Triage Nursing is a Subspecialty
Triage nursing (whether remote, telehealth or emergency department) qualifies as a nursing subspecialty. The triage task (especially remote triage) is unique.
Triage requires expert clinical decision making and symptom risk estimation. Like other subspecialties, triage nurses require specialized training in how to perform timely pattern recognition and symptom risk estimation.
Support systems for triage typically include at least six components: a modified nursing process, specialized clinical training, specialized standards, and audit, guidelines or clinical decision support systems (CDSS) and documentation Electronic Medical Record (EMR).
It may be stressful due to uncertainty and to high call volumes. Triage work may be sporadic, one task among many in a broader subspecialty. In clinical call centers, triage is continuous and shift-long. It is best performed by experienced clinicians who can withstand these stresses, and are able to make good decisions under conditions of uncertainty and urgency.
1) ACCESS TO CARE & TRIAGE?
3) HOW TO TRIAGE:
a) THE DUTY OF DUE CARE
i) SYSTEM COMPONENTS
(1) STANDARDS
(a) AUDIT
(2) CLINICAL TRAINING
(3) TRIAGE PROCESS
(a) WORKFLOW
(b) TOOLS & RULES
(i) ACRONYMS
(ii) RULES OF THUMB
(iii) RED FLAGS
(iv) RED HERRINGS
(4) UNIVERSAL GUIDELINE
Triage Work Flow & Decision Making Process
TRIAGE – REMOTE, TELEHEALTH OR ON-SITE
CLINICAL DECISIONMAKING PROCESS
Please note: All the suggestions here are based on the author’s research, expert witness work on malpractice case or suggestions by class participants.
Triage error can be mitigated by clinical training and learning from one’s erroneous or successful triage decisions. Required mandatory clinical questions help avoid recurrent error in triage (Wolf, et al., 2024, Journal of Emergency Nursing). Developers can integrate mandatory questions into Protocols or Guidelines. Key mandatory questions are in bold:
1. Confirm that you are speaking with patient (Remote triage only)
2. Elicit the number of calls in recent hours to weeks, regarding these symptoms.
3. What made you call today?” (NOT “Why did you call today?”)
Frequent calls from patients are a sign of patient anxiety and possible worsening condition. Two or more calls within hours or days may require an urgent or emergent visit.
Prepare the Patient
“I will ask some questions about your past medical history and
symptoms. Then I will tell you where you might need to be seen and
how soon.
Step 1. Preliminary Assessment
· Identify High Risk Symptoms and High-Risk Patients (SAVED)
· Elicit Past and Recent Medical History back-story: (RAMP) Trust but verify. Update and Correct
· Elicit other details (SCHOLAR) and functional status (ADL, A DEMERIT)
o “How is this illness affecting you right now?”? “How does it affect your ability to carry out your daily routines or to function (ADL)?”
o “Which symptom bothers you the most, or worries you the most?
Universal Guideline or other guideline choose the symptom or guideline that is most likely to lead to appointment, sounds most serious, or concerns the patient the most. Ask remaining appropriate questions
Step 2: Estimate Symptom Urgency
Steps 3. , Communicate Acuity Level and Disposition
1. Communicate Estimated Symptom Urgency, a time frame, and place to be further evaluated (Disposition) as appropriate
“From what you’ve told me, your symptoms (abdominal pain, nosebleed, rash, headache) sound: (life threatening, -emergent, -urgent, -acute, -non-acute).
As appropriate;” I strongly advise you to go to (ED, URGENT CARE, Office) within (01- hour, 1-8 hours, 9-24 hours, other)
2. Obtain Patient Informed Consent
o Compliance: “Will you follow the advice I have given you? And be here within the time frame that I advised?”
o Ensure timely access: confirm that patient can arrive within the agreed upon time frame
o Patients calling from distant locations may require a disposition upgrade. Negotiate transport as needed. As appropriate, if symptoms sound urgent, increase the acuity level.
1. No available car
2. In a remote location, or one or more hours from hospital
3. No capable driver or ability to arrive in timely manner due to traffic
4. Unable to access sporadic public transportation or unsafe or nonexistent public transportation after certain hours at night
3. Closure question “Is there anything else you are worried (concerned) about?” (May elicit the “real reason” why the patient is calling)
4. Final Patient Instructions “Call back if new symptoms appear, or symptoms change or get worse. If your symptom pattern changes or gets worse, my advice will change will you call us back or come in?
SUMMARY
Nursing Process (Modified for Triage)
1. Assess Symptoms
2. Estimate Symptom Risk
3. Communicate Disposition, Obtain Informed Consent
4. Evaluate Outcomes: Error and Successful Decisions
Always Elicit and Document Patient Response to these Questions
1. Confirm that you spoke directly with the patient (as appropriate)
2. Elicit the number of repeat calls regarding problem
3. As appropriate, in concrete terms, tell the patient when, where, and why they need to be seen. Confirm that the patient understands the estimated symptom risk level and agree to the time frame and location to be further evaluated (Disposition)
4. Confirm Patient agreement -- Informed Consent
5. Ask Closure Question
6. Advise Patient Instructions if symptoms change
audit here
Make it stand out.
Take a minute to write an introduction that is short, sweet, and to the point.
