I find that so many nurses become so dependent on the protocols, that they go through each shift with blinders on. Yes, protocols are a huge part of what we do every day, but the one thing that will reassure the caller and prevent multiple call backs in a shift is education.
We have a duty to educate the caller as to why we are giving the advice that we are. Most people are much more likely to follow the advice they are given if they are given an explanation as to why. And, if a nurse sounds reassuring that he or she is confident in the advice they are giving, the caller is much more likely to take them at face value. If the nurse sound like they are reading from a script or unable to give explanations, the caller is going to be unsettled and more likely to call again or ask to speak with the physician.
The best way to become a good educator? Know your protocols first. You cannot give reassuring advice if you have no idea what the protocol says. Take some time to familiarize yourself with them. Keep yourself educated and informed on the latest trends and treatments for various illnesses. Follow the CDC as they track new diseases and patterns of illness. Read the updates in periodicals and magazines. Familiarize yourself with new medications that hit the market.
One great way to keep abreast of the latest trends in telephone triage is to be a member of AAACN. Read their monthly newsletters. Most every month, there is a something for the telephone triage nurse.
To be an effective telephone triage nurse you cannot be stagnate. It is a constantly changing field, and the callers expect the nurses to be informed and provide them with the answers they need. There is also nothing wrong with saying you don't know the answer, but you will certainly do everything you can to help them find the answers. Then, make every effort to do so. They will appreciate your honesty and sincere desire to help them in their time of need.
Monday, March 11, 2013
Thursday, December 27, 2012
Normal Newborn Concerns
I love talking to first time parents. Many of my colleagues don't, but there is just something about being able to educate them that their little bundle of joy is normal, and what they are experiencing will pass. It is gratifying to hear the relief in their voices when you reassure them that they will survive their sleepless night, and this screaming mess will grow to be a cooing miracle.
Here is a short list of some of the more common things that I find that new parents call about frequently that you may find helpful:
Diarrhea- Breast fed infants bowel movements constantly change, and it is very normal for a breast fed infant to have as many as 10 watery, yellow seedy stools per day. Parents should only be concerned if the infant acts sick, develops a fever, poor sucking reflex, not latching on as well, stools become mucusy or bloody, not urinating, or stools dramatically increase in frequency or any other concerning symptoms. Frequent, liquid stools in a breast fed infant is not necessarily diarrhea.
Cyanosis or mottling of extremities- New parents frequently call about noticing this in the feet especially. The circulatory system of newborns and young babies are not fully developed yet, and the feet appearing blue is very normal. If they feel warm to touch and the infant is exhibiting otherwise normal behavior, you might suggest they elevate the extremities for a brief period and see if the color returns to normal. If not, call back or if any other symptoms seen.
Cyanosis around the mouth-This is know as circum-oral cyanosis or peri-oral cyanosis, and if the lips and tongue are pink, respirations are normal, and infant is feeding well, this is can be normal. The parents will often report it as the infant appears "blue around the mouth". This is due to the engorgement of the venous plexis and is normal.
Irregular Breathing- Newborns often do not have quiet breathing. Especially on falling asleep, newborns can appear to be panting with very rapid breaths. This can last from seconds to minutes. They can also have very long pauses lasting 10 to 15 seconds. This is called periodic breathing and can be alarming, but parents need to be educated this can be perfectly normal as long as it does not persists and the infant has no color change.This is due to the central nervous system not being fully developed yet.
Here is a short list of some of the more common things that I find that new parents call about frequently that you may find helpful:
Diarrhea- Breast fed infants bowel movements constantly change, and it is very normal for a breast fed infant to have as many as 10 watery, yellow seedy stools per day. Parents should only be concerned if the infant acts sick, develops a fever, poor sucking reflex, not latching on as well, stools become mucusy or bloody, not urinating, or stools dramatically increase in frequency or any other concerning symptoms. Frequent, liquid stools in a breast fed infant is not necessarily diarrhea.
Cyanosis or mottling of extremities- New parents frequently call about noticing this in the feet especially. The circulatory system of newborns and young babies are not fully developed yet, and the feet appearing blue is very normal. If they feel warm to touch and the infant is exhibiting otherwise normal behavior, you might suggest they elevate the extremities for a brief period and see if the color returns to normal. If not, call back or if any other symptoms seen.
Cyanosis around the mouth-This is know as circum-oral cyanosis or peri-oral cyanosis, and if the lips and tongue are pink, respirations are normal, and infant is feeding well, this is can be normal. The parents will often report it as the infant appears "blue around the mouth". This is due to the engorgement of the venous plexis and is normal.
Irregular Breathing- Newborns often do not have quiet breathing. Especially on falling asleep, newborns can appear to be panting with very rapid breaths. This can last from seconds to minutes. They can also have very long pauses lasting 10 to 15 seconds. This is called periodic breathing and can be alarming, but parents need to be educated this can be perfectly normal as long as it does not persists and the infant has no color change.This is due to the central nervous system not being fully developed yet.
Congestion- Sneezing and congestion can be normal. Newborns have never encountered foreign substances and airflow through their nose, and sneezing is normal process to try to clear the nasal passages.
Jerking or Twitching- The nervous system is very immature, and newborns are very
jittery. Arms, legs, lips and chin can quiver, jerk and shake. They also have
an exaggerated startle reflex that can cause them to jerk their arms and/or
rhythmically shake their arms. Jitters can be distinguished from seizure activity
by holding the arms or legs that are jittery or shaking. Seizures will not
stop, but jitters will once the effected body part is held.
I hope these tips may help some of you dealing with nervous new parents. As I said, it is a job well done when you can talk them off the fence, and they can realize they are have a normal healthy infant that they need to nurture and enjoy and not have to worry that something is terribly wrong.
Tuesday, October 30, 2012
Err on the Side of Caution
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.
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.
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.
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