Remote clinical decision making

need not be uncertain and risky.

Safety starts with a system.

TeleTriage Systems

devises solutions to reduce

recurrent decision making errors

Sheila Quilter Wheeler’s Recent Teletriage Research

Background: The safety of telemedicine in general and telephone triage (teletriage) safety in particular have been a focus of concern since the 1970s. Today, telehealth, now subsuming teletriage, has a basic structure and process intended to promote safety. However, inadequate telehealth systems may also compromise patient safety. The COVID-19 pandemic accelerated rapid but uneven telehealth growth, both technologically and professionally. Within 5-10 years, the field will likely be more technologically advanced; however, these advances may still outpace professional standards. The need for an evidence-based system is crucial and urgent.

Questioning Common Teletriage Assumptions

  1. Is the goal of teletriage to remotely diagnose symptoms, or to estimate symptom urgency?

  2. Are Computerized Decision Support Systems (CDSS) safe, reliable, valid and evidence-based?

  3. Will the EMR/CDSS features supplant other system components as a standalone system?

  4. How do teletriage medical experts define safe patient outcomes in teletriage?

  5. Is the optimum teletriage clinician an RN or MD?

  6. Does teletriage safely reduce innappriate ED, Urgent care, Office and Clinic visits and Hospital Readmissions?

 Questioning Assumptions in Teletriage: Expectations, Error and Evidence-Based Medicine (EBM)

Although telephone triage is a uniquely high-tech field, it is still evolving professionally.  And because it lacks full professional development, it is reasonable to question our current assumptions. For example, is it clincians’ task to remotely perform a differential diagnosis? Does Information technology inherently make the work safer?  Historically, developers have given short shrift to the nursing process and its clinical application to the task of telephone triage. Do medically developed algorithms take the place of lower level clinicians’ critical thinking and clinical training in telephone triage?

 Finally, has technology made our professional lives easier? Is our work less stressful or safer?  New research finds that user-unfriendly software creates more work for some physicians, who now work 11-hour days (Gawande,  2018).  Can telephone triage nurses be far behind?  Some software may exacerbate decision fatigue – a predictable human condition that degrades decision-making after 6 hours (Linder, 2019) 

Safe assumptions about the field of telephone triage are that

  • ·      It is a form of clinical care

  • ·      it is designed to facilitate safe, timely (early or on time) access

  • ·      it is a form of pre-arrival care (takes place prior to arrival on site )

  • ·      it requires clinical decision-making under conditions of uncertainty and urgency

Expectations 

Is the purpose of telephone triage to perform differential diagnoses or to estimate symptom urgency or risk?  No research has definitively determined what is safest -- differential diagnosis or nursing diagnosis.  However, realistically, when one cannot see or touch a patient, nor perform tests or take vital signs, one might reasonably adjust one’s expectations of what can be accomplished in a 7-10 minute phone encounter.  It is reasonable to expect that we can estimate symptom urgency

“Triage is not an endpoint but a beginning.  Systems with a basic premise of attempting to make a tentative medical diagnosis at triage are doomed to fail.  Diagnosis-based triage scales could actually be dangerous because triage, by definition, has limited time, history, and objective data.  The only appropriate focus of triage is to identify key signs/symptoms so as to place patients in an appropriate level for their generic acuity or risk.”            (Manchester Triage Group in Zimmerman, 2001)

 Triage requires critical thinking and traditional skills of gathering and recording data about the chief complaint and patient history.  By using the nursing process, performing a thorough symptom and patient history, and estimating the symptom urgency, one can formulate a nursing diagnosis (part Problem Focused, part Risk-Focused Nursing Diagnosis), while identifying risk factors that contribute to increased vulnerability -- information available in the EHR.

Error:  Unintended consequences of IT

Are our expectation of our electronic/paper guidelines and EHR reasonable?  Has evidence shown them to be reliable and valid?  Or are we being lulled into outsourcing our -medical traditions? -documentation? - critical thinking? Robert Watcher, MD, an internationally known expert in patient safety, quality, and information technology, is also chair of the Department of Medicine at the University of California, San Francisco. In his book “The Digital Doctor”, he describes the profound effects of IT on medical staff, their work, relationships with each other and their patients. (Wachter, 2017) . Watcher describes the “faceless note” a way of charting whereby notes are fragmented, repetitious statements and rendered nearly generic, whereby all traces of the individual are missing.  He encourages clinicians to perform “uber assessments”,  be more expansive, expressive – to tell a story – the medical narrative.

 Jeff Brown, MD, an early pioneer in pediatric telephone triage – also laments the lost art of writing a brief general description of the patient, much to the patient’s deficit.   (Brown, 2017)  There is no reason why this cannot be accomplished in telephone triage.

In a New Yorker article “Why doctors hate their computers” (2018),  Atul Gawande, MD, surgeon, writer and safety expert describes how inadequacies in technology are leading to an epidemic of physician burnout.

“We've learned that automation does not eliminate errors. Rather, it changes the nature of the errors that are made, and it makes possible new kinds of errors. The bottom line is this: Systems that integrate the best of human abilities and technology are the safest for all concerned”.      Captain Sully Sullenberger, Pilot, “Miracle on the Hudson” 

Evidence-based Medicine & Policy 

I recently heard a story of a 74-year-old female patient suffering from severe post-operative pain.  She called the advice nurse on a Saturday morning, requesting that she be seen. The response (in two different calls with two different clinicians) was that “it is our policy to not give advice to post operative patients.  Call back on Monday morning when the Surgery Department is open”.  What type of evidence could possibly support this misguided and dangerous policy?  Is it not abundantly clear that the purpose of telephone triage is to facilitate safe, timely access?  Is it not true that symptoms may be time sensitive, and that care delayed may be seen as care denied? 

 Although studies of patient self-referrals have existed for several decades (North, 2010), perhaps we need to implement a policy that encourages patients to be proactive. Patients experiencing urgent symptoms should be given priority.  In fact, for decades many patients have bypassed the advice nurse (or physician) altogether, taking matters into their own hands, and self-presented to the nearest ED, thereby achieving safer outcomes. 

 New research describes what might be a policy for safer, more timely dispositions than described in the case study above. Researchers found that callers who self-referred by “jumping the queue” were more severely ill than callers who did not bypass the queue (Ebert, 2019).  The study utilized an “Emergency Access Button”, whereby patients were allowed to jump the line, if they felt that their symptoms were urgent.

 Systems Error A recent article in the New York Times entitled “How Corporate Medicine Exploits Doctors and Nurses” (Ofri, 2019) highlights a worrisome trend.  Danielle Ofri, MD -- a physican at Bellevue Hospital --notes that corporate medicine has milked all the “efficiency” it can out the the system.  In recent decades, the workload on medical and nursing staff has increased by 30%.  Nurses and doctors are burning out and even becoming suicidal (and at higher rates than nearly any other profession), likely from the stress of trying to manage the increased workload while still adhering to professional standards and ethics.

 Not surprisingly, higher levels of burnout are associated with medical error.  Ofri concludes that “healthcare is by no means perfect, but what good exists is because of individuals who strive to do the right thing” (Ofri, 2019).  Such observations have particular relevance to the current practice of telephone triage, where staff sometimes find themselves “between a rock and a hard place”.

 Human Error:  Decision Fatigue As a full-time or even 8-hour task, telephone triage requires continuous, unrelenting clinical decision-making – a repetitious, arduous, exhausting and mentally draining task. After 6 hours,  this type of mental work results in decision fatigue. A recent New York Times article described research on physicians’ decision fatigue, advising patients to visit their doctor early in the day (Linder, 2019).   So too, clinicians working full time in high volume clinical call centers (or exclusively on the phone for 8-hour shifts) are likely to suffer decision fatigue, raising questions about safe shift length for this type of work.

 Pre-Hospital Calls and Sepsis  Having served as an expert witness on approximately 35 malpractice cases in telephone triage, the author recently came to the realization that approximately 30-40% of these cases (most of whom died) were later diagnosed as sepsis.

Evidence Based Medicine According to Wikipedia, “evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. “

Little or no research on Early Sepsis Recognition in telephone triage exists.  However, recent research on sepsis finds that 85% of sepsis cases arrive with sepsis.  Furthermore, mortality rates approach 50% when delays occur. Using EBM,  would it make sense to create guidelines, training and policies for pre-Hospital early sepsis recognition? 

EVIDENCE-BASED POLICIES

 Based on the above research, it seems reasonable and prudent to promote a Culture of Safety in telephone triage grounded in EBM polices.

  •  ·      Formally recognize and legitimize Telephone Triage as Pre-hospital care -- the first contact and initial phase of the Continuum of Care, 

  • ·      Enable patients with self-identified urgent symptoms to jump the line

  • ·      Implement Sepsis Early Recognition Guideline especially for children and elderly

  • ·      Integrate the Nursing Process more formally into training materials and guidelines

  • ·      Institute 4-6 Hour shifts in all High Call Volume clinical call centers or 8-hour dedicated positions.

  • Investigate System Error in Teletriage: Expanded access: after hours, safe division of labor in teletriage, a nationally recognized clinical subspecialty.

ASSUMPTIONS AND KNOWING WHAT WE KNOW

The work of telephone triage is nothing if not uncertain, and humans intensely dislike uncertainty.  However, it is prudent to acknowledge the limitations of this work, and to question our assumptions about it.  To quote Donald Rumsfeld “there are known knowns -- things we know we know…..there are known unknowns;  things we know we do not know….there are also unknown unknowns—the ones we don't know we don't know”.  (Wikipedia)

REFERENCES

  • It’s Been A Journey

    Sheila Quilter Wheeler had no intention of pioneering a new nursing subspecialty when she began work as advice nurse 40+years ago.

    Later, as staff nurse, she found herself teaching an in-house class on telephone triage. Basically, she saw a need and filled it, enhancing practice in a new clinical subspecialty. Remote assessment was fraught with uncertainty - and many nurses were anxious about the safest way to carry out the task.

    In the late 1980s, she taught a Continuing Education seminar. “ The Fine Art of Telephone Triage” soon evolved into a training manual. Someone suggested that she write a book. Nine rejected proposals later, DelMar Publishers released “Telephone Triage: Theory, Practice and Protocol Development in 1993. It took two years to write, research was very scarce. Wheeler extrapolated studies of physicians for her recommendations.

    In 1993, Ms. Wheeler consulted to a large medical center serving a population of 1.3 million high risk, low income, low literacy, multi-ethnic patients. That consultation led to the creation of the first three-volume, age-specific, five-level telephone triage Guidelines. This innovative reference was initially self-published, and later published by Aspen Publishers then McGraw-Hill.

    Wheeler’s influencers included front-line telenurses, and experts in medical decision making, emergency medical dispatch, and risk management. Each encounter informed Wheeler’s Vision, Mission and System. Her solid track record of innovation and accomplishments include roles as author, researcher, trainer, consultant and thought leader. 

    Ms. Wheeler founded the first national Telephone Triage conference, consulted internationally, authored articles, performed research, and served as legal nurse consultant on 35 malpractice cases. Working with several software companies, Ms. Wheeler collaboratively developed electronic software guidelines.

  • It Takes a Village

    In 1997, Ms Wheeler launched teletriage.com. The website’s original intent was to serve as an informational resource in a fledgling field. Teletriage.com — currently ranked #10 by Google — has ranked in the top 20 websites related to telephone triage since 1997.

    Over a 40+ year period, Wheeler built a teletriage structure and process through collaboration with like-minded experts and clients from relevant clinical disciplines. Barbara Siebelt, RN, MS and Jeff Clawson, MD were her first major influences.

    Barbara Siebelt — a legal nurse expert - advised a systematic approach to telephone triage. She advised that defendants in telephone triage malpractice cases have written evidence of their system. Siebelt listed the essential system components that expert witnesses request when consulting on a malpractice case: call documentation/transcription, guideline print-out, printed clinical training materials, a job description and qualifications, and practice standards. These elements acted both as evidence of the institution’s system — commitment to the duty of due care, as well as a paper trail. Robert Smith, JD, noted that system component as listed above served as a indoor coat— layers of protection.

    Jeff Clawson, served as Wheeler’s mentor and role model as they respectively developed two emerging fields — 911-or Emergency Medical Dispatch and Telephone Triage.

    Forty years ago, no one could have predicted that a world-wide pandemic would prompt the birth of the telehealth industry, now a permanent and essential fixture of healthcare.

    However, while telehealth technology grew rapidly, it outpaced lagging professional growth. The telehealth industry made little note of this.

    At the same time, research on clinical practice was sparse, misguided, confused and flawed. Some researchers treated the task as simply “appointment making” or “giving advice”. Others treated non-clinicians as legitimate clinical decision makers.

    Thus, it is no surprise that, after four decades, persistent patterns of recurrent errors still threaten patient safety.

    There is still much work to do.

  • Cerno: Teletriage Clinical Co-Pilot TM

    Many experts compared early hard-copy (paper) guidelines to “standing orders” — like having a physician-advisor at one’s side while taking calls.

    In 1993, Ms Wheeler led a Guideline Development Task Force of 25+ expert level nurses, nurse practitioners and physician-reviewers during the two-year development period. Aspen published the guidelines in 1995.

    Ms. Wheeler solicited expertise from the Task Force and drew upon her experience as a front-line advice nurse, trainer, legal nurse consultant, researcher, author and inventor to create a three-volume set of unique guidelines.

    Built for the fast—paced teletriage environment for high risk, low income, low literacy, multi-lingual populations - Wheeler’s guidelines were also innovative — the first three-volume, age-based, 5-level teletriage guidelines in the field.

    Wheeler synthesized information gleaned from experts and front line practitioners alike, research and real-world experience, extrapolating studies and standards from similar medical and nursing subspecialties to build sound, robust guidelines and system.

    Four decades of working in, and witnessing the idiosyncratic evolution of telehealth and teletriage, made two trends clear — that the technology has outpaced telehealth professional standards, and that the industry had also overlooked several key challenges to safety — recurrent system error and decision making error.

    “To Err is Human, to Delay is Deadly” Delays in care and diagnoses likely contribute to patient injury and death, leading to medical malpractice. Wheeler envisions that a powerful hybrid will incorporate generative AI and predictive analytics. Soon, biotelemetry and patient wearables will help reduce recurrent error and will be evidence-based, reliable and valid.

    A content expert with an operational strategy, Ms. Wheeler is currently seeking a software partner to collaboratively develop the Next generation prototype to reduce both system error and "patterns of recurrent mistakes" (Gawande).

.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions

.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions

The Problem of Clinical Decision Making:

How Can Face-to-Face Triage Best Inform Teletriage?

 “Pattern Recognition is a Cornerstone of clinical practice of emergency medicine, guiding the timeliness of the disposition”.

EM Physician Are Required to:

  • “recognize patterns in the patient presentation related to levels of urgency

  • ascertain the contextual impact of age, gender, ethnicity, communication & socioeconomic status

  •  interpret patient descriptions of symptoms”

Simple can be harder than complex: you have to work hard to get your thinking clean to make it simple.

But it’s worth it in the end, because once you get there, you can move mountains.”

—-Steve Jobs