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.
Saturday, March 26, 2011
Wednesday, February 16, 2011
All In The Approach
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.
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.
Monday, January 24, 2011
Mentoring
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".
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".
Sunday, January 2, 2011
The Benefits of Nursing Triage Services
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.
Tuesday, November 16, 2010
Will Your Note Hold Up in Court?
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.
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.
Wednesday, October 20, 2010
Flu Season Nightmares
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!
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!
Friday, September 17, 2010
Unforgetable Patients
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. ~
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. ~
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