PROBLEM DESCRIPTION     Timely and appropriate access to care in the emergency department (ED) setting is a problem which has reached crisis proportions.  Overcrowding (too many clients) and overutilization (innapropriate and unnecessary ED visits) impede access to healthcare services,  sometimes barring those who genuinely need emergency care.   However,  little attention has been paid to the fact that many initial attempts at ED access begin with a phone call for advice.  Currently,  this simple request actually exacerbates the access problem, by encouraging unnecessary ED visits which contribute to overcrowding and inappropriate utilization.  

The purpose of this paper is to explore and describe the current role of telephone triage as gatekeeper and its potential to facilitate appropriate  ED access while reducing cost.     Telephone triage is  the assessment, advice, treatment, counseling and crisis intervention for health related problems by telephone.  Telephone triage should remain “symptom based” (relating on symptoms presented any the caller) and provides a provisional or “working diagnosis”.   Although it is practiced in settings such as medical offices and HMOs,  no where are standards of practice more critical than in the emergency department.  In the ED setting, the call volume may be high (30 - 80 calls per shift) and the acuity may range from low (informational) to  high (crisis intervention), challenging  the expertise and resourcefulness of the most experienced nurse.  At worst, poorly performed telephone triage is costly and can result in injury, death or lawsuits; at best, it  save lives and money.   Current ED telephone triage practice is ineffective,  creating a barrier to healthcare rather than  facilitating  access.

Joan Ritter is sitting at home in one state taking a call from a patient who is living in or traveled to another state on business.  When she takes that call, where is she practicing?  You might be surprised to learn that most state Boards of Nursing feel that nursing takes place where the patient is (not the nurse) and thus you might be practicing in the state from which the patient is calling.  The question is: Are you licensed to practice in that state? 

Telehealth nurses and organizations have been closely following the proposed Interstate Compact for Mutual Recognition of Nurse Licensure (Interstate Compact),first proposed by the National Council of State Boards of Nursing (NCSBN) in 1997.  The need for this compact arose when the provision of care by telephone and thus provision of care across state lines (interstate practice) became common.  The model for this Compact is based on the Driver’s License Model, which holds that a resident of one state may drive in another state, as long as they maintain a valid driver’s license in their home state and follow the driving laws of the state in which they’re driving. While the question of providing care to patients in other states is an obvious concern for many call centers, this is an issue faced by nurses from many venues such as doctor’s offices and clinic settings.  While some call centers have bought multiple state licenses for their nurses, this certainly isn’t occurring universally, and nurses are at risk every day. 

Where Are We Now?  Since Utah enacted the Interstate Compact in 2000, 17 other states have followed suit and more are sure to follow (see http://www.ncsbn.org/nlc/index.asp
). Until then, nurses in non-compact states or those who are talking calls from patients in non-compact states (including “snow-birds” and patients on vacation) may be in a position to be regarded as practicing nursing without a license.

Among states that have not yet signed on, they cite such concerns as loss of revenue (from license renewals), loss of control (directly stemming from nurses in other states practicing in their state), and the dilemma of who would pay for transportation and other costs associated with the disciplinary hearing for a nurse accused of practicing without a license in the state in question.  While it might be desirable for all 50 states to pass the Interstate Compact, it is likely that some never will.  Until such time as the interstate compact becomes universal, nurses who are taking calls from other states are at risk.

If they (standards) exist, they must be detailed, consistent and comprehensive...
    Marker, 1998

Since the mid-nineties, the telephone triage industry has experienced breathtaking growth.  Still, there is a lack of consensus about everything from scope of practice to terminology.  Which title describes most accurately, what we do:  advice-, telephone triage-, triage-, consulting-, telehealth-, e-health-, informatics-, or  tele-  nurse?  

Whether you are evaluating electronic or paper based protocols, begin the process by obtaining paper copies of the following items: 1. table of contents; 2. three representative protocols (Abdominal pain; Nausea and Vomiting; or Respiratory Problems); and 3. the documentation form. Start by asking the following questions of the vendor:

Experts project that in the near future, telehealth will subsume telephone triage, with the addition of visual display of patients from home, telemetry and internet access by both nurse and patient. Disease management will grow as home health assessment includes heart, lung, and bowel sounds, blood pressure and pulse readings, gait, neuro exams and mood assessment.

Training programs will grow to 40 hours and will include internet-based training based on "real life" problems. Sophisticated training programs will provide simulations with "patients" calling from off site and nurses utilizing telemetry and computerized protocols.

Telehealth will be an international phenomenon.  Within the next ten years, experts from the Europe, the United Kingdom, Australia and South America will converge to network and share solutions and expertise from a multi-national and multicultural perspective.