Evidence-Based Triage Guidelines and Nurse Critical Thinking: A Winning Combination
There is a perception among some in the telehealth triage community that using triage guidelines or protocols will always lead to a safe and successful patient outcome. However, this idea underestimates the significant nursing assessment that precedes the selection of a guideline and the critical thinking that accompanies its application.
Like any equipment used in the health care setting, a triage guideline is only as effective as the healthcare provider operating it. It is the education, training, and experience of the operator that ensures a successful intervention and outcome.
When speaking with a caller, you are talking to a specific family about symptoms and confounding variables such as time of day, distance from services, and available resources that are specific to them at the time.
A guideline cannot incorporate all the unique nuances extracted during the dynamic interview process between nurse and caller. It is in the first minutes of the telehealth encounter that the stage is set for a successful outcome.
The Caller’s Agenda: 90 Seconds of Listening
Starting your triage conversation with a simple, open-ended question such as “So, tell me what’s going on?” is the single most important element of a successful interview and assessment.
First, you are handing over the conversation to the caller, telling them that the information they share is important and relevant.
It is very important to respect this sacred space where the caller is given the opportunity to share in their own words what they see and why they are concerned.
Consider the courage it takes for a caller to reach out to (in many cases) a stranger for guidance on a situation that is a concern, if not a crisis, in their family’s life.
For many, they have been waiting for a return call, or to be the next call answered and have rehearsed their concern over and over to get it just right.
This is an opportunity to honor the story the caller shares and to listen carefully to the rich description they have to offer.
Take notes and jot down key information. But listen in silence. This is not the time to ask “clarifying questions” or interrupt. (An exception would be any emergent or red flag symptoms. For those, stop and clarify the severity of the symptom with the caller.)
Callers will seldom speak for more than 90 seconds before they stop for a response. This is not only personal experience at our call center, but it is backed up in research.1
When your caller pauses, thank them for sharing and then you can request additional clarifying information.
These 90 precious seconds have done several important things.
The simple act of listening has created a trusting environment where the caller knows they are in a safe and caring relationship and are respected.
It also gives you a significant amount of information and insights on which to launch your triage.
Unfortunately, many triagers do not realize the importance of these first 90 seconds. They may interrupt or redirect the caller and the precious moment of creating trust is lost. Important clues can be missed or disregarded because the triager is listening with their personal bias or focused on their own agenda and not really hearing all the key information shared by the caller.
Now Complete Your Assessment
Does your documentation “paint a picture of the patient at the time of the call”? If not, fill in any missing pieces. Have you asked: “What is the person doing right now?” Have you addressed hydration, pain, and activity? If you can picture this unique patient in your mind, then it is time to select the appropriate guideline based on all the information that has been collected.
Select the Right Guideline for Your Patient
A guideline serves as a “guide” to ensure nothing was missed during your interview and assessment. Always select a guideline that addresses the most serious symptom identified during your assessment. Selecting the wrong guideline can lead you down the wrong path.
Make sure the guideline definition matches your patient’s symptoms. If it doesn’t, you most likely are in the wrong guideline.
If the guideline questions don’t seem appropriate for the information you’ve gathered, consider an alternative guideline.
All guidelines have a “See More Appropriate Guideline” or SMAG section. Don’t skip this step, there may be a more precise guideline for your patient.
If additional information comes up while working your way through the guideline, pause, be curious, and ask more clarifying questions.
Review the Guideline Disposition
Apply the important data you collected in the first 90 seconds before signing off on your guideline’s recommended disposition.
Are you confident you have a reliable historian?
What is your learning readiness assessment of the caller? Can they follow directions safely?
Does the caller have the resources needed to follow your care advice? Is this a safety concern?
Does the patient have a complex disease? Should a specialist be involved to ensure you arrive at the safest disposition? These patients are much more likely to have complications and can be medically fragile.
Consider weather conditions and distance to a care facility. A call back from the PCP may be a better alternative in this situation.
Does the caller agree with your recommendation, and are you confident they will follow through? If not, what is the disconnect? Summarize what you heard from the caller and ask for any clarifications. This new information may change your final disposition.
Always work with the caller to reach a disposition agreement. If you can’t, escalate the disposition or work with them to reach a mutually agreeable resolution.
Summary
Telehealth guidelines are essential tools, but they are only as reliable as the intelligent, experienced, highly trained nursing professionals who use them. The combination of evidence-based guidelines and expert triage nurses creates the best opportunity for a safe outcome for the patient!
Authors
Kathleen Martinez, RN, MSN, Nurse Manager, Pediatric Call Center Children’s Hospital Colorado; STCC Pediatric After-Hours Guideline Reviewer; Former President, AAACN
References
1 Langewitz, W., Denz, M., Keller, A., Kiss, A., Rütimann, S., & Wössmer, B. (2002). Spontaneous talking time at start of consultation in outpatient clinic: cohort study. Bmj, 325(7366), 682-683.