Telephone Triage for Otorhinolaryngology and Head-Neck Nurses
Margaret M. Hickey, RN, MSN, CORLN
Trends in healthcare financing and changes in care delivery have shifted care from inpatient to outpatient settings. This has resulted in a demand for RNs in the ambulatory care setting. In March 2004, just over one-half (56%) of RNs worked in hospitals, a decrease from 59% in 2000, whereas the number of RNs working in ambulatory settings increased from 9.5% to 11.5% (U.S. Department of Health and Human Services [DHHS] Health Resources and Services Administration, 2006). Although this shift in care delivery settings is a general healthcare trend, it clearly reflects today’s setting for care of the otorhinolaryngology (ORL) patient.
The traditional nursing role has been challenged by this change of patient care delivery setting. The inpatient setting continues to be the primary location of basic nursing education, yet during their career, many nurses find themselves practicing in the outpatient setting. Nurses often transition to ambulatory care expecting to use the same knowledge and skill set learned in their acute care practice. Although some competencies may be transferable, the expertise and skills needed by acute care nurses and ambulatory nurses are not the same (Swan, 2007). Nursing care in the outpatient setting allows limited time with the patient, and the focus shifts from the nursing-based model of practice to the medical model.
The telephone is an essential and effective means of communicating and sharing information and is an important tool for the ambulatory care nurse. Since the invention of the telephone in 1876, it has been used as a tool to seek healthcare assistance. In fact, Alexander Graham Bell’s first recorded telephone call was for help after he spilled sulfuric acid on himself (Boston Innovation and History Collaborative, n.d.). Performing telephone triage and providing telephone advice are essential skills for ambulatory nurses and are a new skill set for nurses who move into this setting. Regardless of the nursing specialty (e.g., pediatrics, ORL, oncology), nurses in outpatient clinics often find themselves performing assessments and providing triage and advice over the telephone. Telephone calls from patients are a major component of ORL outpatient nursing practice and should be taken into consideration when establishing nursing roles and responsibilities, as well as during budget development.
Telephone assessments and triage have become an integral component in ambulatory care delivery, improving appropriate access to care as well as a means to control healthcare costs. One large study completed in 2004 explored the impact of an after-hours pediatric call center in Denver, Colorado, by surveying 8,980 callers. Nearly one-half (49%) of the callers would have sought emergent care prior to their call, whereas only 13.5% of these callers were identified by the call center as needing urgent disposition. Fifteen percent of cases in which the parents would have stayed at home were given an urgent disposition by the nurses. Provided the advice was followed, the estimated savings per call based on local costs was $42.61. This study illustrates the importance of telephone triage and advice on improving patient care by assisting callers in making the appropriate decision to seek emergent care when needed, as well as the resulting financial savings to the healthcare system (Bunik et al., 2007).
The types of calls received and the care provided need to be individualized for the patient and his or her problem. Mastery of telephone triage is a difficult yet necessary skill for outpatient nurses. Office triage nurses must quickly become knowledgeable about the patient, including his or her current and past medical history and social situation. Telephone assessments require nurses to be experienced in the nursing specialty, with an expert knowledge base of the usual disease states or conditions and treatment regimens. These nurses must possess excellent communication skills that allow for a quick rapport and a complete and accurate patient assessment that is based on limited auditory clues alone (Derkx, Rethans, Knottnerus, & Ram, 2007).
ORL nurses are especially challenged in meeting their patients’ needs over the telephone. A nursing assessment of a patient with an ear, nose, or throat (ENT) problem can be quite complicated. The primary problem as well as side effects from treatment can affect the patient’s ability to communicate and can cause a variety of symptoms. The nurse may be taken off guard by the patient’s telephone call, as it can occur at any time. The patient’s chart, with a complete medical and cancer history and treatment plan, may not be available when the nurse first responds to the call. (Tip: Have the secretary or receptionist locate the chart prior to transferring the call to the triage nurse.) The complex patient assessment is made even more difficult when the assessment is performed over the telephone because the nurse is unable to visually observe or examine the patient. This is a significant challenge, as visual messages and nonverbal communication account for up to 55% of the impact in a face-to-face patient assessment (Car & Sheikh, 2003).
Nurses are direct care providers. They are educated and practice in settings in which they use their senses when assessing and caring for patients. As nurses gain more experience, they assimilate and process information through their senses so rapidly that they often are unaware of individual thought processes. This is commonly described as “intuition” or “a gut feeling.” Regardless of how nurses define this ability, the thorough nursing assessment, including sensory observations, allows expert nurses to make prompt and accurate decisions. This intuition often is lost when the assessment is performed over the telephone because of the lack of sensory input. Nurses cannot see, touch, or smell and must rely solely on verbal and listening skills. Furthermore, nurses may be communicating with a family member or friend who is attempting to describe the patient’s complaint.
It is not surprising that telephone triage can be a daunting task for ORL nurses unless they are well prepared. A systematic process within the busy practice setting, including written protocols or guidelines and complete and concise documentation, allows nurses to give the required time and attention to patients’ calls. Preparedness requires an in-depth understanding of ORL and ORL care and excellent assessment and telephone communication skills. Nurses with years of experience and skill in telephone assessment and communication may develop a “telephone intuition” that allows them to ask a few pointed questions to quickly get to the root of the problem. They are able to hone in their assessment not only with their knowledge of the specialty but also with their knowledge of the patient. These nurses will listen “between the lines,” focusing not only on the patient’s words but also on the tone of voice. Expert telephone nurses can quickly identify the patient’s anxiety, pain, or other symptoms such as shortness of breath. However, for nurses who have not yet gained these skills, few resources are available.
The goal of this book is to provide useful tips for ORL nurses as they develop telephone triage or telephone nursing practices in their clinical settings. To date, there has not been a text that addresses the special needs of patients with ORL problems or the special skills required by ORL telephone triage nurses. The authors hope this book will help both expert and less-experienced nurses. The purpose of this text is to provide “how-to” tips for telephone assessment, communication, and documentation, as well as for the telephone triage process, including a sample of legal concerns and models of practice. The telephone guidelines and protocols are symptom based and were selected to address the common complaints of patients with ENT disorders and head and neck cancer. These protocols offer basic structure to handling telephone calls in an outpatient setting while providing continuity of care for the patient with cancer.
This text is designed to be a resource for ORL nurses who are learning the telephone nursing role. However, expert nurses will find this text a useful resource when educating newer nurses and a guide in how to develop a formalized telephone nursing practice in the clinic. The telephone symptom-related protocols will assist expert nurses as calls arrive with complaints they have not handled in the past.
The following chapters will provide tips to improve telephone communication and a systematic approach to performing a telephone nursing assessment, information on legal issues and concerns, a discussion of telephone triage practice models, and an exploration of the history of telephone triage. Symptom-focused telephone protocols or guidelines are included to direct nurses in the development of guidelines in their practice settings. It is essential that these protocols are not implemented without the review and approval of the physician or physicians who manage the patients in the practice. These telephone protocols are written to serve as a guide to nurses to meet the specific needs of the ORL patient population.
ORL nurses from across the United States have contributed these protocols in an effort to help other nurses improve patient care. Each protocol is credited to the nurse or nurses who were responsible for submitting a protocol that was used, at least in part, in the development of the published protocol. Thanks to each of these nurses who were so kind to share their expertise. This text could not have been accomplished without the sharing spirit and collegiality of ORL nurses.
Boston Innovation and History Collaborative. (n.d.). Telephone, Alexander Graham Bell 1847–1922. Retrieved from http://bostoninnovation.org/bostoninnovation/telephone.htm
Bunik, M., Glazner, J.E., Chandramouli, V., Emsermann, C.B., Hegarty, T., & Kempe, A. (2007). Pediatric telephone call centers: How do they affect health care use and costs? Pediatrics, 119, e305–e313. doi:10.1542/peds.2006-1511
Car, J., & Sheikh, A. (2003). Telephone consultations. BMJ, 326, 966–969. doi:10.1136/bmj
Derkx, H.P., Rethans, J.J.E., Knottnerus, J.A., & Ram, P.M. (2007). Assessing communication skills of clinical call handlers working at an out-of-hours centre: Development of the RICE rating scale. British Journal of General Practice, 57, 383–387.
Swan, B.A. (2007). Transitioning from acute care to ambulatory care. Nursing Economics, 25, 130–134.
U.S. Department of Health and Human Services Health Resources and Services Administration. (2006, June). The registered nurse population: Findings from the March 2004 national sample survey of registered nurses. Retrieved from ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf