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Telephone Triage for Otorhinolaryngology and Head-Neck Nurses........^17 Susan Newton, RN, MS, AOCN ® , AOCNS ® Although nurses have been using the telephone to assist patients for many years, very little is available in terms of specific models of care for telephone nursing care, referred to in this book as telephone triage. Telephone triage is a component of telephone nursing care; however, when the processes involved are discussed in this manual, they are being referred to as telephone triage. Another term commonly used is telehealth nursing, which encompasses all types of tele- communication technology including the Internet, fax, videoconferencing, and the telephone (Espensen, 2009). As discussed previously, the concept of triage originated during World War I. It was implemented so as to not waste resources on victims with fatal injuries. The concept of using the telephone to obtain medical advice dates back to around the same time the telephone was invented (Wheeler, 1993). HMOs instituted telephone advice services in the early 1970s. A hospital ED initiated the first 24-hour telephone advice program. Since then, telephone triage has become a sophisticated practice and a common duty for nurses (Wilson & Hubert, 2002). However, the triage sys- tem used in an ED is quite different from what typically takes place in an office or facility. Nurses performing telephone triage must be skilled in communicating, critical thinking, clinical skill and expertise, patient assessment, and evaluation. Two recent studies have examined the scope of oncology calls received by outpatient oncology centers. Lucia, Decker, Israel, and Decker (2007) recorded the volume and topics of calls received. The study results provided information on cost savings incurred because of avoiding office visits, ED visits, and symptom management–related visits, as these are primarily nurse-managed tasks and yet are not reimbursed. In another study, Flannery, Phillips, and Lyons (2009) tracked patient phone calls in an outpatient oncology office over a four-month period. The sample included 5,283 calls received from 1,486 different individuals. This study found that for every 10 scheduled clinic appointments, 7 telephone calls were either made or received, demonstrating the importance of a designated telephone triage nurse and the need for experienced nurses performing this task. Several theories or systems for performing triage are discussed in the nursing literature. These include
- The nursing process
- Problem-oriented system
- OLD CART assessment
- Communication model
- Informal systems or procedures developed by individual institutions or prac- tices.
18........^ Telephone Triage for Otorhinolaryngology and Head-Neck Nurses
THE NURSING PROCESS
The nursing process is the model that AAACN recognizes as the model of choice. The steps include assessment, analyzing and planning, implementation, and evaluation. To perform an assessment over the telephone, nurses should assess the entire situation, including not only what patients are saying but also how they are saying it (psychological status), how they are communicating (mental status), and what the environment is like (background noise). Allow the caller to explain in detail the purpose of the call. During the assessment step, data are collected to implement the triage process (Espensen, 2009). Analyzing and planning are the next phases of the nursing process. This would include using the appropriate guidelines and resources, including discussions with physicians and other members of the healthcare team. Intervention or implementation follows analyzing and planning. This includes applying actions such as teaching, coordinating resources, scheduling follow-up appointments, providing support, or any other necessary actions related to using problem-solving skills to come to the correct solution for the patient. Does the patient understand the plan that has been proposed? This is part of the final step, which is evaluation. Other questions to ask are Will the patient comply with the plan? and Is the patient satisfied with the resolution of his or her concern? Determine what type of follow-up is necessary and communicate this to the patient or caregiver.
PROBLEM-ORIENTED SYSTEM
In the problem-oriented system, a series of questions are asked using the al- phabetical nomenclature P, Q, R, S, T, and T: the provoking factor (P), the quality (Q), the region (R), the severity (S), the time (T), and the treatment (T) for each symptom that the patient is reporting (Seidel, Ball, Dains, & Benedict, 2006). Specific assessment questions for each topic may be
- P (provoking factors): What makes the symptom better? What makes it worse?
- Q (quality): Use descriptive words to explain the symptom. For example, in describing pain, is it shooting? Jabbing? Cramping? Burning? Sharp? Dull? Nagging? Achy?
- R (region): Is the symptom focused in one area? Where is it located? Is it radiat- ing to or from another region?
- S (severity): Have the patient rate the severity of the symptom using a 0–10 scale. For example, if pain is the symptom being reported, then 0 is no pain and 10 is the worst pain that the patient can imagine.
- T (time): When did the problem start? Is this the first time it has occurred? How long has it been happening?
- T (treatment): What has been done so far to treat the symptom? Has it been effective?
20........^ Telephone Triage for Otorhinolaryngology and Head-Neck Nurses of nurse-managed telehelp lines or medical call centers. These phone services, typically offered by hospitals, are of benefit to the entire community. Anyone can call in with his or her symptom and be given advice as to how to handle the situ- ation (Briggs, 2002). On an oncology-specific note, many of these services are offered by cancer centers. ORL offices that are within medical centers may have calls that begin with the telehelp department and then are sent to the ORL office.
CONCLUSION
Several models of telephone triage are used in practice today. The nursing pro- cess is the best documented model, as it is the one recognized by AAACN. The problem-oriented system is less formalized. It focuses on specific questions used to assess patients’ symptoms. The OLD CART acronym is similar in that it gives the nurse a way to remember how to fully assess patients’ problems. Finally, the com- munication model suggests a method of collecting information in terms of phases of the communication process. It is important that each ORL office or department selects a method or model that works best and that all nurses performing telephone triage are familiar with the model being used.
REFERENCES
Briggs, J.K. (2002). Telephone triage protocols for nurses (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Espensen, M. (2009). Telehealth nursing practice essentials. Pitman, NJ: American Academy of Am- bulatory Care Nursing. Flannery, M., Phillips, S.M., & Lyons, C.A. (2009). Examining telephone calls in ambulatory oncology. Journal of Oncology Practice, 5, 57–60. doi:10.1200/JOP. Lucia, V.C., Decker, V.B., Israel, C.E., & Decker, D.A. (2007). Telephone contacts between triage nurses and cancer patients: An integral part of a community oncology practice. Community Oncology, 4, 350–353. Seidel, H.M., Ball, J.W., Dains, J.E., & Benedict, G.W. (2006). Mosby’s guide to physical examination (6th ed.). St. Louis, MO: Mosby. Wheeler, S.Q. (with Windt, J.H.). (1993). Telephone triage: Theory, practice, and protocol development. Clifton Park, NY: Delmar. Wilson, R., & Hubert, J. (2002). Resurfacing the care in nursing by telephone: Lessons from ambulatory oncology. Nursing Outlook, 50, 160–164. doi:10.1067/mno.2002.
