TRIAGE LOGIC 2013

Teletriage is one of the riskiest (legal-wise) positions a nurse can work in. We rely heavily on our callers to provide accurate, truthful and reliable information about themselves or child/ren to help us make informed and educated decisions about the level of care that is needed. In return, our clients expect us to provide accurate, truthful and reliable information back to them.

We (the professional RN) have to ASK the right questions to illicit the right answer from the caller. We have to use senses other than our eyes to perform an accurate assessment on our patient. Patients can not be expected to provide our entire triage, sometimes we need to “pull” that pertinent information out.

Quality assessment and caller satisfaction depends on effective communication between the nurse and the caller. Certain techniques foster effective communication by providing an atmosphere of openness and mutual trust, which contributes to information gathering, mutual satisfaction, and compliance by the caller with the disposition. Nurses’ skills in these techniques not only improve communication, but may also help resolve problems by providing an atmosphere of acceptance that allows people to think.

It is important to remember WHY we do this job. Our Number One concern should be the safety of our patients .

Remember our mission statement when talking to each client.

These are the tools that are going to assist you in determining the SAFEST disposition for your client. If you choose an incorrect guideline, that patient is not receiving THE BEST possible care you can provide and the door to being legally responsible if there are injuries has been opened!

The more familiar you are with the protocols, the more spontaneous (and less scripted) your triage will become. Parents appreciate a nurse that uses her knowledge and skills verses only reading and giving advice from a protocol

Know the protocols, especially the top 25

Know which protocols take priority Stay up-to-date with protocol revisions

and new protocol Develop and use standardized

statements to elicit informationExample/s: “Tell me why you called

tonight.” or “What is different about the problem tonight that causes you to be concerned?”

You should be able to talk and type at the same time while LISTENING to what your caller is saying. The parent will probably be telling you information that may not be relevant to your assessment. It is up to you to determine what is important and what is not.

Spell check does not catch everything. Be sure to review your note for typographical errors or incorrectly spelled words that can change the meaning of your note.

A lawyer is not going to cut you any slack if you did not take the time to proof read and correct inconsistencies in your note.

Know the keyboard (typing skills) Know your software (shortcut keys and

shortcuts) Use the fastest system—mouse OR the

keyboard

It is impossible to sit in an uncomfortable position for an entire shift and give your patients 100%. It can affect not only your physical ability oerform a triage but your mental ability also.

You can not be on your “A-GAME” if you are uncomfortable or in pain.

Adjust your computer, lighting, chair, key board and mouse to your specific needs prior to working. Close your door to block out noise.

Also, if there is background noise (family, pets, TV, radio, Farmville etc..) in the background you may miss relevant information from the caller or sounds in the callers background that would change your assessment.

Adjust your work station and headset at the beginning of this shift.

Maintain a quiet, private atmosphere in the home office.

Ensure you maintain good posture and change position frequently

Obtain screen glare guards if light reflection is a problem

Use wrist supports if needed

We are all hired because we are EXCELLENT nurses with EXCELLENT judgment and years of nursing and/or triage experience. We should not be relying solely on protocols to tell us what we already know. Our patient safety is our highest priority.

Use ALL of your nursing skills when assessing your patient. Sometimes you have to put your pen down and LISTEN to your caller.

Your notes should be ACCURATE, INTELLIGENT, WELL THOUGHT OUT, HAVE A LOGICAL FLOW, be COMPLETE and DETAILED.

Notes should “Paint- A- Picture” of your patients symptoms that any health professional reading your note will understand and appreciate.

Trust your assessment skills and nursing judgment Don’t speak with the child unless it is directly related

to your assessment Ensure that your assessment and documentation

support the growth and development level of the child, for example:

Mom is telling you that her four-month-old has a “sore throat.” How does she know this when the baby cannot talk? Is the baby drinking less? Does the throat look red, or has the baby just been fussier today? Document and deal with the actual behavior.

Listen to the parent when they are telling you something is wrong with their child, as they know their child better than anyone else, and most of the time they are right. BUT don’t ignore your nursing judgment or experience- Think Outside the Box and don’t get caught up in the idea that the parent’s “diagnosis” is correct. Look for Zebra’s when you hear hoof sounds!

A recent JCAHO report noted that: "Ineffective communication is the most frequently cited category of root causes of sentinel events. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces error and results in improved patient safety.“

With that said, we do have to collect some information to assure we have accurate information. The patients name (spelled correctly), DOB and Practice information should be collected as soon as possible in the call. Sometimes the patient will begin rattling off symptoms before you can verify this. Let them talk for a minute, when they take a breath- let them know you can help them but have to verify a little information first to be sure the note is faxed to the correct physician.

You should begin your with an introduction such as:

Nurse:  Hi, this is <<name>>>, a registered nurse with….  I’m returning a call.

Parent:  yes, she has had a fever all day and now she is vomiting…

Nurse:  okay, well let me quickly get some basic information and history and then we’ll see what’s going on and what we need to do for her.

Parent:  okay… Nurse:  proceeds with demographics and HPI, then

assessment and triage.This approach lets the caller know that their child is

important but that we need to verify information to be sure that we have it correct.

A calm and Quiet Tone of Voice. Talking in an abrupt/hurried, or bored/detached tone can be interpreted as you being uninterested in what the caller is saying or about their child.

Be Attentive: Let the caller know you are listening by making appropriate responses. “Oh,” “hmm,” and “uh-huh” work well. Respond early and genuinely. Stay alert during the conversation.

15 seconds of silence on a phone line seems like much longer to an anxious or sick caller.

Be Non-Judgmental: Convey to the caller that this is a safe place to say whatever needs to be said. Accept the caller’s point of view. Callers need to express their feelings before they can begin to get control of their problems.

Show Empathy: Focus on feelings and convey understanding by paraphrasing: “Sounds like you feel miserable.” Avoid blocking out emotional areas. (This can be difficult if you do not agree with the caller’s view of the situation.)

Show Respect: Respect callers. Show a willingness to mutually define and solve the problem. “I can give you a hand with this.” “We can work on this.”

Avoid using your medical knowledge to manipulate.

Don’t use slang terms-stay professional at all times. (“honey”, “sweetie”, “bless your heart” etc..)

Choose positive, active words during the interaction with the caller.

Positive terminology helps project the image of a knowledgeable healthcare provider and increases credibility with the caller.

Positive statements convey action-oriented behavior and enhance the perception of the caller that our purpose is to help them “get things done.”

 

This lets the caller know that what they are doing is the right thing and it is helping. Sometimes they just need the information from a different perspective to help them realize that what they are doing is actually helping.

If the caller is rambling and you are uncertain why they are calling, refocus them on the information that you want to know. Do this by asking direct questions.

Examples: Okay, I understand that you have a lot of

concerns, but what is going on tonight/right now?

What’s the worst problem you think you/your child is having? Let’s talk about that one first.

What has changed that made you decide to call in tonight?

What’s different now than when he was seen in the office today?

Don’t allow the caller to put you on hold. Calm the caller down as soon as

possible. Stay away from unrelated or social

topics Stay focused on current problems

during the call. Do not allow outside distractions—

maintain privacy in the home office.

We have all had the occasional “Difficult Caller”. The person that can not be consoled, reasoned with or pleased despite our best attempts. So what do you do?

Try to remember, it is not personal. The caller/parent is probably extremely anxious, nervous or scared that they or their child is sick. Sometimes they feel frustrated that they had to “jump through loops” just to get to the triage nurse. You, the triage nurse, are the only target they have to vent their concerns too.

Let them vent for a moment, then show empathy and try to redirect the call to the real reason they called- their sick child.

Do not take the anger personally. Let the caller express their issue without interrupting. Do not argue.

Note all important details of the caller’s issue/concern. Repeat these facts to the caller to verify accuracy.

Listen closely and acknowledge how the person is feeling, e.g., “I can imagine how frustrating this has been for you.”

Identify the expectation of the caller. What do they want? In what time frame? Do they expect a response from a specific department or individual?

Offer suggestions. Let them know what you can do and what you need from them. Move to a positive solution. “I will notify your physician and have him caller you as soon as possible.” or “I will notify your physician that you will be calling the office in the morning.”

Document the callers behavior using objective statements and use direct quotes as much as possible. Avoid using labels such as “nasty” or “angry.” You may document that their tone of voice is stern or that they are speaking loudly, swearing, etc. Try to describe the behavior accurately and professionally.

Documentation of the callers behavior should be done in the notes section call, not in the assessment. Remember, the assessment is used for subjective information from the parent concerning the child’s symptoms, not objective observations by the nurse.

Be aware of your voice quality. What you say and how you say it are very important.

Adjust the volume of your voice to the caller.

Ask their name. It helps personalize the call and it is required information when triaging.

Match your pace to the caller’s natural rate of speed.

Be aware of word choices. Avoid the use of jargon and complex

medical terminology. Enunciate and speak confidently.

Try not to interrupt the caller while they are talking- this occasionally has to be done to regain control of a call, but it should be done in a redirecting kind of way, not just cutting them off

Be sure to explain the triage process to the caller. A good line can go like this: "okay, well let me get some information and then I will ask you some questions and we will address all of her symptoms and determine what we need to do for tonight.”

The parent should feel like the nurse is partnering with them to take care of the child.

Be honest, warm, straightforward and GENUINE. Parents can spot rudeness, inattentiveness and incompetence a mile away.

We do not have all the answers, but we should know where to FIND all the answers, whether is it paging the MD, using our protocols, asking our co-workers or referring our callers to appropriate UCC, ED, lactation consultants, or pharmacists.

Smile when you talk and keep a mirror next to your work station to remind yourself to keep smiling....