I mentioned in a previous post about as RNs, we should exercise critical, independent thinking skills and use protocols as a guidance in helping us do that. The following is an example of how one of our nurse's did just that.
The nurse received the call on a weekend morning from a worried mother regarding her 14 year old son who had been experiencing right sided lower abdominal pain for 24 hours. The only other symptom the child had was abdominal pain on urination. The mom called because the pain appeared to be getting worse, and the child did not sleep well the night before. He had been drinking fluids well, but a had a decreased appetite. He had no other symptoms classic of appendicitis. There was no fever, no vomiting, no pain on palpation, nothing.
One might interpret the symptoms as possible a kidney or bladder stone or maybe even a UTI since there was pain on urination. However, the nurse used the protocol as a guide, and erring on the side of caution, sent the child to the ED for evaluation as the protocol recommended. The child was subsequently diagnosed with acute appendicitis and had an appendectomy later that afternoon.
Often, I find nurses wanting to read too much into the problem and try to second guess or diagnose what they think the problem is. That is not within our scope of practice to diagnose. Our position as effective triage nurses is to recognize there is a potential problem and to determine what needs to be done to get the patient safely to the next level of care, doing so with caution and being intuitive that there could be a potentially worse situation than what we even realize.
Does this mean send all patients to the ED? Of course not. It means using good listening skills, being an excellent critical thinker, and "going with your gut". Just because all the symptoms are not present to give a disposition of ED does not mean that is the best decision to make. If your instinct is telling you that the patient needs a higher level of care, it is best to seek that option for them, and what is the worst that could happen? The patient is seen unnecessarily in the ED. That sure beats the alternative of hearing later that the they suffered undo harm because the nurse did not pick up on the subtle symptoms. Remember, all patients are individuals and do not always present with textbook signs.
Tuesday, October 30, 2012
Thursday, October 18, 2012
Recommended Reading!
I commented on my last post that I am reading the new book written by Carol Rutenberg and Liz Greenberg, The Art and Science of Telephone Triage. This is a brand new resource that was released this year by Anthony J.Janetti, Inc, and endorsed by the AAACN!
So far, I have found this book to be enjoyable and educational. It takes you from how telephone triage came into being, where it is now, and where it is going. Along the way, they have included how to correctly run a successful triage program, whether it be in an office or a call center, the legal aspects of telephone triage nursing across state lines, and my personal favorite, true triage stories to learn by.
So far, I have used some of these stories in our staff monthly newsletter as a training tool, and our nurses have commented on how much they too have learned and how interesting they are.
This resource has been needed for a long time. There are several telephone triage books and resources available, but none puts the pearls and perils into the same perspective as this book does. I would encourage anyone to read it and use it as a valuable resource for their telephone triaging. I also think it would be a great book for someone who is interesting in entering this specialty area, and a valuable training resource for those new to the field as well.
I am encouraging our nurses to read it!
So far, I have found this book to be enjoyable and educational. It takes you from how telephone triage came into being, where it is now, and where it is going. Along the way, they have included how to correctly run a successful triage program, whether it be in an office or a call center, the legal aspects of telephone triage nursing across state lines, and my personal favorite, true triage stories to learn by.
So far, I have used some of these stories in our staff monthly newsletter as a training tool, and our nurses have commented on how much they too have learned and how interesting they are.
This resource has been needed for a long time. There are several telephone triage books and resources available, but none puts the pearls and perils into the same perspective as this book does. I would encourage anyone to read it and use it as a valuable resource for their telephone triaging. I also think it would be a great book for someone who is interesting in entering this specialty area, and a valuable training resource for those new to the field as well.
I am encouraging our nurses to read it!
Thursday, October 4, 2012
Real Telephone Triage
There are so many telephone triage companies now that it would be impossible to name them all, and I am definitely not here to say there is any one program that is better than another. However, has telephone triage gotten so complex that many have lost focus on what it really is?
I have seen complex programs, and have spoken with many experienced telephone triage nurses that tell me they feel like robots reading from computer screens. Systems have gotten so complex that they are not given the ability to actually use what they were trained to do, and that is be independent critical thinkers and use the nursing judgment skills they were trained with. Many of these nurses are now expected to be secretaries among other duties and track waiting times in urgent cares for instance. Is that really providing patient focused care?
What is wrong with being able to follow a protocol for questions to ask, to get the information needed to make a sound judgement of if the patient needs immediate treatment, or can it wait until the office opens? And, if there is not a protocol that fits, to be able to use nursing judgment to give sound advice? I know that I have spoken with patients who are grateful to be able to get appropriate advice from someone who can think independently from a computer screen, and I know the patients can tell when that advice is being read to them vs actually coming from a voice of experience and reassurance. Offices have verbalized that they appreciate personalized attention given to their patients from experienced telephone triage nurses.
Alot of money can be spent in some elaborate systems, and they sure look attractive, but I am proud to say that we ARE what telephone triage nursing is...Quality telephone advice given following standardized protocols, by caring, experienced triage nurses who go the extra mile to educate, advocate and direct the caller to the most appropriate next step of care. All completed without the complexities of navigating among many screens for one symptom.
Our nurses care about their callers, and many will tell you they will take patient focused care and the freedom to be a real nurse any day!!
It would be interesting to see how many other triage nurses feel the same.
I have seen complex programs, and have spoken with many experienced telephone triage nurses that tell me they feel like robots reading from computer screens. Systems have gotten so complex that they are not given the ability to actually use what they were trained to do, and that is be independent critical thinkers and use the nursing judgment skills they were trained with. Many of these nurses are now expected to be secretaries among other duties and track waiting times in urgent cares for instance. Is that really providing patient focused care?
What is wrong with being able to follow a protocol for questions to ask, to get the information needed to make a sound judgement of if the patient needs immediate treatment, or can it wait until the office opens? And, if there is not a protocol that fits, to be able to use nursing judgment to give sound advice? I know that I have spoken with patients who are grateful to be able to get appropriate advice from someone who can think independently from a computer screen, and I know the patients can tell when that advice is being read to them vs actually coming from a voice of experience and reassurance. Offices have verbalized that they appreciate personalized attention given to their patients from experienced telephone triage nurses.
Alot of money can be spent in some elaborate systems, and they sure look attractive, but I am proud to say that we ARE what telephone triage nursing is...Quality telephone advice given following standardized protocols, by caring, experienced triage nurses who go the extra mile to educate, advocate and direct the caller to the most appropriate next step of care. All completed without the complexities of navigating among many screens for one symptom.
Our nurses care about their callers, and many will tell you they will take patient focused care and the freedom to be a real nurse any day!!
It would be interesting to see how many other triage nurses feel the same.
Thursday, August 16, 2012
What is My Patient's Problem TODAY???
So many times I see nurses having difficulty discerning what the main focus of the call is, and therefore it impedes their advice ability as well as productivity. This is especially true when the patient has multiple complaints or many chronic illnesses.
Sometimes the caller has difficulty expressing what their main concerns are or reason for the call, and you simply have to just ask, "So what concerns you that made you call TODAY?" That will usually get the answer you are looking for so that you can determine the chief complaint, and find the correct protocol.
Focus on what the current symptoms are, and not symptoms they had last week that are no longer an issue such as, the patient now has a fever for 3 days, but diarrhea a week ago. The protocol used should be fever, and if the patient is now having normal BMs, why would you even ask any questions about the diarrhea?
One good way to determine if you have done a thorough assessment of the complaint is by remembering
*P Problem/Chief Complaint
*H (How are you feeling?)
*O Onset
*S Associated Symptoms
*H Pertinent History
*P Precipitated by
*A Aggravated or Alleviated by
*T Timing
*E Etiology (Have I overlooked anything?)
Problem- Listen to decide what the chief complaint is. Ask for all adjectives used to describe this problem. If not able to determine the complaint, ask the appropriate questions to draw out the information, like "What is bothering you the most?"
Onset- Did it come on suddenly or gradually? When did the symptoms start?
Associated symptoms- What else is bothering them? Use caution to "not put words in the patient's mouth".
Pertinent history- Have you been ill or seen the doctor recently? Have they had this problem before, and if so, what was it? Who said? How was the decision made?
Precipitated by- Is there anything they do that brings it on? Is there any way they can predict it's recurrence?
Aggravated or Alleviated by- What makes it better? What makes it worse?
Timing- Is there any time of the day, week or month that you notice this problem more?
Etiology- Have I overlooked anything? Did I consider all the pertinent findings?
Following this will ensure an accurate and complete assessment, will keep the call in focus and productivity at it's best.
(Carol Rutenberg2012)
Sometimes the caller has difficulty expressing what their main concerns are or reason for the call, and you simply have to just ask, "So what concerns you that made you call TODAY?" That will usually get the answer you are looking for so that you can determine the chief complaint, and find the correct protocol.
Focus on what the current symptoms are, and not symptoms they had last week that are no longer an issue such as, the patient now has a fever for 3 days, but diarrhea a week ago. The protocol used should be fever, and if the patient is now having normal BMs, why would you even ask any questions about the diarrhea?
One good way to determine if you have done a thorough assessment of the complaint is by remembering
*P Problem/Chief Complaint
*H (How are you feeling?)
*O Onset
*S Associated Symptoms
*H Pertinent History
*P Precipitated by
*A Aggravated or Alleviated by
*T Timing
*E Etiology (Have I overlooked anything?)
Problem- Listen to decide what the chief complaint is. Ask for all adjectives used to describe this problem. If not able to determine the complaint, ask the appropriate questions to draw out the information, like "What is bothering you the most?"
Onset- Did it come on suddenly or gradually? When did the symptoms start?
Associated symptoms- What else is bothering them? Use caution to "not put words in the patient's mouth".
Pertinent history- Have you been ill or seen the doctor recently? Have they had this problem before, and if so, what was it? Who said? How was the decision made?
Precipitated by- Is there anything they do that brings it on? Is there any way they can predict it's recurrence?
Aggravated or Alleviated by- What makes it better? What makes it worse?
Timing- Is there any time of the day, week or month that you notice this problem more?
Etiology- Have I overlooked anything? Did I consider all the pertinent findings?
Following this will ensure an accurate and complete assessment, will keep the call in focus and productivity at it's best.
(Carol Rutenberg2012)
Monday, June 11, 2012
This Takes Skill
It is time for telephone triage nursing to be recognized as a true skill. Maybe it is just me, but it gets frustrating when you attempt to explain to others, including nurses, what it is that you do, and they either just look at you or say " I am afraid I would lose my skills". This growing area of nursing IS A SKILL! Not just any nurse can do it.
I have seen a great number think this is a eat bon-bon, watch a movie, and throw a party in between calls, kind of job. That fairy tale would be a dream if it were true, but that is all it is, a fairy tale. Having been a nurse for over 20 years, and worked in many different areas of nursing, this is the most mentally challenging of them all by far. Not even managing a 150 bed skilled facility or working a 12 hour shift in an ICU can leave you as exhausted. Sure, you don't do venipunctures, start IVs or treat wounds, but if you miss one vital piece of information, you do cause un-do harm or worse yet, death to the patient you are talking to.
True triage is not just asking a few questions, and then giving advice. You are trying to come to the best solution in the shortest amount of time. You have to be a quick thinker, a good reasoner, an excellent multi-tasker, and a polite, well rounded person to be the most successful. There is nothing like trying to calm an anxious first time mom with a 3 year old crouper, listen for warning signs that may say the child needs to be seen in the ED tonight, while the other line has a physician beeping in about a medication call you paged him about 30 minutes ago. You have to be able to change courses quickly, place the current call on hold, handle the medication call, go back, finish the croup call, and then call the patient back about their medication. Don't forget, finishing your documentation falls in there, along with your co-worker asking your opinion on how to handle the newborn jaundice call they are dealing with. And, that my friends is not a skill?
I may be a little rusty on trying to start an IV right now, but I can guarantee you I can advise you on how to handle your child's bicycle accident in 5 minutes or less, and at the same time be a resource to my co-workers, speak to a physician and call a pharmacy.
Having done this job for years, I find it changes the way I problem solve day to day as well. I find I am always looking for the shortest way to reach my goals in the quickest amount of time, and I love it. I don't think I will ever look a situations any differently again.
Yes, this is a skill to be proud of, and it does not make me any less a nurse. We all have areas that we are good at, and that is what makes nursing unique. If we all liked or wanted to work in the same areas, patient needs would not be met. After all, isn't that why we chose nursing? To be a patient advocate and to care for them to the best of our ability.
I have seen a great number think this is a eat bon-bon, watch a movie, and throw a party in between calls, kind of job. That fairy tale would be a dream if it were true, but that is all it is, a fairy tale. Having been a nurse for over 20 years, and worked in many different areas of nursing, this is the most mentally challenging of them all by far. Not even managing a 150 bed skilled facility or working a 12 hour shift in an ICU can leave you as exhausted. Sure, you don't do venipunctures, start IVs or treat wounds, but if you miss one vital piece of information, you do cause un-do harm or worse yet, death to the patient you are talking to.
True triage is not just asking a few questions, and then giving advice. You are trying to come to the best solution in the shortest amount of time. You have to be a quick thinker, a good reasoner, an excellent multi-tasker, and a polite, well rounded person to be the most successful. There is nothing like trying to calm an anxious first time mom with a 3 year old crouper, listen for warning signs that may say the child needs to be seen in the ED tonight, while the other line has a physician beeping in about a medication call you paged him about 30 minutes ago. You have to be able to change courses quickly, place the current call on hold, handle the medication call, go back, finish the croup call, and then call the patient back about their medication. Don't forget, finishing your documentation falls in there, along with your co-worker asking your opinion on how to handle the newborn jaundice call they are dealing with. And, that my friends is not a skill?
I may be a little rusty on trying to start an IV right now, but I can guarantee you I can advise you on how to handle your child's bicycle accident in 5 minutes or less, and at the same time be a resource to my co-workers, speak to a physician and call a pharmacy.
Having done this job for years, I find it changes the way I problem solve day to day as well. I find I am always looking for the shortest way to reach my goals in the quickest amount of time, and I love it. I don't think I will ever look a situations any differently again.
Yes, this is a skill to be proud of, and it does not make me any less a nurse. We all have areas that we are good at, and that is what makes nursing unique. If we all liked or wanted to work in the same areas, patient needs would not be met. After all, isn't that why we chose nursing? To be a patient advocate and to care for them to the best of our ability.
Wednesday, April 18, 2012
Identifying High Risk Callers
It is so easy to become like a robot, taking one call after another and going through the motions...reciting protocol after protocol. There are, however, a select group of calls that should stand out as high risk.
Extremes of age: The very young, as in newborns, and the old (those above age 65) are at higher risk of developing complications. They are also physically less tolerant of symptoms such as fevers.
Comorbidities: Those with diabetes, post-op patients, immunosuppressed.
Repeat Callers: (Repeat calls for the same problems) Maybe the caller is not understanding instructions given? Are the patient's symptoms worsening, and the caller does not understand how to communicate this? Is there a high level of anxiety?
Frequent Flyers: Are they anxious? Is there a lack of caregiving in the home? Is the caller difficult to educate?
Patients with Multiple Complaints or Poor Historians: Multiple complaints makes it more difficult to determine what the call is actually regarding, and it is difficult to give accurate advice if you cannot make a complete assessment based upon what information the caller is giving you.
These types of calls deserve extra attention to the protocol and follow through. If there is any question about level of understanding, concerns about adequate caregiver availability, risk of the caregiver and/or patient not following advice given, or any risk to the patient's well being, the physician on call should be contacted to lessen the responsibility of the nurse, and possibly even referred to the ED for further evaluation and care.
Extremes of age: The very young, as in newborns, and the old (those above age 65) are at higher risk of developing complications. They are also physically less tolerant of symptoms such as fevers.
Comorbidities: Those with diabetes, post-op patients, immunosuppressed.
Repeat Callers: (Repeat calls for the same problems) Maybe the caller is not understanding instructions given? Are the patient's symptoms worsening, and the caller does not understand how to communicate this? Is there a high level of anxiety?
Frequent Flyers: Are they anxious? Is there a lack of caregiving in the home? Is the caller difficult to educate?
Patients with Multiple Complaints or Poor Historians: Multiple complaints makes it more difficult to determine what the call is actually regarding, and it is difficult to give accurate advice if you cannot make a complete assessment based upon what information the caller is giving you.
These types of calls deserve extra attention to the protocol and follow through. If there is any question about level of understanding, concerns about adequate caregiver availability, risk of the caregiver and/or patient not following advice given, or any risk to the patient's well being, the physician on call should be contacted to lessen the responsibility of the nurse, and possibly even referred to the ED for further evaluation and care.
Wednesday, February 8, 2012
How To Be An Effective Triage Nurse
I just returned from a great two day conference in Atlanta that was hosted by Carol Rutenberg's Company, Telephone Triage Consulting, Inc. The guest speaker was Kathy Koehne, BSN, RNC-TNP. What a wonderful presenter she is!
One of the things that really stuck out to me were the characteristics of effective triage nurses. They must be self-directed, focused on short-term results, be a strong patient advocate, and have practical intelligence.
With self direction, you must be able to function independently, especially if you are working from a remote location. There is no one there to call on if you have a question, need help in making a decision, or your call volume begins to get overwhelming. Sure there are co-workers on line or one that you can call, but yet, you have to be autonomous. All the while, it is important to realize the value of your position and your role, even though your authority is limited.
To be successful, you have to have a good work ethic. You must be reliable and dependable, especially so if you work remotely. So many times nurses think if they are working from home, they can work if they feel like it. No matter the location, you still have patients depending on you, just as if you worked in a facility. If there are no nurses, the patients don't get taken care of, and therefore no business.
This position requires honesty. You are given the trust to work independently, and many times, you are the only nurse that patient encounters. Your supervisor is trusting you to be honest in your advice, documentation, and productivity.
You must also be flexible. This is not a 9 to 5 job with weekends and holidays off. If you desire a position like that, maybe you should ask yourself, "Why did I choose to be a nurse?" Sickness does not decide to only occur during business hours, and therefore, it requires us to be flexible in our schedules to accommodate higher call volume needs.
To be focused on short-term results, you have to be good with time management. You have to be able to take control of the call to complete it in a timely manner, complete your documentation before the next business day, and be able to be productive enough to be a team player in getting the calls done.
You have to like checklists and bite-sized tasks. After all, when you are assessing the patient on the other end of the phone, you are going through mini checklists of each system in your brain, and the task at hand is to get the caller to the next level of care, whatever that may be.
You have to enjoy and measure effectiveness with measurable outcomes. You are gathering information, deciding on a plan and teaching the caller. You can measure the effectiveness of your teaching by asking the caller to repeat instructions back to you, and the outcome is, did they follow your teaching by seeking the appropriate follow-up? Did you make a difference in what could be a potentially life-threatening call? Do patient satisfaction surveys reflect happy patients as an outcome?
You must be a strong patient advocate. One of the most important points in gaining a caller's trust is if the nurse is empathetic. You will also be much more effective if the caller trusts you, but be careful with giving your own personal experiences. You may think you are being empathetic, but sometimes the caller only wants to talk about themselves. They do not care to hear about you. You must know when the right time to share your experiences with the patient is.
The last characteristic, practical intelligence, is one that you either have or you don't. You cannot teach someone common sense, and to be successful in this position you must be a quick learner, relate new information to previous knowledge, and enjoy learning. You must keep abreast with new trends in healthcare, and new medications, and be able to apply that to and build on what knowledge you already have.
Wow,what a tremendous amount of responsibility! Yet, if you are a telephone triage nurse, you should be proud of your position. We have the ability to change someone's life in one phone call!
You may be the last person that caller ever talks to...Make it count!
One of the things that really stuck out to me were the characteristics of effective triage nurses. They must be self-directed, focused on short-term results, be a strong patient advocate, and have practical intelligence.
With self direction, you must be able to function independently, especially if you are working from a remote location. There is no one there to call on if you have a question, need help in making a decision, or your call volume begins to get overwhelming. Sure there are co-workers on line or one that you can call, but yet, you have to be autonomous. All the while, it is important to realize the value of your position and your role, even though your authority is limited.
To be successful, you have to have a good work ethic. You must be reliable and dependable, especially so if you work remotely. So many times nurses think if they are working from home, they can work if they feel like it. No matter the location, you still have patients depending on you, just as if you worked in a facility. If there are no nurses, the patients don't get taken care of, and therefore no business.
This position requires honesty. You are given the trust to work independently, and many times, you are the only nurse that patient encounters. Your supervisor is trusting you to be honest in your advice, documentation, and productivity.
You must also be flexible. This is not a 9 to 5 job with weekends and holidays off. If you desire a position like that, maybe you should ask yourself, "Why did I choose to be a nurse?" Sickness does not decide to only occur during business hours, and therefore, it requires us to be flexible in our schedules to accommodate higher call volume needs.
To be focused on short-term results, you have to be good with time management. You have to be able to take control of the call to complete it in a timely manner, complete your documentation before the next business day, and be able to be productive enough to be a team player in getting the calls done.
You have to like checklists and bite-sized tasks. After all, when you are assessing the patient on the other end of the phone, you are going through mini checklists of each system in your brain, and the task at hand is to get the caller to the next level of care, whatever that may be.
You have to enjoy and measure effectiveness with measurable outcomes. You are gathering information, deciding on a plan and teaching the caller. You can measure the effectiveness of your teaching by asking the caller to repeat instructions back to you, and the outcome is, did they follow your teaching by seeking the appropriate follow-up? Did you make a difference in what could be a potentially life-threatening call? Do patient satisfaction surveys reflect happy patients as an outcome?
You must be a strong patient advocate. One of the most important points in gaining a caller's trust is if the nurse is empathetic. You will also be much more effective if the caller trusts you, but be careful with giving your own personal experiences. You may think you are being empathetic, but sometimes the caller only wants to talk about themselves. They do not care to hear about you. You must know when the right time to share your experiences with the patient is.
The last characteristic, practical intelligence, is one that you either have or you don't. You cannot teach someone common sense, and to be successful in this position you must be a quick learner, relate new information to previous knowledge, and enjoy learning. You must keep abreast with new trends in healthcare, and new medications, and be able to apply that to and build on what knowledge you already have.
Wow,what a tremendous amount of responsibility! Yet, if you are a telephone triage nurse, you should be proud of your position. We have the ability to change someone's life in one phone call!
You may be the last person that caller ever talks to...Make it count!
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