helpful refresher information on the clinical signs and symptoms of influenza listed on the CDC's website:

Influenza viruses are spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a susceptible person). Transmission via large-particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only a short distance (less than or equal to 1 meter) through the air. Contact with respiratory-droplet contaminated surfaces is another possible source of transmission. Airborne transmission (via small-particle residue [less than or equal to 5µm] of evaporated droplets that might remain suspended in the air for long periods of time) also is thought to be possible, although data supporting airborne transmission are limited. The typical incubation period for influenza is 1—4 days (average: 2 days). Adults shed influenza virus from the day before symptoms begin through 5—10 days after illness onset. However, the amount of virus shed, and presumably infectivity, decreases rapidly by 3—5 days after onset in an experimental human infection model. Young children also might shed virus several days before illness onset, and children can be infectious for 10 or more days after onset of symptoms. Severely immunocompromised persons can shed virus for weeks or months.

Uncomplicated influenza illness is characterized by the abrupt onset of constitutional and respiratory signs and symptoms (e.g., fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis). Among children, otitis media, nausea, and vomiting also are commonly reported with influenza illness. Uncomplicated influenza illness typically resolves after 3—7 days for the majority of persons, although cough and malaise can persist for >2 weeks. However, influenza virus infections can cause primary influenza viral pneumonia; exacerbate underlying medical conditions (e.g., pulmonary or cardiac disease); lead to secondary bacterial pneumonia, sinusitis, or otitis media; or contribute to coinfections with other viral or bacterial pathogens. Young children with influenza virus infection might have initial symptoms mimicking bacterial sepsis with high fevers, and febrile seizures have been reported in 6%—20% of children hospitalized with influenza virus infection. Population-based studies among hospitalized children with laboratory-confirmed influenza have demonstrated that although the majority of hospitalizations are brief (2 or fewer days), 4%—11% of children hospitalized with laboratory-confirmed influenza required treatment in the intensive care unit, and 3% required mechanical ventilation. Among 1,308 hospitalized children in one study, 80% were aged <5 years, and 27% were aged <6 months. Influenza virus infection also has been uncommonly associated with encephalopathy, transverse myelitis, myositis, myocarditis, pericarditis, and Reye syndrome.

Respiratory illnesses caused by influenza virus infection are difficult to distinguish from illnesses caused by other respiratory pathogens on the basis of signs and symptoms alone. Sensitivity and predictive value of clinical definitions vary, depending on the prevalence of other respiratory pathogens and the level of influenza activity. Among generally healthy older adolescents and adults living in areas with confirmed influenza virus circulation, estimates of the positive predictive value of a simple clinical definition of influenza (acute onset of cough and fever) for laboratory-confirmed influenza infection have varied (range: 79%—88%).

Young children are less likely to report typical influenza symptoms (e.g., fever and cough). In studies conducted among children aged 5—12 years, the positive predictive value of fever and cough together was 71%—83%, compared with 64% among children aged <5 years. In one large, population-based surveillance study in which all children with fever or symptoms of acute respiratory tract infection were tested for influenza, 70% of hospitalized children aged <6 months with laboratory-confirmed influenza were reported to have fever and cough, compared with 91% of hospitalized children aged 6 months—5 years. Among children who subsequently were shown to have laboratory-confirmed influenza infections, only 28% of those hospitalized and 17% of those treated as outpatients had a discharge diagnosis of influenza.

Clinical definitions have performed poorly in some studies of older patients. A study of nonhospitalized patients aged 60 and older years indicated that the presence of fever, cough, and acute onset had a positive predictive value of 30% for influenza. Among hospitalized patients aged 65 years and older with chronic cardiopulmonary disease, a combination of fever, cough, and illness of <7 days had a positive predictive value of 53% for confirmed influenza infection. In addition, the absence of symptoms of influenza-like illness (ILI) does not effectively rule out influenza; among hospitalized adults with laboratory-confirmed infection in two studies, 44%—51% had typical ILI symptoms. A study of vaccinated older persons with chronic lung disease reported that cough was not predictive of laboratory–confirmed influenza virus infection, although having both fever or feverishness and myalgia had a positive predictive value of 41%. These results highlight the challenges of identifying influenza illness in the absence of laboratory confirmation and indicate that the diagnosis of influenza should be considered in patients with respiratory symptoms or fever during influenza season.

Hospitalizations and Deaths:

In the United States, annual epidemics of influenza typically occur during the fall or winter months, but the peak of influenza activity can occur as late as April or May (Figure 1). Influenza-related complications requiring urgent medical care, including hospitalizations or deaths, can result from the direct effects of influenza virus infection, from complications associated with age or pregnancy, or from complications of underlying cardiopulmonary conditions or other chronic diseases. Studies that have measured rates of a clinical outcome without a laboratory confirmation of influenza virus infection (e.g., respiratory illness requiring hospitalization during influenza season) to assess the effect of influenza can be difficult to interpret because of circulation of other respiratory pathogens (e.g., respiratory syncytial virus) during the same time as influenza viruses.

During seasonal influenza epidemics from 1979—1980 through 2000—2001, the estimated annual overall number of influenza-associated hospitalizations in the United States ranged from approximately 55,000 to 431,000 per annual epidemic (mean: 226,000). The estimated annual number of deaths attributed to influenza from the 1990—91 influenza season through 1998—99 ranged from 17,000 to 51,000 per epidemic (mean: 36,000). In the United States, the estimated number of influenza-associated deaths increased during 1990—1999. This increase was attributed in part to the substantial increase in the number of persons aged 65 years and older who were at increased risk for death from influenza complications. In one study, an average of approximately 19,000 influenza-associated pulmonary and circulatory deaths per influenza season occurred during 1976—1990, compared with an average of approximately 36,000 deaths per season during 1990—1999. In addition, influenza A (H3N2) viruses, which have been associated with higher mortality (54), predominated in 90% of influenza seasons during 1990—1999, compared with 57% of seasons during 1976—1990.

Influenza viruses cause disease among persons in all age groups. Rates of infection are highest among children, but the risks for complications, hospitalizations, and deaths from influenza are higher among persons aged 65 years and older, young children, and persons of any age who have medical conditions that place them at increased risk for complications from influenza. Estimated rates of influenza-associated hospitalizations and deaths varied substantially by age group in studies conducted during different influenza epidemics. During 1990--1999, estimated average rates of influenza-associated pulmonary and circulatory deaths per 100,000 persons were 0.4--0.6 among persons aged 0--49 years, 7.5 among persons aged 50--64 years, and 98.3 among persons aged 65 years and older.

We can better educate our patients if we educate ourselves and keep abreast of all the latest trends and information on the upcoming flu season. See how you do with this little quiz!

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Unforgetable Patients

2010-09-17T08:22:00.000-07:00

I know the following story does not relate to telephone triage, but I do think there is something in it that anyone can learn from. Sometimes, in our hurried lives, we have to take time for the little things in life...

Time for Martha
I gathered my bag from the trunk of my car, took a deep breath, and headed for the door. I was new to Home Health, and Martha was one of the many patients assigned to my caseload. I was there to assess her, and draw labs, and was admittedly, a little nervous about meeting her for the first time. When you are a case manager, it is very important that you develop a bond with your patients, and I was not sure of how well our first meeting would go.
The one thing I was not aware of was, Martha had a HealthCare Power of Attorney, who was her friend and neighbor, and the Power of Attorney’s mother was her housekeeper. They too were waiting inside for me.
Martha appeared to be the picture of anybody’s grandmother, a typical petite, white haired, 80 something year old who was very cordial, but her POA was anything but nice. Jan almost immediately began laying out the rules of how things went in Martha’s house, and demanded to be included in her care. The mistake I made that day was focusing on Martha, and paying little attention to Jan. Martha, after all, was fully alert and oriented, and was capable of making her own decisions, and I wanted to be the good home health nurse and provide my patient the best care I could. I would learn later that Jan was very protective of her friend, and she felt it was her “duty” to take charge.
Martha took my hand, looked me in the eye, introduced herself to me, and welcomed me into her home. She was widowed, had no children, and had moved to our town approximately 20 years before to retire. She had been diagnosed with lymphoma less than 18 months earlier. Her prognosis was not good, and yet, what drew me to her was her liveliness. Instead of focusing on her condition, she immediately began asking me questions about my life. She was genuinely interested, and not just being respectful. I had a difficult time redirecting her back to the reason for my visit.
I finished my visit, and thought all had gone well, until I went back to the office and was called in to speak to my supervisor. Right after my visit, Jan had called my supervisor, angry that she was not allowed to “take charge”, and wanted me removed from the case. My supervisor had made the decision to call Martha and ask her thoughts on the matter before that decision was made. Martha being the honest, straight-forward person she was decided she wanted to give me a chance, and was not happy that Jan had called when she was unaware. Needless to say, the next few visits after that, I felt like I was walking on egg shells.
I scheduled Martha as one of my first visits of the day because she lived so close to the office, but I quickly learned that was not going to work. She was Jewish, and having tea or coffee with her visitors was very important to her. It was her way of welcoming you to her home and showing friendship. If you quickly completed your visit and left, she was insulted. So, I changed her visit time to the last one for the day, so there would be enough time for Martha. I would call her when I was on my way, and she would have the coffee and cookies ready by the time I arrived. Sometimes, Doris her housekeeper, would be there, but she never said a lot. She just listened. Over time, Jan began to appear less and less, and when she was there, she appeared more relaxed and friendly, much to my relief.
Martha and I developed a bond over the months that followed, and I for a while had a hard time believing her prognosis. She was so full of life. She loved to laugh, and tell stories about her days as one of the only female investment bankers in New York, how she met her husband, and how she learned her colorful vocabulary. Martha professed a strong faith in God, but would very quickly let the curse words fly if something made her mad. Only Martha could pull that off with class.
It was so hard to believe such a tiny person could have such a large heart. It did not take me very long to learn not to admire anything in her home, because if you did, Martha would give it to you. Value did not matter. What mattered to her was making her friends happy. During my time with Martha, I was pregnant with my third child, and she worried about me as if she was my grandmother. My friend and I went to lunch one day, and were involved in a minor car accident. I was not hurt, but asked the office secretary to call her and let her know that my visit with her that day was going to be delayed. By the time we arrived back at the office, the secretary approached me, and urgently advised me to call Martha and let her know that I was ok. Her words to me were, “Martha is ready to send flowers to your funeral”.
One day, I began to see a decline in Martha. She had less energy, and was having more pain. Suddenly, Martha was not as talkative as she used to be, but always smiled when I was there, and continued to ask me about my life and family. I think it created a diversion for her, even for a brief period, to help her forget about her pain. I approached Hospice with her, but she would hear nothing of it. “Hospice is about dying”, she would say, “And besides they cannot do anything for me that you cannot do”.
We continued to make adjustments in her pain medications, and try to make her as comfortable as possible, until one weekend, I received a frantic call from her housekeeper, Doris. She was very apologetic for calling me on my day off, but was distraught and said, “You are the only one she will listen to. Martha is very depressed, and saying she is going to take her entire bottle of pain medication”. I spent an hour on the phone with Martha and Doris that day, and hung up with Martha promising she would not do anything to hurt herself until I saw her again. She never threatened suicide anymore after that, but began to become more distant over time.
Not long after that, I learned Martha had been admitted to the hospital with acute leukemia. The next morning, I made plans to visit with her, but was stopped short by a telephone call from Doris. Martha had died that morning. As I sat there choking back the tears, Doris comforted me by telling me how much our visits had meant. She said, “You always made time for Martha, and that was so important to her”.
Thirteen years later, I still think about Martha from time to time, and laugh when I think about her spunk and charm, but most of all, I think about how she taught me that sometimes it is just the little things in life that matter most. ~

Taking Control of The Call

2010-07-26T16:10:00.000-07:00

To be an effective telephone triage nurse, you must not only give accurate advice according to the protocols, but the call must also be completed in a timely manner. Most calls can be completed in 3 to 5 minutes. Some of the more complicated ones, such as those you have to page a physician for, can sometimes take as long as 15 min for more.
In order for the call to be completed in that 3 to 5 minute window, you must take control of the call from the first second the caller answers. Let's examine further how to accomplish that.
First things first. Get the housekeeping stuff out of the way. By that, I mean verifying spellings, dates of birth, etc.(Make sure the demographics are correct.) Nothing messes with a billing statement more than to have 1 patient with 4 different spellings of the name. Also, with varied accents, and telephone reception, many letters sound the same. So, when you have similar letters such as "d" and "b", it is always a good idea to verify using examples. For instance, you can say, "Do you spell Abby, A, b as in boy, b as in boy, y?". This decreases errors dramatically.
Next, in obtaining the medical history, it is not necessary to obtain all of it, just what is pertinent to the current situation. Medications and allergies should also be obtained and this could include any OTC medications that the pt is taking.
There are certain questions that you should never ask in order to keep the call under control, and quickly gather the assessment information that you need. You should always ask questions that require short, quick responses if possible. One question that should be removed from your vocabulary is, "Tell me what is going on tonight". That leaves the caller wide open to give you any information they want including information that may not obtain to the situation at hand. This leaves you taking longer time trying to decipher what information you need and what you don't.
Stick to the questions in the protocols. If you ask all of those that pertain, you will have a complete picture of what is really going on, and the information will be obtained in a lot less time. If the caller starts to wonder off in the conversation, you can redirect politely by saying, "Let's get back to that in a second.I need to ask you some questions first".
Make the call flow from beginning to end, just like your documentation. Gather all of your assessment information before giving advice. If you skip around, you may miss some valuable bit of information, plus it adds more time to your call. And, by continuously asking all the questions in the protocols, it does not leave time for the caller to think of unnecessary information to tell you.
Finally, smile and be reassuring! Explain to the caller why you are giving the advice that you are. This is the time to educate, but keep it in understandable, layman's terms. Reassure them that they are not alone, and instruct them when they need to call back and what to watch for. If you are reassuring and give them all the information they need to feel empowered, they are more likely to give a good report back to their physician and less likely to call back several times in the same night with more concerns or questions on the same issue.

I Am A Telephone Triage Nurse

2010-07-16T21:00:00.000-07:00

I love it when I meet someone that asks me about my job. If you tell them you are an R.N., the first thing they think is that you work for a hospital somewhere. I love to see the expressions on their faces when I describe to them how I never have to worry about donning scrubs, bad weather, not seeing my family for 12-14 hours per day, or traffic congestion, (unless you count the dogs in the hallway outside my office). I can proudly say I am a Telephone Triage Nurse.

I know from what you have just read, you are thinking, how hard can that be? How can you be a nurse, and actually like your job, or even yet, LOVE it? Some days, after a long shift, I am more tired than when I worked 12 hours on a telemetry floor, but it is more rewarding and enjoyable than I could ever have imagined nursing to be. Sure, when I was a new graduate, I hit the Med-Surg floor with rose colored glasses ready to save the world. It did not take too long before I realized the only thing I was going to be able to save was my sanity.

Nursing has always been a demanding job, and in 2010, the statistics don’t look any better than they ever have for nurses. With the economy in poor shape, tighter restraints have been placed on hospital budgets. This has lead to hiring freezes, holds on raises, and lay-offs. Ultimately, the result is increased patient load for the nurse on the floor. Acuity levels are higher, and nurses are finding themselves filling multiple roles. At the end of the day, you are left saying, “Is this what I want to spend the rest of my career doing?”

After struggling for years in one specialty area or another, I begin to think that there had to be something else better out there. Something that was enjoyable, that allowed me to spend time at home, and yet, the pay was still comparable to what I was earning in a hospital. I earnestly began my search for a new me. Hey let’s face it, nursing is a big part of who we are as individuals! Thus, began my life as a Telephone Triage Nurse.

My work day typically begins about 5:00 in the evening, and ends about 12am. On the weekends and holidays, the hours vary. They can run from 3 to 12 hour shifts that begin with logging onto websites, checking in with the other nurses to see if any updates, checking emails for changes, and getting my headset and phone ready to go. I take a quick peek at the screen, and see only 4 calls in there that need to be returned. Not a bad way to start a July day. If it were January, it would not be unusual to see up to 20 or more calls that all need to be returned within 30 minutes.

Triage nursing is not about chatting on the phone. It is about following specialized protocols for the age specific population that you are dealing with. In addition to protocols, there are office specific requirements, paging physicians, advising over the counter medications when appropriate, correct documentation, and sometimes, true emergencies. (Being computer savvy has its advantages. You could never keep up without at least some basic computer skills.) When you call that patient or parent back, you never know what you are going to find waiting on the other end of that line.

There are times that the job can be so demanding that you wonder if you are going to make it to the end of your shift without either dying from a splitting headache, dehydration because you have not had time to get a drink of water, or a ruptured bladder because there is no time for a bathroom break, but nothing is more heartwarming than to hear the comfort in the first time mom’s voice when she understands that she is not alone at 3am with a newborn who has a temperature of 103, or the reassured elderly gentleman that realizes he is going to be ok, even though he mixed up his medications.

Each call can be so different from the last, and the outcomes are sometimes never known. I have often sent patients who appeared to be critically ill to the ED, and wondered if they lived, or if the advice I gave might have played a part in saving their life. Sometimes, even curiosity plays a role. You can sometimes hang up from a complicated call questioning what is really wrong with that patient.

The one thing that I think I enjoy the most is providing excellent customer service whenever possible. That’s right. The patients are our customers, so are they physicians and for that matter. The other nurses are too. You see, I can’t do this job alone. It requires team participation, and each member of the team is my customer. Excellent customer service means returning calls in a timely manner, attempting to give the most appropriate advice, being respectful to the patient and attempting to meet their momentary needs, respect for the physicians in calling them only when necessary, and supporting my team members because they are there on the front lines with me, side by side. That is the sum of job satisfaction!
I am a telephone triage nurse,….and I LOVE MY JOB!

In Search of a Miracle 911

2010-06-04T18:08:00.000-07:00

We have all been there. The frustrated parent on the other end of the line is searching for someone to make her child better now. Tomorrow is too late. As you attempt to calm this anxious mother, and gather the necessary information to give an accurate assessment and advice, she becomes angry, and questions why you are asking her "unnecessary questions" when she just wants some straight answers. Does this sound familiar?
Let's pause for a moment, and consider what this parent may be going through.Parents like to be in control of every aspect of their child's life, especially when they are small. Most parents take the charge that is given to them seriously,and therefore,they desire to meet that child's basic needs for food, clothing, shelter, and love, and they continue to want to meet that child's needs when they are sick. Consider for a moment though, illness is the one thing that parents have no control over. They can't just pick that child up, love them, read them a book,rock them to sleep, and make it all go away. If the child has a chronic illness, the parent may have to endure watching their child suffer through hours of pain, tests, and treatments, and that is all they can do is watch. They feel very helpless, and often become angry at themselves, at God, at the physicians, nurses or anyone else who just happens to be there at that moment. They are angry this is happening to them, and to their child, and there is nothing they can do to stop it.
How do you deal with it you ask? It is certainly not an easy task to be the nurse on the other end of that line. It is very easy to become frustrated with the difficult parent, and feel like they are just being belligerent and inconsiderate of the Golden Rule.The best technique is to stop, take a deep breath, and consider some effective communication skills for a more effective outcome.
Even though the non-verbal aspects of communication are minimized when performing a telephone assessment, one study suggests that 85 percent of the telephone interaction is based on "tone of voice" with the remaining 15 percent being the word content.
When we think of communication skills, we often think of speaking, but active listening comes first and is often overlooked.
Let's look at blockers that prevent active listening. Are there environmental distractions? If you are in a call center, is it busy? Is there alot of background noise? Is someone standing in front of you? Is you cell phone going off simultaneously?
Do you have Third Ear Syndrome? Two ears are listening to the patient, but the 3rd ear is listening to the siren outside or to the teenager having a tantrum just outside your room.
Be careful of jumping ahead. We can think at 500 words per minute, we can hear at 300 words per minute, and we speak at 125 to 150 words per minute. It is easy to jump ahead in attempts to be more time efficient.
Be careful of emotional filters. Is the caller the same demanding one that calls about the same issue all the time? Good listeners will avoid the emotional filter unfairly influencing the interaction.
Avoid mental side trips. You are on your fourth call of the day giving out diarrhea advice, and what you are really thinking about is what you want for lunch.
Sometimes, it is easy to deal inappropriately with emotional cues, and instead display blocking behaviors, such as: offering advice and reassurance before the main problem has been identified, explaining away distress as normal, attending to the physical aspects only, switching topics or "jollying" the patient along.
Some more common sense approaches are paying attention, assess the patient's level of knowledge, read between the lines, consider the patient's prospective with empathy, and consider hidden agendas/unspoken requests.
The following are seven speaking principles when triaging a call:
*Smile
*Use the caller's name.
*Reflect back important points
*Incorporate courteous remarks
*Display empathy
*Mirror the patient (using similar vocabulary, if appropriate)

Finally, don't use jargon or abbreviations when speaking, don't mumble, and don't use negative language(eg. "I am sorry the doctor will not go back to the office to see you" versus "The quickest way to be seen would be if you are able to make it to an Urgent Care".
Remember the angry caller? One rule of thumb to always keep in mind is "They don't care what you know, until they know you care".

How To Safely and Effectively Remove A Tick

2010-05-17T13:03:00.000-07:00

Through its bite, a tick can transmit the spirochete, virus, rickettsiae, bacteria, and protozoa that cause a wide array of infectious diseases in children, including Lyme disease, Q-fever, ehrlichiosis, babesiosis, Rocky Mountain spotted fever, and tularemia.Some ticks secrete a neurotoxin that produces tick paralysis, with neurologic manifestations and ascending paralysis.

Not all species of tick attach to humans and, of those that do, the likelihood that one will transmit a pathogen depends on its developmental stage and prevalence of infectious pathogens in a particular geographic area. Estimates are that the prevalence of the spirochete responsible for Lyme disease, Borrelia burgdorferi, in the nymphal stage of Ixodes scapularis, the deer tick, in endemic areas of the Northeast and Midwest, is 15% to 30%. (The responsible vector in the western states is I pacificus, a deer and cattle tick.) The likelihood of disease transmission from the bite of an infected tick is only 1% to 3%.A patient who develops a tick-borne disease is unlikely to recall a tick bite—generally because a tick drops off its host after feeding.

Whether any pathogen is transmitted by the bite of a tick is determined by the location of that organism in the tick's gut and the duration of the tick's attachment to its host. A pathogen residing in the salivary glands of the tick will pass to its host more quickly and efficiently than one in the tick's lower gastrointestinal tract. The principal determinant of disease transmission, however, is the duration of the tick's attachment: The longer a tick is attached, the greater the likelihood that the pathogen will transmit to host.

Each pathogen requires a different duration of attachment.3 Transmission of B burgdorferi from an infected deer tick is unlikely with less than 24 hours of attachment, more likely after 48 hours than after 24, and highly likely after 72. Shorter periods of attachment may suffice for an infected tick to transmit Ehrlichia chaffeensis and E ewingii, the pathogens responsible for ehrlichiosis.This research confirming the relationship between duration of attachment and the spread of infectious agents underscores the importance of timely tick removal.

The tick employs several appendages to achieve its tenacious grip on your patient host. On each side of the hypostome—a rod-shaped structure through which the tick sucks blood from the host—are cheliceral digits that painlessly penetrate the host epithelium (see figure). Hundreds of barbs on the outer surface of the hypostome grip the skin like fishhooks as it enters the break in the epithelium. To strengthen its hold, the tick secretes a ring of cement around the cavity, fixing itself in place for a feast. It is while the tick feeds—a meal that can last several days or a week—that pathogens may be transferred to the host. Meal complete, the tick detaches from the patient's epidermis, leaving the cement behind. (Depth of attachment varies by tick; dog ticks, for example, attach superficially, whereas lone star ticks and Ixodes species attach more deeply within the epidermis.

Petroleum jelly? Gasoline? How about angled forceps?
The definitive treatise of tick removal has yet to be published, despite the abundance of anecdotal suggestions in the medical literature.The few randomized trials that have compared removal techniques have significant limitations; most studies used animal models, and others were underpowered.
The primary goal of tick removal is to remove the tick's body, head, mouth and mouth parts, and the cement—anything left in the skin can cause infection and local irritation or lead to a granuloma. The best technique is one that allows you to:

* remove the tick as soon as possible to minimize or interrupt the transfer of infectious material
* prevent the tick from regurgitating infectious material into the patient
* minimize damage or pain to the patient undergoing the procedure.

Techniques to remove an embedded tick employ either mechanical force to pull it out or application of agents such as viscous lidocaine, petroleum jelly, nail polish, isopropyl alcohol, or gasoline that irritate or suffocate the tick and cause it to spontaneously detach. Because a tick breathes at a rate of three to 15 breaths an hour, suffocation methods are rarely effective. Animal studies have demonstrated that irritating the tick with a lighted match, heated nail, or pocketknife—which may burn the child or cause the tick to regurgitate its contents into the host—do not stimulate the tick to detach.Researchers who injected lidocaine and lidocaine with epinephrine below the site of attachment also failed to induce the tick to detach.

Nine steps and a steady hand—surest way to remove a tick
Although no technique will remove completely every tick, one that employs slow, steady traction applied at the point of attachment is more likely to remove the tick intact with the cement.One such method is described in "Nine steps and a steady hand—surest way to remove a tick." Success depends on the type of tick, its developmental stage, and depth of attachment. Note that nymphs that penetrate deeply are less likely to be removed intact by any method.

Experts recommend a blunt, medium-tipped, angled mosquito or splinter forceps. (Using your fingers to grasp the tick will force its contents into the host and is less likely to remove the mouth parts and cement.) Any retained mouthparts or cement should be removed promptly with forceps; alternatively, the area can be excised with an 18-gauge needle, as would be done for a splinter.

Commercial devices for tick removal demonstrate varying degrees of utility.One such tool has jaws that allow the operator to grasp the tick at its mouth and then pull it away from the skin. A second tool incorporates a V-shaped notch so that, as the operator slides the tool along the patient's skin, the tick is trapped at the apex and then pulled from the skin. Although these instruments may be as useful as tweezers or forceps for tick removal, they are not commonly found in most offices or hospital emergency departments.

Post-procedure considerations

It is unnecessary to preserve the tick's remains in alcohol because the predictive value of tick analysis has not been defined.Post-exposure prophylaxis with antibiotics also is not recommended, because of, first, the low risk of disease transmission after a tick bite and, second, the risk of adverse effects from doxycycline and the unproven efficacy of amoxicillin for prophylaxis.Consider prophylaxis, however, in a patient who has multiple tick bites or if a tick's attachment is known to have lasted at least 72 hours. Counsel parents to monitor the child for signs and symptoms of infection.

Parents and child may need to be reminded that avoiding tick bites is key to avoiding Lyme and other tick-borne diseases, and that avoidance can be achieved by simple measures:

* Wear long pants in areas where tick exposure is likely, and tuck pant legs into socks to ward off the immature ticks on the ground and on low growth.
* Inspect the skin, especially the armpit and groin areas, immediately after outdoor activities to detect and remove ticks before transmission can occur.
* If skin exposure is unavoidable, apply an appropriate insect repellent to skin or clothing to protect against tick bites.

We Appreciate Our Nurses 365 Days A Year

2010-04-21T10:17:00.000-07:00

National Nurses Week is coming soon in May. Most facilities and corporations put something together during that week, or maybe just for one day to show their nurses their appreciation. It is obvious however, that nurses give far more to their employers than anything that they could be given in return, monetarily or in any other way.

There are two kinds of people in this world, givers and takers. We nurses surely fit into the giver category. We literally pour ourselves out for others, in caring. How do we do this? How do we give and give and care and care, over and over again? What do we contribute to our community? In my opinion, our greatest “giving” contribution to our community is our children. You might feel this is irrelevant, but consider that most of us are parents or future parents. We realize that loving, teaching, and preparing our next generation of productive citizens is the GREATEST gift we can give to our community. We prepare our children for the joys and struggles that lie ahead for them. The giving and caring starts in our homes where we make parenting a priority and tremendous sacrifices for the family. Let us never forget the mighty work that dedicated parenting is for the community.

Beyond our homes, our attention and energy expands out to our studies and our work. We chose to be givers in this world when we answered that calling into nursing which we hear initially. We endure our rigorous studies and finally achieve that hard-earned goal, our nursing license. When we enter the profession, we are enchanted and enamored by the excitement and challenges, but all too soon the disillusionment sets in. We realize that things aren’t quite like the textbooks explain, and that maybe not every patient always gets the right amount of attention and effort devoted to them that they each deserves.

We realize that time and resources are finite, so we figure out ways to do more with less, and get more mileage out of our day. We learn to multi-task better, to streamline our processes better. We start to skip lunches, forget to drink and hydrate ourselves, and hardly ever make it to the bathroom. We put ourselves aside for the sake of the patients.

Throughout our careers, we CONTINUE to show that we are givers by not only living out our higher calling, but by choosing to stay and remain in our work. Even though we have our fair share of legitimate reasons to abandon ship, ALL of us here haven’t done that. We have CHOSEN NOT to. It’s our decision. It’s our decision to stay. It’s our decision to still care. It’s our decision to continue to endure the sometimes harsh conditions and situations we find ourselves in. The list of ways we show this determination and dedication to our patients is endless.(Christina Feist-Heilmeier, RN, MSN)

Nurse Telephone Triage Service is proud of our nurses, and appreciate the care they give to the patients we serve on a daily basis. For that, we say THANK YOU for your dedication, your hard work, your positive attitude, and your commitment to make NTTS the successful corporation that it is!

Foreign Body Ingestion in Children

2010-04-14T13:10:00.000-07:00

It is inevitable that children will put objects into their mouths from time to time, and sometimes they end up swallowing them. The age group most prone to swallowing foreign bodies is preschoolers. Most of the time, it is either coins or non metallic sharp objects. X-rays can detect 100 percent of metallic objects swallowed, and about 85 percent of glass objects, while detection of fish bones is only about 25 percent. Children who swallow foreign bodies are not always symptomatic. About 50 percent have no symptoms at all. Often, non metallic sharp objects that are swallowed are lodged in an area that can be successfully removed with direct laryngoscopy alone. About 40 percent of swallowed coins can be removed in this manner. Absence of symptoms should not preclude presence of a foreign body in children. Particular attention should be paid to mentally handicapped children with vague GI symptoms.
Most swallowed foreign bodies pass harmlessly through the GI tract. However, if it has a sharp edge, is greater than 1 inch in diameter, or batteries, the patient must be evaluated as soon as possible. Children with preexisting GI abnormalities (eg. tracheoesophageal fistula, stenosing lesions, previous GI surgery)are at increased risk of complications and are more likely to retain foreign bodies in the stomach.
Most complications of pediatric foreign body ingestion are due to esophageal impaction either at the thoracic inlet, cricopharyngeus sling or the mid esophagus. Once the foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve. Foreign-body induced appendicitis has been reported. Besides sharp, pointed, toxic, or objects that are too long or wide, another important exception is the child who has swallowed more than one magnet. Reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to small bowel obstruction or necrosis of intervening tissues. Systemic reactions, such as a nickel allergy, are unusual but have been reported.
Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring or perforation. Foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia or other respiratory disease. Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
Esophageal foreign body symptoms may include dysphagia, food refusal or weight loss, drooling, emesis or hematemesis, foreign body sensation, chest pain, sore throat, stridor, cough, unexplained fever or altered mental status.
Stomach/lower GI tract foreign body symptoms may include abdominal distention/pain, vomiting, hematochezia, or unexplained fever.
Most children who have swallowed a foreign body do not need specialized care. Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.
If the child is not at increased risk, asymptomatic, and the object swallowed is not determined to be harmful, homecare advice can be given. Reassure the parent that most anything that can get to the stomach will pass through the intestines over the next 3-4 days without difficulty. Test the child's ability to swallow foods. If no symptoms are present and the object was small and smooth, ask the parent to give the child some water to drink. If the water is swallowed easily, the child should be able to eat some bread or other soft foods. Inform the parent that most foreign bodies are passed in a normal BM in 3-4 days, and there is nothing you can do to hurry the process. Have the parent call back if the foreign body was not passed in 3 days, abdominal pain, vomiting or bloody stools develop, or the child becomes worse.

28 states seek to expand the role of nurse practitioners

2010-04-14T06:18:00.000-07:00

With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor's watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called "Doctor."

For years, nurse practitioners have been playing a bigger role. With 32 million Americans gaining health insurance within a few years, the health care overhaul is putting more money into nurse-managed clinics.

Newly insured patients will be looking for doctors and may find nurses instead.

The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association says a doctor shortage is no reason to put nurses in charge and endanger patients.