Unraveling The Mystery

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

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

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

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

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

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

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.