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TelehealthandTelephoneTriage
Kathleen Keating, RN, MSN, CPNP-PC, CNS/DDDDNA March 2018
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Givingcredit....
Thematerialinthispresentationhasbeentailoredspecificallyfornurseswhocareforindividualswithintellectual&developmentaldisabilitiesby
KathleenKeating,RN,MSN,CPNP-PCinconsultationwith
CarolRutenberg,RN,MNSc,CENofTelephoneTriageConsulting
DevelopmentofthismaterialwassupportedbyagrantfundedbytheNewYorkStateDepartmentofLabor
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Uponcompletionofthisseminar,youwillbeableto:
• Definethevariousformsoftelehealth• Describetheroleofthenurseintelephonetriage• Identifytheroleofprotocolsintelephonetriage• Conductameaningfulinterviewbyphone• Documenttoincreasequalityanddecreaserisk
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WhatisTelehealth?
• Abroadvarietyoftechnologiesandtacticstodelivervirtualmedical,health,andeducationservices.
• NOTaspecificservice,butacollectionofwaystoenhancecareandeducationdelivery.
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Knowingtheterms• Telehealth– Thedeliveryofpreventative,promotiveandcurativeaspectsofhealth
• Telemedicine– medicaldiagnosisofpatients’problemandtheirmedicaltreatmentoverthephonebyphysicians
• TelephoneTriage– Estimatingsymptomurgencytogetthepatienttotherightplace,attherighttime,fortherightreason
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Modalities• Live(synchronous)– “realtime”
• Store-and-forward– Transmissionofrecordedhealthhistory(forexample,pre-recordedvideosanddigitalimagessuchasx-raysandphotos)
• RemotePatientmonitoring– collectandtransmitdatafromanindividualinonelocationtoaproviderinadifferentlocation
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Telemedicine
• Asubsetoftelehealth• Theevaluation,diagnosisandtreatmentofillnessbyanauthorizedprovider(MD,PA,NP)atadistanceusingtelecommunications.
• Allowscliniciantotalkdirectlytotheirpatientsinrealtime
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TelephoneTriage
• Oldestformof“live”telehealth• Practicedsincethe1980’s• Aninteractiveprocessbetweenanurseandacallerthatoccursoverthetelephone• Involvesidentifyingtheurgencyofperson’shealthcareneedsanddirectinghim/hertotheappropriatelevelofcare
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WhyDoTelephoneTriage?
Providesforimprovedqualityofcareforpersonswesupport.
Providesprofessionaldirectionandsupportforunlicenseddirectcarestaff.
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DoesTelephoneTriagework?
A2015articleintheJournaloftheAmericanBoardofFamilyMedicine concludedthat“Implementationofnursephonecarewasassociatedwithlowerinappropriateantibioticusageandfewerunnecessaryprovidervisits.”
Pittinger et al, 2015
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WhatisthePurposeofTelephoneTriage?
Toestimatesymptomurgencytoallowthenursetodirecttheindividual
ü totherightlevelofcare,ü attherightplaceü attherighttimeü withtherightprovider
sothats/hereceivestheoptimumtreatment
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Nodiagnosinghere
• Doesnotinvolvemakingeithernursingormedicaldiagnoses
• Recognizeandmatchsymptomstothoseinaprotocol
• Assignacuity
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DecisionMakinginConditionsofUncertainty
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SelfDoubtAssociatedwithDecisionMakingisa
CharacteristicofExpertisePatBenner(1984)
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WhySpecialTrainingforTelephoneTriage?
• Studyof35adolescentcareclinics
• Simulatedtriagecalls– Adolescentactress– R/Oectopic
Rupp,Ramsey,Foley(1994)
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Findings:
• >1/3gaveinappropriateadvice• <1/3ofadvicegivenbyRN
• NodifferenceinthequalityofadvicegivenbyanRNandasecretary!!!
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WhatCanWeDoAboutIt?
• Knowledgedeficit• Beingrushed• Underestimatingtherisk
– (It’sonthephone,soit‘snotserious!)
– Frequentflyers– Aid-initiateddiagnosis
• Fatigue• Multitasking(distracted)
• Protocols;STUDY!• Slowdown!Useprotocol• Lookforurgents
– (allarelifethreateninguntilprovenotherwise)
– Eventheycangetsick!– Runtheotherdirection!!!
• Share/rotatecall• Taketimeto“shiftgears”• Makestrongeffortsto
concentrateoneachcall
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Pointstoconsider
AmericanHealthcareAccreditationCommission-URACstandards– StaffmustbeproperlytrainedRNsorMDs– Mustcallbackwithin30minutes– Ifusingautomatedsystem,mustconnectto“live”personwithin30seconds
– Mustusedecisionsupporttools– Mustdocumentallcalls– Mustprovidefor/ensurecontinuityofcare
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NursePracticeIssues
• LPN– In2005theNCSBNfoundtherewasgeneralagreementamongstatesthatLPNscannotdotelephonetriage
– LPNsmaynotassessindependently
–WorksundersupervisionofRNorMD
In general, only RNs may conduct patient assessment
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RoleoftheOn-CallNurse
• Assessment
• Advice/Treatment
• Occasionally– Messagetaker– Appointment/referral
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PatientAssessmentOverthePhone
And why are you calling today?
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WhyAreYouCollectingtheData?
• EstablishUrgency
• Protocolselection
• Communicatewithprovider
• Documenttheencounterwiththeaide
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TypesofDecisionMaking
• PatternRecognition– Immediateresponsebehavior
• Focused– Limitedproblemsolving
• Deliberative– Deliberateproblemsolving
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OpeningtheCall
• Settone– Unhurried,caring,concerned– Establishrapportquickly
• Staffwillgenerallytellyou–Whotheyare–Whatresidencetheyarecallingfrom–Whotheindividualistheyarecallingabout–Whytheyarecalling
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Firstthingsfirst• Askifthereisanyproblemwith– Airway/breathing– Circulation– NeuroDeficit(alteredlevelofconsciousness– Affect(nothimself?Differentfrombaseline?)
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MovingInOntheProblem
• IsolateChiefComplaint– Becomemorefocusedbasedonhypothesis
• Establishurgency– Ifcallerisconcerned,takethemseriously
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Mnemonictohelpyouremember
“OLDCART”• O=Onset• L=Location• D=Duration• C=characteristics• A=aggravatingfactors• R=relievingfactors• T=treatment
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ThingsstaffshouldknowAllstaffshouldbetrainedinobjectivemeasures:
– Vitalsigns– Pulseoximetry– Fingerstick bloodglucose
Whencallingstaffneed:– Vitalsignsalreadydone– MAR– DateoflastMDappointment
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NursingProcess
• Assessment– Subjective,Objective,Conclusion(Triagecategory)
• Planning– Collaboratively—leavesomeresponsibilitywithaide
• Implementation– Continuity!
• Evaluation– Knowbeforeyouhangup—”let’stalkagain…”
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EmergentPresentations
• Suddenparalysis,lossofconsciousness• Suddenlossofvision• Crushingchestpain• Severedifficultybreathing,stridor• Suddenonsetsevereabdominalpain• Suddenonsetcold,paleextremity• Penetratingtraumaofheadorthorax• Suicidalideationwithplan&meanstocarryout• Testicularpainand/orswelling
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EmergentPresentations
• Sudden paralysis,lossofconsciousness• Sudden lossofvision• Severeorcrushingchestpain• Severe dyspnea,stridor• Sudden onsetsevereabdominalpain• Sudden onsetcold,paleextremity• Penetratingtraumaofheadorthorax• Suicidalideationwithplan&meanstocarryitout• Testicularpainorswelling
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UrgentPresentations
• Worseheadacheoflife• Pinkeyewithpainordecreasedacuity• Uncontrolledseverehighbloodpressure• Severecough,fever,weakness• Acuteonsetmildabdominalpain• Bluntextremitytraumawithpain• Seizure– newpresentation/type
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Non-urgentPresentations
• Typicalpreviouslydiagnosedmigraine• Mildsorethroatwithoutothersymptoms• Sinuscongestionwithoutredfaceoreye• Cough,fever,nochestpain,feelsOK• Uncomplicatedrashorbeesting• Dysuria• Usualseizurepattern/type• Limited,short-termvomitingordiarrhea
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Protocols…
• Clinicalrulesforhandlingcallsandgivingadvice
• Guidethenurseindecisionmaking
• Shouldallowforstructurewithoutbeinginflexible
• ShouldNEVERsupercedenursingjudgment
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ProtocolsAvertDisaster• Decreaselikelihoodofoverlookingimportantfacts
– Functionasachecklisttopreventoversights– Willhelpabusynursefocus
• Supplementknowledgedeficits• Standardizeapproachtotheproblem
– Daytoday– Nursetonurse– Patienttopatient(protects“frequentflyers”)
• Decreaseambiguityindecisionmaking– (Provideatangiblebasisfordecision-making)
• Representthestandardofcare– Recommendedbyprofessionalorganizations– Arewidelycitedinnursingliterature
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ProperUseofProtocols
• CompleteinitialassessmentBEFOREopeningtheprotocol(toassureproperprotocolselection)– Patientsfrequentlycallwithmostworrisomeassociatedsymptom(notchiefcomplaint)
– Patientsfrequentlyself-diagnosewrong!
• Reviewallappropriateprotocols,takehighestlevelactionrecommended
• Protocolsdon’trepresentartificialintelligence;Deviate(anddocument)whenit’sindicated
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Typesofprotocols• Prescriptive– Givespecificdirectionsforaction– Leavelittleornoflexibility– Generallyeasytousewithlittleornoinstruction
• Flexible– Givedirectionswithinarangeofpossibilities– Leaveflexibilityfornursetodevelopplanofaction
– Sometimesrequirespecificinstructioninuse
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• ExperienceofRNstaffwhowillbeusingthem• Easeofuse• Portability• AdaptabilitytoMR/DDpopulation• Cost
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RolePlay
7:30AMYoureceiveaphonecall
“Hello!Charliestartedcoughingwhileeatingbreakfast”
Whatwouldyouask?
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Choking&AspirationProtocol(Example)KeyQuestions:Name,Onset,Cause,PriorHistory,PainScale
Ø ASSESSMENTA. Isthefollowingpresent?
Ø ThepersonisunconsciousandnotbreathingYes-Call911andstartCPR!No–GotoB
B.Isthefollowingpresent?Ø consciousbutunabletospeak,coughorbreathe?
Yes-Call911andstartfirstaidNo–GotoC
C.Areanyofthefollowingpresent?Ø DifficultyBreathingØ Bluelipsorface
Yes-Call911No–GotoD
D.Areanyofthefollowingpresent?Ø ForeignbodyaspiratedintolungsØ Coughingupbloodorseverepainafterdislodgingforeignbody
fromthroatØ Unabletoremoveforeignobjectfromthroatandnoother
symptoms
Yes-Call911No–GotoE
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E. Are any of the following present?Ø Able to speak and coughØ No difficulty breathingØ Frequent episodes of choking on saliva, foods, or fluids
YES Call back or call PCP for appointment if no improvement and follow Home Care Instructions
NO Follow Home Care Instructions or Agency Protocol
HOME CARE INSTRUCTIONS: CHOKINGØ For frequent choking, eat slowly and take smaller bitesØ Allow time for swallowing between bites of food and fluid consumption.Ø Ensure the person is in the proper eating position and that the mealtime protocol is being
used.Ø Ensure that the proper adaptive equipment is being used.
Choking & Aspiration Protocol (Example, Con’t)
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HaveIoverlookedanything?
TraumaInfectionStressOther
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Trauma
• Fall• Bumpedhead• MVA(MotorVehicleAccident)• Foreignbodyinorifice• Twisting/straining/lifting• Bites• Burns
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Bites,Human/Animal(Example)KeyQuestions:Name,Age,Onset,Cause,LocationHumanoranimal
ASSESSMENT ActionA. Areanyofthefollowingpresent?
Ø difficultycontrollingbleedingwithdirectpressureØ DeformityorinabilitytouseaffectedlimbØ Head,face,neckorhandlacerationØ
Yes-seekemergencycareatERorUCNo–GotoB
B.Areanyofthefollowingpresent?Ø AnimalisnotimmunizedforrabiesØ AnimalisnotavailableforobservationØ Lacerationtoarms,legsortrunk
Yes-Seekmedicalcarein2-4hoursNo–GotoC
C.Areanyofthefollowingpresent?Ø signsofinfection:redness,pain,swelling,redstreaksfromthe
wound,drainageorpusØ Tetanumimmunizationgraterthan10yearsoldØ Historyofdiabetes,hemophiliaorimmunosuppression
Yes-seekmedicalcarewithin24hoursNo–GotoD
D.Areanyofthefollowingpresent?Ø smalllaceration/abrasion/puncturewound
Yes-callbackorcallPCPifnoimprovementwithin24-48hoursandfollowHomeCareInstructionsNo–FollowHomeCareInstructions
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HOME CARE INSTRUCTIONS: Bites, Human/AnimalØ Clean the area well with soap and water.Ø Apply usual antibiotic per instructions on the label.Ø Leave wound open to air unless it is oozing bloodØ Apply ice pack for swelling during the first 24 hours. Apply heat to area after 24 hours.Ø Check wound daily for signs of infections. Cat and human bites become infected easily.Ø Observe animal for 2 weeks for sign of rabies or illness.Ø Report animal bites to animal control or appropriate authorities.Ø Report bat and skunk bites.Ø Report dog and cat bites when the following occurs:
o the animal is sicko bite was unprovokedo animal is a strayo there is no indication of rabies vaccination; oro circumstances surrounding the injury are suspicious or unclear/uncertain.
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Traumabasedrulesofthumb
• Neverremoveimpaledobjectsnomatterhowsmall
• Burnspotentiallymaybeworsethantheyinitiallyappear
• Anyjaworfacetraumaisaheadinjuryuntilprovenotherwise
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IsitAbuse?• Traumashouldbeconsideredabuseuntilprovenotherwiseif:– aninjuryisunexplained,– Theinjuryisinconsistentwiththereportedmechanismofinjury
– theseverityoftheinjuryisincompatiblewiththehistory,
– thehistorykeepschanging,or– thereisadelayisseekingmedicalcarefollowinganinjury
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Stress
• Stress-inducedillness– Gastrichyperacidity– Tensionheadache– Irritablebowelsyndrome
• Psychosomaticcomplaints– Givetheconsumerthebenefitofthedoubt– Usecautionin“labeling”orstereotyping
• Post-traumaticstressdisorder
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RedFlags• Severe,strangeorsuspicioussymptoms• Co-morbidities• Painthatawakensorpreventssleep• Debilitated(orchallenged)• Frequentflyers• Repeatcallers• Poorhistorians• Concernedaide/family/pt• “Gutinstinct”• Extremesofage
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Elderly• Presentationmaybeatypical,silentorlate
• Physiologicchanges• ImpairedADLs• AlteredLOC
– Neurologic– Dehydration– Sepsis– Poly-pharmacy/adversedrugreactions
• Changefrombaseline
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Considerations• Age,gender,culture,ethnicity,education
• Whenlastseenbyprovider/nextappt?
• Accesstocare– Distance– Timeofday– Transportation
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ClosingtheCall• “Sothisiswhatyoutoldme…”
– Readnotetocaller• Plancollaboratively• Havecallertakenotes!• “Now,tellmewhatyouplantodo”
– (confirmunderstanding&intenttocomply)• “Areyoucomfortablewiththisplan?”• Otherquestionsorconcerns?• Whattoexpect&callbackinstructions
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Closingtheloop• Alwaysfollowup– Toensurethatdirectionswerefollowedand– Outcome:needtodoanythingelse?
• Continuityofcare:Youareresponsibleuntilyou“handoff”– Toahigherlevelofcare(ER,UC,etc.)– TotheRNresponsibleforthesite
• Writee-mailandleavevoicemessageonphone
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InterviewingPitfalls
• Jumpingtoconclusion/stereotyping• Beinginahurry;beingdistracted(notthinking)
• Languagerelatedmisunderstandings• Evasive/uninformedcaller• CALLER-INITIATEDDIAGNOSIS!
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Remember…
• OverreactingisaGOODthing
• ALWAYSerronthesideofcaution
If in doubt, send ‘em out
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DOCUMENTATION
DocumentALLcalls
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IFIT’SNOTWRITTEN,ITDIDN’THAPPEN!
DocumentALLcallsDocumentalladviceandinstructions
Documentallpertinentfindings
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Documenting
• Dependingonyouragency’ssystem,informationgenerallydocumentedincludes:–Whocalled– Chiefcomplaint– Questionsasked/answered– Protocolused(e.g.Briggs:Nausea/vomitingp339)
– Instructionsgivenincludingfollowup.
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Anddon’tforgetthelog…
• Calltracking• QA• Legalrecordofcallsnotenteredintomedicalrecord
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RISKMANAGEMENT
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RiskManagementTips• OnlyRNsmaybeoncall• Ifyoureceiveacallaboutthesameperson2or3timesin24hours,thepersonshouldbeseen.
• Ifthecallerisconcerned(orifyouareconcerned)thepersonshouldbeseen.
• Followpolicy/protocolunlessitdoesn’tfit.Thendeviateanddocumentwhy.
• Watchforco-morbiditiesandhighriskgroups.
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• Documentthoroughly• Besurethecallerunderstandswhatworselookslike
• Besurecallerknowswhattodoifthepersondoesn’tgetbetter.
• Performregularqualityassurance(continuity/follow-up)
• Ifindoubt,ALWAYSerronthesideofcaution!
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WhatPromptsLawsuits?
Anger(caller/family)relatedto• NegativeRNattitudes• Lackofcaringandconcern• Unwillingness/unavailabilitytocommunicate• Dissatisfactionwithhandlingofproblems
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TESTFORLIABILITY• Duty
• BreachofDuty
• Damages
• Causation
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Duty
• Relationshipmustexist
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BreachofDuty
• BreachoccursifthepractitionerfailsthepatientbynotmeetingtheStandardofCare.
• StandardofCareismeasuredbywhatanyreasonable,prudentpractitionerwoulddounderthesameorsimilarcircumstances.
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Damages
• Abadoutcome?• especiallyifthefamily(orfamilyrepresentative)isANGRY!
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Causation
• Whowasnegligent?– TheTriageNursebydoingsomethingorfailingtodosomethingthatresultedinthedamages?(givingbadadvice)
– TheagencynursefornotprovidingUAPswithappropriatetrainingandsupervision?
– TheUAPforwillfullyorotherwisefailingtocarryouttheRN’sinstructions?
OOPS!
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ToProtectYourselfandYourPatient
• Followprotocol&documentit(unlessitisn’tappropriate)
• Besurethecallerunderstandswhattodoifthepersondoesn’tgetbetter.
• Besurethecallerunderstandswhatworselookslike.
• Ifindoubt,ALWAYSerronthesideofcaution.
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CommonCausesofLawsuitsFailureto…
• Failuretoprovidefortheconsumer’ssafety(eg.falls)• Failuretoproperlyadministermedications• Failuretoproperlyassessthepatient• Failuretocommunicatechangesintheconsumer’scondition• Failuretoquestionorders&intervenethroughchainof
commandintimelyfashion• Failuretodoproceduresperproperstandards• Failuretodocumentcondition,treatment&responseto
treatment
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CommonCausesofLawsuitsFailureto…
• Failuretoprovidefortheconsumer’ssafety (eg.falls)• Failuretoproperlyadministermedications• Failuretoproperlyassessthepatient• Failuretocommunicatechangesintheconsumer’scondition• Failuretoquestionorders&intervene throughchainof
commandintimelyfashion• Failuretodoproceduresperproperstandards• Failuretodocument condition,treatment&responseto
treatment
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SOHOWDOYOUPROTECTYOURSELF?
1.Don’tmakemistakes2.Prayforgoodoutcomes!
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Remember…
Youareanurse.
Everytimeyoutakecareofaperson,youarepracticingnursing…
…evenoverthetelephone!
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Thankyou,andGoodLuck!
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Contactinformation
• KathleenKeating,RN,MSN,CPNP-PC
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