It's All About the Detective Work

When I think of the right way to triage, I think about how to be a good detective. Triage is about sorting through the details to get to the root of the problem, and isn't that what detective work is too?

With triage, you should have protocols or algorithms to follow that are symptom based. If you do not have these in place, then you probably do not have a safe triage program. However, so many nurses get so caught up in sticking closely to these guidelines that they do not allow themselves do think outside the box.

Let me give you an example. A mom calls about a child with a low temperature. The child's temp is 97.1R. In the conversation, the mom tells the nurse that the child was outside earlier in the day, in freezing temps, without proper winter clothing. After which, she came in, bathed and then started to appear as if she was really not feeling well. At that point, the mom decided to take her temperature. The child is now in bed, very fatigued, and barely responsive to mom. The nurse, hearing this, automatically starts thinking frostbite, and goes straight to that protocol. She shuts down the possibility of any other symptoms and fails to ask. She gives mom homecare advice to warm the child, and told mom to call back if symptoms do not improve. The mom follows the nurse's advice, and by morning, the child was rushed to the ED with symptoms of sepsis. If the nurse had opened her mind to other possibilities and asked if the child was recently treated for any illness or injury, or asked if she had any other symptoms present; she would have discovered that the child had just finished a course of antibiotics for a wound infection. The wound was not appearing better, and the mom intended to call the physician's office the next morning to report it.

We can never assume callers are telling us the whole story. It is our duty to ask for it. Many times, the caller assumes that certain information is not relevant and do not think that we need to know. Solving the mystery means asking for the details, sorting through them, following the appropriate guidelines, and coming up with a solution that is safe, agreeable by all, and is in the best interest of the patient.

"Good Help is Hard to Find"

"Good help is hard to find". How many times have we heard that one? It is actually not that good help is hard time, but often is hard to keep. There have been many articles, books and seminars on staff retention, and there are some great ideas that can be obtained. However, it all comes down to staff appreciation.

At NTTS, we make very effort to show our nurses that we care about them as an individual, not that they just have a nursing license. Speaking from personal experience, many nurses feel that is all their employer cares about, and if they died tomorrow, they would not be missed. They would simply move on to the next warm body.Organizations often will pay top dollar and offer great benefits to their nurses, only to find they leave their positions within a couple of years, leaving the employer scrambling to figure out whey the nurses they hire don't stay. Sometimes, it is as simple as figuring out the nurses feel under appreciated. 

We show our staff that we are the exception. We make every effort to work with our nurses to provide them with a schedule that works for them. We have quarterly peer recognition awards for the one nurse who has the most nominations for being exceptional, in addition to recognizing birthdays monthly and bonuses for filling in on short notice and working extra when busy. Nurse's Week is never forgotten. We try to chose a practical personalized gift for our nurses to show our appreciation for their efforts, and sometimes....just a simple "Thank you" goes a long way.

Our nurses treat each other like family. They have been known to donate to a chronically ill nurse who could not work, visit each other when sick, and send flowers. Many of ours nurses have developed life long friendships even though they don't see each other day to day.

Yes, we occasionally do have turn-over, but many of our nurses have been here five years or longer. Our nurses take ownership in their position and in the company, and in return, the physicians we serve appreciate the quality of care their patients are receiving after hours. At NTTS, we recognize our nurses make our company exceptional. It is a winning relationship for all involved.

High Risk Calls

Practically any call can turn out to be high-risk, but there are some that triage nurses should be especially attuned to. The typical ones that most think of are breathing issues, chest pain, abdominal pain, trauma, suicide and overdose calls. However, there are other red flag calls to be concerned about.
If the caller is calling again for a 2nd and 3rd time during a shift, there is something they are very concerned about. This is the time that the triage nurse needs to hone in his/her assessment questions, and make sure there is not something there they are missing. This would be good time to ask, "So, what is it that concerns you that made you call tonight?" This is a perfect question to ask if the symptoms are not new, or you are having difficulty discerning why they are calling to begin with, and even more so, that they are concerned enough to keep calling back. Triage nurses should be really listening for any subtle changes, and if it is concerning enough, send them on to the ED. It is best sometimes for someone to actually lay eyes on the patient to really determine what is going on. This is especially true if the caller is a poor historian, and even the best assessment questions does not get the answers you are seeking, or if there is a language barrier.
Newborn calls is another group to be especially attentive to. We have all dealt with nervous new parents who are concerned that their baby is crying. However, newborns can get sick very quickly, and we, as triage nurses, need to have assessment skills to be able to determine if that cry is normal or if there is something more serious going on. Newborn parents need extra time and attention, and alot of education!
Medication calls could potentially be high risk calls as well. If the parent is requesting to know the dosage of acetaminophen or ibuprofen, we should be finding out why. Is it a fever of 105? A patient calls for an albuterol inhaler refill. How often are they using it? What are the symptoms now? Any respiratory distress? These calls should always be thoroughly assessed to make sure that the patient does not need a higher level of care, and that medication is appropriate. We should never take it for granted that the caller is capable of discerning this on their own.
Telephone triage is about constantly assessing, planning, and thinking about the what-ifs. It takes keen listening and thinking skills to get the patient through to the next level safely.

Telephone Triage Is Not Just a Job Anyone Can Do............

It is very difficult to explain the training that should be provided for telephone triage to someone who has no idea the complexity of the skill. Yet, we see front line people in offices and answering service personnel making triage decisions everyday, and the scary thing is, they do not realize they are making medical decisions without a license. Don't get me wrong, ancillary personnel are very important in the day to day operations of businesses, but you never want to put your business at risk by not having properly trained personnel in key areas.
Anyone on the front lines of answering telephone calls should be very careful in their selection of answers when patients ask questions or with giving information such as urgent care availability. A good example of this would be if the patient calls and states they have a nosebleed and they are taking anticoagulants. If the receptionist says "You can go to the walk in at XYZ location, but I will put your call in to the nurse". That is giving medical advice. The patient could interpret that as they should go to the walk in to be seen, and not wait for the call. You might say, "Ok, so?" Here is the worst case scenario. The patient goes to the walk in. His nose is bleeding profusely. A quick INR fingerstick at the office shows it is 5.4. The office calls for an  ambulance and he is sent to the ED. He ends up having Vitamin K and blood transfusions due to the amount of blood loss from the delay in treatment. He goes from there into CHF because of fluid overload from the transfusions, and .....well, you get the picture? And with any luck, some good malpractice attorney somewhere does not pick up on it.
Here is another scenario. The receptionist at the office has been there for 15 years and knows the ins and outs of everything about the office. She takes a call from a 45 year old female patient with what she thinks is a left shoulder strain. The receptionist, not being medically trained, and not knowing other questions to ask, says "Ok, I will let the nurse know, and she will call you back before lunch". The patient does not make it until lunch. Her husband found her slumped over in the bathroom one hour after the call in cardiac arrest.
Telephone triage is a highly skilled specialty that requires a licensed nurse, preferably an RN, as LPNs must be under the direct supervision of the RN. Even still, the nurse in that position must have received individualized further training on the skills required to perform the job safely. It should not be taken for granted that anyone can answer calls from sick patients. There should be specific protocols in place for non trained personnel on how calls should be handled. It is just not worth the risk not to.

Callers Teach Us.........

Seasoned telephone triage nurses know that a good majority of the time spent with callers is all about education. We teach them causes of symptoms; symptom management; medication management; and parameters to watch for that could indicate an urgent need for evaluation. However, have we stopped to think about how much our patients teach us?
Listening Skills: I know that in the years I have been doing triage, my listening skills have become much more sharpened in everything I do, not just triage. During a call, I am listening for the tone of the caller; breathing sounds of the patient; history of what led to the call and symptoms. In my day to day conversations, I also find that I am paying closer attention to what others are saying and discerning if there is an unspoken meaning or need.
Patience: During flu season, there is nothing like having a chatty caller on the line while you are worried about how many respiratory emergencies are waiting in the que. Telephone triage teaches you that the chatty caller is just as important as the respiratory emergencies that are waiting, and they have a need that is just as urgent to them as any of the others. It is up to us, as a specialized practice, to assist them with that need.
Multitasking: There is nothing like trying to carry on a conversation with a caller and attempt to get a complete history of the problem while a physician is calling you on the other line, It means you have to put that caller on hold, switch gears for a minute, and then come back to that caller and re-focus on their need. Let's not forget monitoring the que, answering a co-worker's question, and seeing an urgent e-mail that needs to be answered at the same time. It changes your way of problem solving, and I know it carries over into other areas of my life as well. I find myself thinking for most day to day problems, "What is the fastest way to come to a solution?"
Compassion: It is often said that nurses are naturally born compassionate people, I believe this is true, and even more true in telephone triage. Many times, we receive calls that deal with raw emotion and urgency. Often callers find it easier to open and honest with telephone triage nurses than they do their own physician's office. They are not face to face with us and therefore, it decreases feelings of embarrassment or anxiety. If we are truly listening to their concerns, we realize they value our knowledge and depend on us to help them solve their personal crisis. This has taught me that their mountain they are facing is huge to them, and given their situation, I would want a caring, compassionate voice on the other end of the line.
In the years since I have been in telephone triage, I have learned much more than can ever be documented, and many of the callers I have encountered have taught me many valuable life lessons. If they only knew........

Calming Fears

With Enterovirus and Ebola being all over the news, it is natural for parents to worry when their child gets a fever or develops cold symptoms. Nurses may think the parent is over-reacting or being too anxious, but you have to put yourself in the layman's shoes. If you had no medical education, and all the information you had was what you heard on the news or searched on the internet, you would be scared too. I mean, after all, that is how the news gets ratings. They dramatize the story.
As a triage nurse, you have to be well educated on the current medical conditions that are making their way across the country and the globe. You cannot expect to educate callers and calm their fears if you are not sure about what you are educating them on, and you have to remember, they can tell in your voice if you are confident. Nothing increases a caller's anxiety more than to speak with a nurse who is hesitant in their advice. Most likely, they will get upset with you, and even demand to speak with a physician at that point.
How do you educate yourself so that you know you are giving the correct advice? Besides following the guidelines or protocols set into place by your organization, some reliable internet sites are good ways to keep abreast on current trends and treatments. One site to reference is the CDC, and another good pediatric reference site is the American Academy of Pediatrics. When doing internet searches, please keep in mind, you want to only use credible sites.
One last point is you must be comfortable in your role. That comfort will be transmitted to the caller, and they will likely follow the advice you give if they trust you and feel you are knowledgeable in your discussions.

Time Management

Let's face it. Anyone who has ever done telephone triage knows this can be the most mentally challenging job you might ever do. It is not an easy endeavor to take on. Not only do you have to be a quick thinker and problem solver, but you must be able to coordinate looking at protocols, listening to the caller, typing and thinking of a plan....all at the same time. To be efficient and proficient, you must be able to utilize your time wisely.
One of the things I try to instill in new nurses, is to be organized. You cannot be organized enough in this position. If someone were to look at my desk, they might not think that of me, but there is a method to my madness. I know where everything is, and I can access it in a minute. I also have notes stuck everywhere as reminders and quick access if I should need it. Not everyone would be able to function like this, but it works for me. That is what matters. You have to set up your own system.
Another thing is, when you are actually taking calls, you have to be aware of the length of time you are on the call. I am not saying you should rush through it and miss important assessment information, but you should be taking control of the call. If you allow the caller control from the beginning, you may never return. We all know that many callers want to tell you everything about their life, and much of what they want to talk about is not pertinent to the call. If you begin the call with asking assessment questions, such as "So I see you are calling because John has a fever. When did this fever start?", it allows you to get the information you need much more quickly and keeps the caller focused. Saying, "What can I help you with?" is a very broad question and makes it harder to keep the call under control.
Another thing I find nurses do is skip around. It works much better to gather all of the assessment information first, and then give the advice. If you stop in the middle of the call to give fever advice and then go on to assess cold symptoms and give advice for that, it is more time consuming. Also, how can you give complete advice if you don't have the whole picture? After all, we know that one symptom can influence another.
Finally, I encourage nurses to think outside the box. You should never be so focused on protocols that you miss the big picture, and don't get yourself caught up in little unnecessary details. For instance, I have seen calls regarding immunization reactions where most of the child's arm is very red and swollen and the nurse gets caught up in what kind of immunization they had. That is great if the parent knows, but the ultimate outcome is they need to seen asap to have it evaluated. Give them the necessary advice, and move on. There are other calls waiting.
You cannot be a successful telephone triage nurse overnight. It takes time to learn and change the way you think. It is not like any other area of nursing you have experienced.