Literally overnight, the COVID pandemic fueled the explosive growth of remote nurse triage and telehealth. Pre-hospital triage was transformed into an essential, convenient and permanent clinical service. Current technological growth appears to outpace clinical safety and professional values but is lacking in regulation and EBM research to guarantee patient safety in this emerging subspecialty.
What Are Safe, Timely Standards for Access
for Remote Triage?
What Parameters Constitute Safe, Timely Patient Access to Care?
Standards for access to care are hotly debated for scheduled surgical procedures using delays of days, weeks, and months to determine what is acceptable or reasonable.
No such time objectives exist in Emergency Departments (or for remote nurse triage) where delays of minutes or hours for unrecognized problems can be the difference between life and death.
Without using a standard measure such as a national triage scale it will be difficult to measure acuity, perform case mix comparisons, or develop ED operational standards.” Adapted from American College of Emergency Physicians (1999)
All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. They all have at least three common elements: expectation of selflessness; of skill; & of trustworthiness. Aviators have a fourth expectation -- discipline”. (Atul Gawande, MD 2010)
FAQ About Remote Nurse Triage
What is Remote Nurse Triage? Remote Nurse Triage defined as the safe, timely clinical assessment and disposition of patient symptoms by registered nurses using technologiy. — telephone and “virtual visit”.
Are remote diagnosis and triage synonymous? No. Are remote diagnosis and remote risk estimate synonymous? No
What is the most difficult type of triage to perform? The most challenging method of triage is remote triage (known as telephone triage or pre-hospital triage) because clinicians cannot see, physically examine or take vital signs of the patient. Because of these limitations, nurses may relay on professional caution in addition to protocols or guidelines. Under such circumstances, the rule of thumb “err on the side of caution” allows for a margin of error. This rule is an example of the “duty of due care” - doing what the reasonable, prudent nurse would do under the same or similar circumstances.
How do nurses perform triage? Nurse Triage is based on the nursing process, modified to apply to the triage process - that of estimating symptom and patient acuity. The task requires assessing, estimating and classifying patient symptoms according to urgency, including the patient past and recent history - to establish patient risk.. The goal of triage is on-site evaluation, testing and treatment. Nurse triage has been defined as clinical “decision making under conditions of uncertainty and urgency” (Patel, 1995). . It is also an emerging nursing subspecialty and the first phase of the the the thecontinuitycontinuity of care - pre-hospital triage.
What are the components of a remote nurse triage system? Like other nursing specialties, remote nurse triage requires key components : clinical training, specilaized standards, specific experience and job requirements, Guidelines and Documentation of encounters - carried out remotely.
How important are Remote Nurse Triage Components? These components represent an integrated system or Framework, as well as the evidence of the Duty of Due Care.
Why is evidence of the Duty of Due Care important? In cases of malpracticevidence, evidence (written, audiotaped or other) to present in court validates institutions’ or individual clinician’s intentions, efforts and actions to create a system for safe practice of remote nurse triage..
What are typical settings for nurse triage? Nurse Triage is ubiquitous, often occurring at all hours of the day. Nurse-patient encounters occur in a range of clinical settings - ambulatory and acute. For example patients calling Ambulatory settings, Medical Offices, Clinics, Student Health Centers, or clinical call centers to get advice on when, where and whether their symptoms require on-site evaluation. On-site, face to face or in-person triage encounters take place in acute settings like Emergency or Urgent Care departments, where nurses are able to perform more in-depth triage to determine the triage acuity level, when the patient might be seen by a physician and resources required.
Does the Continuum of Care apply to Triage? Remote triage (pre hospital, telephone or virtual television) is the first contact on the continuum of care, and a form of care and. Patients call to have symptoms assessed, classified and then be advised on next steps to take.
Human Error. In the ValuJet plane crash, “mechanics employed a “good old-fashioned pencil whipping”, resulting in the ValuJet plane crash. These “blizzards of small judgments” amount to a “widespread form of the ‘normalization of deviance’”. Langwiesche laments the failure of large systems that create an “entire pretend reality” that includes:
Unworkable chains of command
Unlearnable training programs
Unlearnable training program
Unreadable manuals
A fiction of regulations, checks and controls. Langeweische (1978)
TELEHEALTH NURSING DEVELOPMENT
Beginning in the 1980s, HMOs introduced telephone triage to improve cost-effectiveness by reducing inappropriate emergency department and office visits. This created competing pressures between cost containment and patient safety, making remote assessment a time-pressured clinical activity and potentially threatening safe practice.
Remote care, initially limited to auditory cues and later expanded to include visual input, is inherently risk-prone. Nurses responded to patient-initiated calls regarding concerning symptoms by using the nursing process to make clinical decisions and determine appropriate acuity levels and dispositions.
Telephone triage is the clinical precursor to telehealth nursing. Virtual televisits expanded rapidly during the COVID-19 pandemic because of the need to reduce the risk of contagion. Virtual televisits are typically pre-scheduled appointments with an RN or Nurse Practitioner and have become a permanent and essential form of healthcare delivery.
RN and NP virtual assessments use auditory, visual, and biometric information. Nurse Practitioners can prescribe medications, order tests, refer patients, and remotely diagnose conditions such as urinary tract infections (UTIs), conjunctivitis (pinkeye), sinus infections, and chronic diseases. However, conditions such as chest pain, difficulty breathing, neurologic deficits, severe dehydration, or suspected sepsis require in-person evaluation.
During pre-scheduled appointments, virtual Chronic Care Nurses use auditory, visual, and biometric information to monitor and remotely manage patients with chronic illnesses or ongoing medication treatments.