IS NURSE TRIAGE A CLINICAL SUBSPECIALTY OR A SKILL?

A subspecialty is a focused area of nursing practice , advanced knowledge and skills in a specific patient population, disease, or care setting (e.g., Cardiology). Requirements include a specific body of knowledge, education, training, and experience. A skill defines how care is delivered.

So, is triage — conducted virtually, via phone and on-site— a clinical subspecialty or simply a set of skills? Nurse triage has many hallmarks of a nursing subspecialty:

WHAT ARE TYPICAL TRIAGE SETTINGS?

• Unlike most nursing subspecialties, Triage is ubiquitous. Patient typically call from home, but these calls are received in a diverse range settings, from ambulatory care —medical offices, clinics, student health centers, clinical call centers— to acute hospital settings such as urgent care units and Emergency Departments. Some triage nurses work from home.

• WHAT ARE UNIQUE FEATURE OF NURSE TRIAGE WORK?

• Intensity of Task, Work Environment, and Technology. Working in a clinical call center may require 8 -hour long shifts, making repeated, rapid (within 3-15 minutes), complex clinical decisions, under conditions of uncertainty. Patients (unknown, unseen or virtual encounters) contacting clinicians about worrisome symptoms — possibly life-threatening to non-acute. Triage volume and intensity may present a high risk for decision fatigue, whereas some ambulatory settings may be sporadic, low acuity and informal.

• Challenging Patient Populations include diversity in age, language, culture and educational level.

• Inadequate Clinical training specific to triage with an emphasis on pattern recognition, patient context and rules of thumb to identify and triage high risk patients, symptoms, and/or situations

  HOW DO NURSES PERFORM TRIAGE?

NURSES estimate symptom urgency using the four-step nursing process, modified for triage.

1. Assessment – Elicit presenting symptoms & patient context, using pattern recognition, past and current medical history or patient context to estimate symptom urgency. (Lephrohon, Patel, 1995)

2. Diagnosis or Estimated Symptom Urgency – clinical decision support system (CDSS) to determine the appropriate, timely disposition

3. Planning/Implementation or Disposition confirm patient agreement to the disposition (When, where, why to get further evaluation). Nurse must elicit informed consent

4. Evaluation or Patient Outcome – Determine the patient outcome. A QA step to determine safety of Nurse Decision Making and/or Guideline (CDSS) validity & reliability.

WHY IS NURSE TRIAGE SO STRESSFUL?

• TRIAGE IN ANY SETTING typically involves repeated, rapid, clinical decision-making under conditions of urgency and uncertainty.

WHAT KEY POLICY CHANGE MIGHT REDUCE ERROR IN TRIAGE?

• Research by the National Institute of Health indicates that triage error is best mitigated by  Planned Error Recovery. Historically, triage nurses work in a vacuum - never learning about patient final outcomes after triaging. However, learning from one’s mistakes and improving practice and systems requires feedback about clinical outcomes.

  WHAT ARE TWO COMMON ERRORS IN PRE-HOSPITAL TRIAGE?

• Two patterns of recurrent error in telephone triage include 1. neglecting to speak directly to the patient and 2. neglecting to ask about recent repeated calls and/or visits.

• RULE #1: Speak directly with the patient if at all possible.

• RULE # 2: ”Always ask patients if they have made recent, repeated calls and/or visits about the chief complaint(s)”. Recent, repeated calls and/or visits is a “Red Flag” frequently overlooked by nurses — and a pattern indicating possible patient acuity, resulting in error and malpractice lawsuits.

• These recurrent Errors and others, are based on Ms. Wheeler’s experience as an expert witness on 35 real life malpractice cases. They also inform Ms. Wheeler’s system components.

• WHAT TRIAGE SYSTEM COMPONENTS CAN IMPROVE PATIENT SAFETY?

  • PLANNED ERROR RECOVERY

  • CLINICAL TRAINING 

  • STANDARDS  - QA AUDIT

• RULES OF THUMB