So What Exactly Is A Telephone Triage Nurse?
Written: Dec 03 '00 (Updated Dec 08 '00)
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Pros: Highly Gratifying Interventions, Lower Stress Level Environment
Cons: Carpal Tunnel Syndrome Is A Real Risk
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I first encountered the term triage when I was taking some Red Cross training as a teen. A French term, triage initially was a means of assigning a priority to those injured and waiting to be treated. The moderately injured who get a toe tag marking him as first to be seen. Lightly injured would be seen after these patients, and woe unto those assigned black toe tags: reserved for gravely injured, with little hope of survival these unfortunate victims were seen last, if at all. One of Nursing's founding heroines, Florence Nightingale triaged wounded soldiers on battle fields, long before black comedies like MASH, brought the sorting of casualties into the realm of foil-wrapped dinners in front of the family TV.
The practice continues today: with disaster response teams, busy Emergency Room settings, and with Red Cross banded medics the world over. A lesser known, and more recent use of triage is provided by Telephone Triage Nurses, or Advice Nurses, as they are commonly called.
The Nurse Call Center, is one such telephone advise line. Located in Stockton, CA, it is part of larger, regional health system, and we receive calls from a total of 11 Northern and Central California counties.
We have a total of 23 Registered Nurses, with an average of 15 to 20 years experience each. Of these sisters of mercy, 21 are primarily responsible for handling an average of almost 10,000 calls per month, along with a top-notch department manager and personable first line supervisor, (both which have critical care/emergency room expertise and are more than competent at wrangling a headset)!
This is a 24 hour a day Call Center, and we have a variety of services, such as Contract, (HMO, PPO), free community line, physician referral line, and general health information provided by nurses, through an audio health library, and internet researched articles furnished without cost by our affiliate Community Resource Center.
A recent front page spread in our regional newsletter highlighted the 10 Most Common Concerns handled by the Nurse Call Center, using a variety of physician guided protocols*:
Colds (Pediatric)
Fever (Pediatric)
Abdominal Pain
Vomiting (Pediatric)
Diarrhea (Pediatric)
Cough (Adult)
Cough (Pediatric)
Headache
Chest Pain
Constipation (Pediatric)
Each caller first hears a greeting then a menu that directs them either to a Resource Nurse or to the audio Medical library. Additionally, all callers are advised to hang up and call 911 if there is any medical emergency. Telephone triage nurses begin by gathering registration information, (name, age, zip code, PCP, et al), which as a medical record is held in strict confidence. The next step is often most crucial, gathering key bits of information as to the symptoms the caller, family member or friend may be experiencing.
Sometimes the caller is distraught, nervous, or in pain, and we strive to gather essential information as quickly as possible. In our Centramax computer template, we input symptoms and choose from a list of possible conditions. The program then begins with an overview of the condition, and we "walk" the caller through a descending list of possible dispositions, from 911, ER, refer to PCP, Urgent Care, call Doctor during regular office hours, see in 24 hours, home care, et al., based on the severity of the symptoms/cluster of symptoms.
We are free to upgrade or downgrade the recommended dispositions, just needing to type in our rationale, as most changes in level of care are based on the RN's judgement. For example, if an elderly patient has a severe earache, I might upgrade that from see in 24 hours to UC, based on the fact the patient has a heart condition and high blood pressure. A child, who was seen by his Doctor the previous day for a sore throat, might not need to see the MD within 3 days, if he has only been on antibiotics for less than 48 hours. And so it goes.
Let's take the most common call, for advice on what to do for a child who had symptoms of runny nose, stuffy nose, cough and sore throat, with a low grade fever, (between 100 and 102, orally). By guiding the triage, we find out the child has had these symptoms for two days, and has no accompanying earache, headache or stiff neck. The nurse asks the parent to bring the phone to the child so we can listen for croupy cough, wheezing, hyperventilating, or any type of breathing problem.
We next determine the child is not retracting, (using the small muscles of his chest, called accessory muscles), and his fingernails and lips are not purple, grayish or blue, (all signs of poor oxygen exchange). Armed with this information, we input selected symptoms, and the computer program offers up Colds, (Pediatric) as matching all of the symptoms. Many times from 5 to 15 choices come up, so we will be using our nursing training and judgement to fine tune the protocol we select.
The recommended disposition for an uncomplicated cold is home care. We highlight and offer health interventions such as understanding that a runny nose is beneficial, (it is the immune system's way of shedding viruses), a low grade fever is another way the body "kills" bacteria and viruses, by essentially cooking them, (another immune system response, which requires a fever above 99 to do its work). Recommendations are made for use of a cool mist humidifier, (dry mucous membranes allow germs into the respiratory tract in the first place, and a dry throat promotes both sore throat and that nagging, hacking, scratchy cough). Variations, such as having a crock-pot, kettle or steamer full of water simmer on the stove, or sitting with the child in a steamy bathroom for 10-20 minutes can also pinch hit for the inexpensive (about $10) humidifier, (but are not strictly part of the physician-guided protocols).
Sharing the knowledge that cold or iced fluids will promote coughing spasms, and that herbal teas, chicken broth or warmed apple juice or water will help thin secretions, open airways, enables families to care for simple infections in their own environment. Shotgun cough, cold and sinus preparations are never recommended, and a teaspoon or so of simple corn syrup can quiet many coughs without dangerously suppressing them.
For parents who are receptive to these simple, but Doctor-tested remedies, the satisfaction of having their child breath and sleep easier can help the entire household.
The Telephone Triage Nurse is handicapped, more than her ER sister, by the fact she has only her sense of hearing, (and gut instinct), to guide her through the assessment process. This becomes more difficult when there are barriers of language, (we have AT&T translator services available), or if a caller is a poor historian, giving only vague information. Some calls, must be redirected: requests for prescriptions, requests for a diagnosis, or requests to speak with the physician only.
A few callers are obscene, verbally abusive or threatening, and are handled in a matter of fact way, (generally then disconnected). The nurses I work with on evening shifts, (I work alone on night shifts), can commiserate and offer support after such unpleasant calls, but the majority of callers are happy to have such a service available at any hour of the day or night, on Holidays and weekends, and appreciate the hard work telephone advice nurses provide.
It can be difficult when a mother is hostile, and becomes incensed with a recommendation that her child's, (uncomplicated), middle-of-the-night earache can be seen in the following 24 hours, and does not necessitate an ER visitation. Of course we never deny anyone access to the type of medical intervention they desire, but we work hard to coach such a caller that her child may be better served, in the short run, by a dose of mild OTC pain reliever, a warm (or cool) compress to the affected ear, and especially with an accompanying cold or sinus problem, judicious use of a nasal decongestant.
In our busy, frenetic paced world, people are conditioned to want quick fixes. Hence the emergence of antibiotic resistant bacteria, (overuse and misuse of antibiotics, say for viruses, against which they have no effect!). While genuine emergent situations can be handled in 2 or 3 minutes, more time is taken to teach the nervous new mom or dad how to take a temperature, what is considered normal, (and the importance of a low grade or even moderate fever in fighting viral attacks on the system), and home interventions that can empower them to participate in their child's own wellness, and health maintenance.
Some people use the Nurse Call Center instead of regular Doctor's visits, and that is not the intention of the Telephone Triage Nurse. Our goals are to educate, to inform and to assist callers in both symptom relief, and selecting the appropriate level of care. On a recent trip to a local emergency room, I was amazed by the number of visitors with minor complaints, that might have otherwise been helped by a call to the Resource Nurse:
6 children, ranging in age from 9 months to 9 years, with a variety of garden variety sniffles and coughs, none with a dangerous high fever, stiff neck, or serious breathing problem. 2 kids with head lacerations, who by the look of them, were appropriate candidates for exam and suturing. 3 people with rashes-none of them weeping, (open), or of the more ominous pinpoint size and dark red or purple color, that might indicate meningitis. An elderly gentleman with the classic COPDer's barrel chest, turning a light shade of blue and requiring an emergency breathing treatment. 3 people holding emesis basins and looking green around the gills-none of which looked dehydrated or in extremis. And my fiance, with sharp, sudden chest pain, who, two days after I asked him to have this initially checked out, turned out to have a fractured rib.
Of course I'm not supposed to triage patients away from my regular job, but at 3a.m. on a Saturday morning, it was impossible for me not to glance around and informally take in the whole picture. Most people were camped around the lone mounted TV, snacking and joking; kids being kids, yelling and running around. I think my point was, that all but five of these dear souls might be better served in another, less acute setting.
I'm betting that a bunch of these suffering souls have never heard of a Nurse Call Center, much less a Telephone Triage Nurse. People new to us are often pleasantly surprised, and we treat all callers, whether covered under a fancy HMO or medically indigent, with the same care, concern and compassion. Sometimes just having a soothing voice on the other end of the line can do much to calm an otherwise volatile situation.
It doesn't matter if a caller has the most predictable call in the world, ("my baby's stool is yellow, should I take him to the ER?", "I have a temperature of 118 {101.8)!", "do you know what this white spot is on my toenail?"), or is a genuine emergency, ("I sort have this pain in my chest, like heartburn...yeah I'm nauseated and sweaty...should I just wait and see?", "my mouth is drooping on the left side and it feels like I can't swallow anything, should I call my Doctor tomorrow?"), every call is taken seriously, a knowledge base determined, and appropriate health guidance shared.
I've heard a handful of other nurses, (nurses who should know better), say, "Oh, that's not a real nursing job! They aren't out on the floors, providing direct patient care, they just sit in chairs all day, staring at a computer and type." Hopefully, this comes more from ignorance than mean spiritedness and it scarcely affects me as I think of the grateful young man I talked through a devastating panic attack, the scared teen I shared tears with after an unavoidable miscarriage, or a frantic mom trying to control her child's nosebleed.
Whether working in an entrepreneurial practice, (Nutritional Counseling, Massage Therapy, or Nurse Practitioner role in conjunction with an MD), or in a school, factory, clinic, office or hospital setting, we are all members of the same demanding profession. My wish is that this review can provide a small glimpse into the training, prerequisites, demands and joys of my newfound, (2 years), field of practice-both for interested lay persons and fellow members of my profession.
Nursing is not a static profession but rather continues to redefine its own standards of practice, and place in the ever-changing world of healthcare.
In our ever-evolving field of practice, unlike the ICU, CCU, medical and surgical nurses, we have the comparative luxury of taking calls one at a time. We can use our active listening skills and concentrate our efforts individually, rather than flying from room to room hanging IVs, checking Hep Locks and overseeing a variety of medical and non-medical staff. While we might not be in the trenches of local ERs or busy Clinics, there is a feeling of profound satisfaction that comes from providing a service to others, and helping to ease physical, emotional and mental pain.
A Telephone Triage Nurse can be a combination of counselor, (listening, empathizing), teacher, (teaching, coaching and offering guidance), and nurse, (healer, friend and problem solver). Most RNs in this field offer a wealth of skills; many come from the direct fire of Emergency and Critical Care practice. A few, such as myself, have a variety of nursing experience and may have a subspecialty, such as Peds, or in my case, Psych. Can you imagine just how many late night calls are received with a component of anxiety, frustration and fear?
Advise Nurses typically make 5 to 10% less than their floor nurse counterparts, yet enjoy all the associated benefits common to more traditional practice RNs. There is virtually no lifting or heavy physical work required, which can be a plus for those middle-aged and beyond. As a person with sometimes restrictive major health problems, (lupus, fibromyalgia, 3 herniated lumbar discs), this is the type of field that is especially kind to those with what would otherwise be debilitating conditions, yet embodies the very essense of nursing.
You will need to be able to sit for extended periods of time, be able to type a minimum of 45 words per minute, have excellent documentation skills and have a working familiarity with basic computer skills using a Windows OS environment. People skills, especially communication, and a voice that conveys warmth and compassion, are highly desired, but not requisite to the specialty.
If you would like more information about this interesting field of nursing, I can heartily recommend what has become the leading reference text, Telephone Triage, by Sheila Quilter Wheeler. This was very useful during my 3 month orientation period, and there is an accompanying audio tape available for practice. Those in the helping professions can often use this bible/tape package for obtaining those needed C.E. credits, required to maintain active licensure.
* All pediatric protocols follow the excellent, down-to-earth advice of eminent Pediatrician, Dr. Barton Schmitt, and a paperback volume of his many years of sensible wisdom is provided through this stellar reference, Your Child's Health.
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