Triage of After-Hours Hospice Calls
Over half of the people enrolled in Medicare are now admitted to a hospice program at the time of their death (NHPCO, 2021). This number is increasing. Many people choose hospice care to avoid emergency room visits and hospital stays and to receive end-of-life care in the comfort of their own home. For a hospice program to help patients and their families reach these goals, telehealth triage nurses must be available 24/7. The triage nurse can provide immediate reassurance and care advice. In addition, the triage nurse can alert the hospice program nurse if an urgent or nonurgent home visit (or another type of follow-up) is needed.
Several hospice programs have communicated to us the need for hospice-specific telehealth triage guidelines. Hospice programs have a long history of providing high-quality, patient-centered care. The addition of hospice-specific triage guidelines can further extend hospice programs’ capabilities to deliver quality care.
With the help of a group of expert hospice provider and nurse reviewers, the adult STCC editorial team developed 11 new hospice guidelines. There are now 13 adult hospice-specific guidelines that cover the main types of calls received by hospice programs after-hours. These guidelines promote a consistent, evidence-based approach to the triage of hospice patient and caregiver calls. Additional hospice guidelines are in development for 2023.
In this newsletter, we highlight some important ways the triage of hospice calls differs from standard adult triage. Nurses who provide telehealth triage for hospice patients should be knowledgeable about the goals, resources, and general principles of hospice care and how these impact the triage process. N
Key Difference #1: Focus of Care
Standard Adult Triage: The focus of care is the patient’s symptoms and concerns (e.g., injury, illness, or symptoms) in majority of calls.
Hospice Triage: The focus of care includes BOTH the patient’s AND their caregivers’ (e.g., family members, loved ones) concerns and symptoms. The goals of hospice care are to provide care and support for the patient/caregivers as a unit. Caregivers frequently need education and support, especially as the patient nears death. In every hospice triage guideline, we include an initial assessment question that asks how the caller and other loved ones are doing.
Key Difference #2: Dispositions
In standard adult triage guidelines, the disposition levels often start with Call EMS 911 Now or Go to ED (Emergency Department) Now.
The main task of the triager is to determine how likely is it that the patient’s symptoms are serious or life-threatening. The triager advises the patient on how soon and where they should be evaluated.
If an evaluation is needed, the patient may be advised to go to the ED, an urgent care center (UCC), or primary care/specialist office for care. Some patients may be seen by a provider via a telemedicine video visit.
In hospice triage guidelines, dispositions of Call EMS 911 Now or Go to ED Now are generally not used. A goal of hospice care is to keep patients in their home surroundings and avoid emergency department visits when possible. The Triage Assessment Questions in the hospice telehealth triage guidelines are written using decision logic that incorporates the goals of hospice care and focus on symptom management.
Almost all hospice care can be provided to the patient in their home or other residence (e.g., nursing home). Hospice patients typically have a designated care team that provides 24-hour support 7 days a week to the patient and their family members.
The main task of the hospice triager is to determine how soon does the patient and/or caregiver need further assessment and care. Instead of directing the patient elsewhere for care, care is brought to where the patient resides. Often it is a hospice nurse who makes a home visit. In some programs, a medical provider can visit the home when needed. The option of a video visit is available for some patients.
A home visit is indicated when there are new or worsening symptoms, or the patient and caregiver need additional support.
In the rare event an ED visit is needed (such as a serious injury), the hospice nurse should be notified right away. The hospice nurse can help coordinate transportation and meet the patient and family in the emergency department. This helps assure continuity of care. In some cases, arrangements can be made to admit the patient directly to a hospice inpatient bed for acute symptom management and avoid transit through a busy emergency department.
This table shows how hospice triage dispositions compare with standard adult triage dispositions.
Key Difference #3: Care Advice
In the hospice telehealth triage guidelines, you will find that some of the care advice looks familiar. For example, the care advice for a minor cut, scrape, or bruise in the Hospice - Falls and Falling guideline is the same as you would find in the standard adult guidelines (e.g., Bruises; Cut and Lacerations).
However, the care advice for managing symptoms is often uniquely different for patients who have a terminal illness.
For example, many hospice patients have limited oral intake, including fluids. This impacts how we address the symptom of constipation. In the Hospice - Constipation guideline, we indicate that bulk-forming laxatives should usually be avoided in hospice patients due to poor fluid intake and poor impaired peristalsis.
Symptom management also changes as the patient declines, and caregivers need consistent education and support. In the hospice guidelines, we include unique end-of-life care advice such as repositioning, turning, and mouth care. You will also find multiple reassurance and education statements the triager can use to support and educate family members and caregivers.
Another important difference is that the triage nurse must follow the hospice plan of care and medication orders for the hospice patient.
How is a DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation) order relevant to hospice telehealth triage?
Generally, most hospice patients have a DNR (or DNAR) order written by their attending physician or the hospice medical director.
However, a DNR (or DNAR) order is not a legal requirement for participation in hospice. In some cases, the physician may have been reluctant to discuss it. In other cases, the patient or family may not be emotionally ready. A patient (or family members) may also be reluctant to establish a DNR order due to cultural or religious reasons.
Regardless of the presence or absence of a DNR (or DNAR) order, hospice patients (and their families) should clearly know that hospice care means moving the focus of care from cure to symptom reduction.
It is important that the triage nurse is aware of the patient's DNR (or DNAR) status when triaging symptoms.
In the definition of each hospice guideline, the assumption is made that the patient has a DNR order. The call center should have written policies on how to address calls from hospice patients who do not have a written DNR (or DNAR) order. For example, for these patients the calls may be routed immediately to an on-call hospice provider or nurse.
After-Hours Hospice Telehealth Triage Guidelines - Potential Users
We foresee the main users of hospice telehealth triage guidelines will be nurses in triage call centers who support hospice programs after hours.
Also, a hospice patient may reach a general triage service (e.g., by calling their primary care provider office). In these situations, the triage nurse could use the hospice triage guidelines as a reference/resource and direct the patient to call their hospice program 24/7 support number.
We recommend that call centers who provide hospice telehealth triage train nurses on hospice goals, principles of care, and the hospice resources available for the patient.
As with all adult triage guidelines, we recommend that the call center medical director(s) reviews and approves these guidelines prior to use.
Hospice Guidelines - 2022
Here are the 13 Adult After-Hours (AH) Hospice Guidelines currently available:
Hospice - Agitation
Hospice - Anxiety and Panic Attack
Hospice - Breathing Difficulty
Hospice - Confusion and Delirium
Hospice - Constipation
Hospice - Death Imminent or Dying Symptoms
Hospice - Death
Hospice - Falls and Falling
Hospice - Nausea and Vomiting
Hospice - No Guideline Available
Hospice - Pain
Hospice - Urinary Catheter (e.g., Foley) Symptoms and Questions
Hospice - Weakness (Generalized) and Fatigue
In the Background Information section of each hospice guideline, we include Principles of Hospice Care:
Eligibility
Hospice Care Goals
Medications and Standing Orders
DNR or DNAR Orders
Avoiding Emergency Department Visits
This section can be used for training and as a resource for triage nurses. The STCC adult authors plan to gradually expand the Adult After-Hours Hospice guideline set based on input from our Hospice Guideline Workgroup and feedback from users.
Key Points
The number of adults enrolled in hospice programs at the end of life is increasing.
Access to telehealth triage nurses 24/7 is key to a hospice program’s success.
Hospice-specific adult triage guidelines enhance the quality of hospice care by providing a consistent, evidence-based approach to triage.
There are several important ways hospice triage differs from standard adult triage.
Nurses providing telehealth hospice triage should be knowledgeable about the goals, resources, and general principles of hospice care.
“Our triage nurses are often the first contact with the caller in a time of symptom crisis. Using the hospice-specific guidelines along with the patient’s plan of care empowers the nurses to manage these crises with confidence and empathy.” Mary Ann Ruberg, Angela Hospice Home Care
Hospice Guideline Workgroup 2021-22
Janet Bull, MD, Chief Medical Officer Emeritus, Chief Innovations Officer, Four Seasons - The Care You Trust Hospice, Flat Rock - Hendersonville, NC; Past President, American Academy of Hospice & Palliative Medicine
Joan Harold, BSN RN CHPN, Director of Home Care Clinical Services, Angela Hospice Home Care, Livonia, MI
Michelle Johnson, BSN RN, Corporate Triage Manager for Kindred at Home / Curo Hospice, Mooresville, NC
Mary Ann Ruberg, MS BSN RN CHPN, Quality Analyst, Angela Hospice Home Care, Livonia, MI
Sandy Trieu, MD, Clinical Assistant Professor of Palliative Medicine, Stanford Healthcare, Stanford, CA
Martha Twaddle, MD, The Waud Family Medical Directorship, Palliative Medicine & Supportive Care, Clinical Professor of Medicine, Northwestern Medicine; Northwestern Memorial Hospital, Chicago, IL; Past President, American Academy of Hospice & Palliative Medicine
Author
Jeanine Feirer, RN MSN
Nurse Editor
Adult Telehealth Triage Guidelines
Schmitt-Thompson Clinical Content
Co-Authors
Mary Ann Ruberg MS BSN RN CHPN
Quality Analyst, Angela Hospice Home Care, Livonia, MI
Hospice Workgroup Member, Schmitt-Thompson Clinical Content
David Thompson MD
Senior Medical Editor
Adult Telehealth Triage Guidelines
Schmitt-Thompson Clinical Content
Cheryl Patterson, RNC-TNP, BSN
Nurse Editor
Adult Telehealth Triage Guidelines
Schmitt-Thompson Clinical Content
References
NHPCO Facts and Figures, 2021 Edition. October 2021. Accessed at: https://www.nhpco.org/hospice-care-overview/hospice-facts-figures/