Just a Phone Call Away: Nurses Answer the Call of Telephone Triage Challenges

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By Jennifer Larson, NurseZone feature writer

Karen Townsend, RN, knows exactly what to do if you get bitten by a turtle.

Townsend, a charge nurse with the Call a Nurse program at Methodist Children’s Hospital of South Texas in San Antonio, picked up the phone one evening to hear a worried mother on the other end of the line. A small turtle had bitten the woman’s 3-year-old son on the hand and broken the skin. The mom was worried that her son might contract a disease from the bite.

Townsend was used to fielding calls about dog and cat bites, but a turtle bite was a new case for her. She consulted her call center’s computer program guidelines, but it only had information on animal bites in general.

“I had to look it up in one of our reference books, but we still used one of our bites protocols,” she said, adding that she recommended the woman take her son to the local emergency room, since animal bites can get infected easily.

Turtle bites, jellyfish stings, fevers, colds, earaches and upset stomachs: they’re all part of a day’s work for Townsend, who works the night shift for Methodist’s pediatric telephone triage and health information phone line.

While Townsend handles pediatric calls, other health systems’ nurses answer calls about adult health concerns. Some actually schedule appointments for callers, and others provide health information. No matter the job, they all have one thing in common: they provide special health care service over the phone.

While many people lump any phone-related services into the broad category of telephone triage, telephone triage is actually a specific service that encompasses a wide array of nursing skills.

Sheila Wheeler, president of TeleTriage Systems and author of Telephone Triage: Theory, Practice and Protocol Development, writes, “Triage means a sorting out. Telephone triage involves ranking clients’ health problems according to their urgency, educating and advising clients, and making safe, effective, and appropriate dispositions—all by telephone.”

Telephone triage can include symptom assessment, counseling, crisis intervention, information brokering, disease management and referrals for appropriate treatment, according to Wheeler.

Nurses who field telephone calls often report respiratory ailments are common complaints from callers, as are sore throats and colds. Other common calls from adult patients include urinary tract infections and chest pains, said Ginger Gebhardt, RN, a telephone triage nurse with the Mayo Clinic-Scottsdale in the Phoenix, Arizona, area.

Today, many but not all nurses who perform telephone triage services use computerized programs that lead the nurses through a series of standardized protocols for a variety of health care problems that they might be asked to address over the phone.

Methodist Children’s Hospital uses a computer program called Centaurus. The program has guidelines for each nurse to follow.

“We ask them some questions, and that’s how we do our assessments,” Townsend said. “Based on what kinds of symptoms the patient is having, we determine if they need to go to the ER right away or if it’s something they can treat at home.”

Routine home care tends to account for about half the calls received by Call a Nurse nurses. In March, 47 percent of the calls received were routine home care, while about 23 percent of the calls resulted in a recommendation for the caller to follow up with a physician.

There are existing computer protocols for common pediatric ailments like croup, but at some times, the nurses have needed to be creative.

For example, Call a Nurse often gets calls about jellyfish stings because the calling area includes the coastal town of Corpus Christi. But until recently, there wasn’t a prescribed protocol for jellyfish stings.

The service’s medical director gave the nurses some general guidelines, and they worked to put together a protocol in a format compatible with the Centaurus program, Townsend said. Eventually, it became a standardized protocol.

The Mayo Clinic-Scottsdale operates a telephone triage service, but the service has not yet moved to a computerized protocol system, said Gebhardt, who has been working there for about 13 months.

The triage service has three to five nurses taking calls from 8 a.m. to 5 p.m. on weekdays. The nurses refer to the book Telephone Triage by Julie K. Briggs as one guideline and use some existing handwritten protocols.

“And we use each other as backup sources,” Gebhardt said. “If we have any other problems, we go to the physicians directly.”

But the nurses at the Mayo Clinic-Scottsdale do have a computerized system of patient information, so they can pull up a patient’s electronic chart while he’s on the phone. They can add clinical notes to the electronic chart, which they often e-mail to the patient’s physician.

They also talk to people and decide whether to offer home treatment advice over the phone or schedule the caller for an appointment at the clinic. Like other telephone triage nurses, they often refer callers to urgent care centers or the emergency room in certain situations.

However, Gebhardt said, the nurses do have the ability to call in standing prescription orders, such as Diflucan for a patient with a recurring yeast infection, or order simple lab work or X-rays for a patient who is scheduling an appointment.

Not every phone call taken by a nurse is a triage call. Sometimes nurses dispense health care information or make outgoing calls to check up on patients who were recently discharged after surgery.

Mary Willie, RN, is the manager of the Dial A Nurse service operated by St. Vincent’s Hospital in Birmingham, Alabama. The primary function of Dial a Nurse, which operates on weekdays, is to provide health information, Willie said.

Like many other phone services, Dial A Nurse logs phone calls on a computer system.

The nurses field 100-200 calls in an average day, for a total of 2500-3000 per month. But there are days when the nurses are constantly fielding inbound calls while trying to make outbound calls, too.

Some days are “feast of famine” in terms of call volumes, but usually “our nurses are hugely busy,” Willie said. “You just can’t predict what’s going to happen.”

About 20-40 calls each day are made to patients who were discharged after outpatient surgery, and nurses make a few more follow-up calls to patients who suffer from congestive heart failure. A handful of calls are crisis calls, requiring the exquisite care and attention from the nurse who answers such a call.

“Those are probably the most tense ones because you don’t know what you’re up against,” Willie said. “You don’t want to get off the line with them. You want to stay on.”

In those instances, the nurses will try to keep the callers on the line until emergency medical services can reach the caller.

It can be hectic, but the nurses who work as telephone triage nurses often say they love their work for the challenges it presents. Unlike many situations in which nurses work with patients, these nurses can’t actually see their patients.

“I like the variety, the unknown,” Willie said. “It’s always exciting. It’s always challenging, and you stay busy. People do not realize how much work goes on in this tiny little office.”

“It’s like solving a problem without seeing all the puzzle pieces,” added Gebhardt. “I enjoy the challenge of trying to find out what’s wrong and trying to get somebody the correct help that they need.”

April 26, 2002. © 2002. NurseZone.com. All Rights Reserved.