Telephone triage - -

remote, real-time clinical decision making --

need not be so uncertain and risky.

Safety starts with a system.

.......TeleTriage Systems -- Devising Solutions & Strategies to Reduce Recurrent Telephone Triage Error

.......TeleTriage Systems -- Devising Solutions & Strategies to Reduce Recurrent Telephone Triage Error

  • It’s Been A Journey

    Sheila Quilter Wheeler had no intention of pioneering a new nursing subspecialty.   In the early 1980’s, while managing advice calls as an ED nurse, she requested guidelines to standardize the process and advice. The response -- she "was an ED nurse and knew what to do", Wheeler was not reassured. Her new mission: identifying a need, finding solutions – ultimately enhancing practice in a new clinical subspecialty.

    Her first solution was two books, both written for the layman by physicians (Vickery, Fries and Pantell).  They were the first telephone triage guidelines in that ED.  Currently, in 9th and 10th editions, they contain instructions for assessing, triaging and home treatment for common adult and pediatric symptoms.

    Later, as a clinical call center advice nurse, Wheeler developed and taught an in-house telephone triage class. A participant thanked her for the class, adding that she "no longer felt like a stepchild of nursing". At that time, remote assessment was an embryonic field, fraught with uncertainty.  Many nurses were "worried about their license" -- anxious to know safer methods to carry out the task.

    In the mid-1980s, as a consultant, Wheeler taught a clinical course -- “ The Fine Art of Telephone Triage”.  The training syllabus gradually evolved, and, four years later, became a book proposal. Nine publishers rejected the proposal, but she persevered.  In 1993, Wheeler and medical writer, Judith Windt, completed training manual including real-life case-study audiotapes, and “Telephone Triage: Theory, Practice and Protocol Development" was published by Delmar Publishers.

    From 1993 to 1995, Ms. Wheeler served as Editor-in-Chief for first age-based, five-level, patient centric telephone triage guidelines,  published by Aspen Publishers. In 1994, she founded the first national Telephone Triage conference for nurses  In 1997, she launched her website to serve as an informational resource in a fledgling field.

    From 1995 to 2023, Ms. Wheeler served as an expert witness on 35 telephone triage malpractice cases, most involving recurrent mistakes -- still evident today:

    1. Inadequate Preliminary Assessments

    2. Ignoring Red Flags, like multiple calls, risk factors, recent events

    3. Red Herrings: Distractions, previous medical misdiagnosis and visits, misdiagnoses, patient misperceptions

    4. Miscommunications : involving patients, family, healthcare providers

    5. Cognitive Error: Stereotyping, jumping to conclusions. and others.

    6. Guideline Error: Selecting wrong guidelines, using guidelines incorrectly.

    7. System Error: Clinicians working in a Vacuum, Inadequate Error Feedback.

    Since 1982, Ms. Wheeler has identified a new subspecialty's needs, developed solutions and tackled the next problem.  40+ years of recurrent common mistakes both inform her telephone triage system components, as well as her summative product – a Universal Guideline CDSS. Prototype.  40+ years, from practitioner to Pioneer, Telehealth Thought Leader and Visionary.

    Learn More

  • It Takes a Village

    Over a 40+ year period, Wheeler developed a system with a structure and a process, working collaboratively with clients and like-minded experts from relevant clinical disciplines. Her first major influencers were Barbara Siebelt, RN, MS, Robert Smith, JD, and Jeff Clawson, MD

    Barbara Siebelt — a legal nurse expert - related that defendants in telephone triage malpractice cases should have written evidence of their system. She advised Wheeler that, as an expert witness, she should request the "paper trail" --printed documentation/transcript, guidelines used, clinical training materials, job description and qualifications, and practice standards≥ Basic evidence consisting of essential system components demonstrating the legal "duty of due care"

    Robert Smith, JD, advised that these same components be integrated. He cautioned against having " just bits and pieces", noting that each system component served as a kind of coat of safety -- layers of protection.

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

    Early on, clinical practice research was sparse, misguided, confusing and often flawed. Some researchers treated the task of clinical decision-making (often under conditions of uncertainty and urgency) as simply “appointment making” or “giving advice”. Others commingled non-clinicians with legitimate clinical decision makers in their studies.

    Many experts compared early hard-copy (paper) Telephone Triage Guidelines to “standing orders” — similar to having a physician-advisor at one’s side while triaging symptoms remotely.

    From 1993 to 1995, Ms Wheeler led a Guideline Development Task Force of 25+ expert-level nurses, NP's and MD-reviewers to develop paper guidelines. . Drawing upon her experience as a front-line advice nurse, researcher, trainer, author and inventor, she created the first five -level, age-specific, patient-centric telephone triage guidelines.

    With a foundation of real-world experience, Wheeler scoured the research extrapolating standards and tools from authoritative sources and similar subspecialties -- ACEP, Joint Commission, ESI, and ENA- to build a robust, complete system.

    Yet, after nearly five decades, persistent patterns of recurrent error still threaten patient safety.

    There is still much work to do.

    Learn More

  • A Universal Guideline for Telephone Triage (Patent Pending)

    Wheeler’s guidelines were innovative — built for the fast—paced teletriage environment as well as wide-ranging populations — from high risk, low income, low literacy, multi-lingual patients to college educated, high income populations. Wheeler synthesized suggestions gleaned from experts and front line practitioners alike. In addition to and real-world experience, Wheeler scoured the research extrapolating standards and tools from ACEP, and ENA -- similar subspecialties -- to build a robust, complete system.

    Turning Points: 1995, 2000 and 2020

    1995 Wheeler's expert witness work plus four decades of working in, and witnessing the idiosyncratic evolution of teletriage made clear several risky trends: inadequate professional standards, technology outpaced those standards, negatively impacting CDSS design.

    2000 To Err is Human The telehealth industry had overlooked several key challenges to safety — system error (IOM) and common recurrent practice error (Gawande). Inadequate error feedback is a long-standing, misguided, outdated policy, preventing systematic feedback, resulting in recurrent error. In the misguided interest of patient privacy. Clinicians are forced to work in a vacuum, prevented from knowing the results of their decisions.

    2020 Telehealth Emergence Forty years ago, even experts would not have predicted a world-wide pandemic prompting sudden emergence of telehealth industry, now a permanent and essential service. However, telehealth technology grew rapidly, outpacing lagging professional growth. The industry made little note of this.

    “To Err is Human, to Delay is Deadly” Delay in care and diagnoses contribute to patient injury and death, leading to medical malpractice. While generative AI, predictive analytics, biotelemetry and patient wearables may reduce recurrent error, decision support systems still require guard rails - clinical training, standards and built-in error reduction strategies.

    Without a comprehesive, transparent, robust prototype, verifying the validity and reliability of CDSS cannot be assured. Research on CDSS is difficult because of the proprietary nature of software, but is much needed.

    A content expert with an operational strategy, Ms. Wheeler currently seeks a software partner with AI/PA expertise to collaboratively develop and test a Universal Telephone Triage Guideline prototype to reduce "patterns of recurrent mistakes" (Gawande).

    Contact Ms Wheeler for more information

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

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

THE CHALLENGE OF REMOTE TRIAGE

https://pmc.ncbi.nlm.nih.gov/articles/PMC11204574/

What is consensus?

Can On-Site Triage Methodologies Inform Remote Triage?

 “Pattern Recognition (now, including AI and PA) 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, general health, 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

Common Assumptions & the Need for EBM Research Focus on Telephone Triage,

  1. What research demonstrates that current Computerized Decision Support Systems (CDSS) are safe, reliable, valid and evidence-based?

  2. If AI, Predictive Analytics and Advanced EHR/EMR are the future of telephone triage, what CDSS supports validity and reliability of safe outcomes?

  3. If telephone triage is purported to diagnose symptoms remotely, where is the evidence?

  4. Can telephone triage CDSS estimate risk or symptom urgency?

  5. Will the EMR/CDSS features serve as a standalone system in the future, supplanting other system components like training and standards?

  6. How are safe patient outcomes defined in teletriage? What are the parameters (time and place) for Emergent, Urgent, Acute, Non-Acute Symptoms?

  7. Which clinician is the best match for the task of telephone triage — RN or MD? What is the evidence supporting this?

  8. What research demonstrates that telephone triage safely reduces inappropriate ED, Urgent Care, Office and Clinic visits and Hospital Readmissions?

  9. Are the developers of CDSS and Symptom Checkers asking the wrong question?

Telephone Triage:  Error, Expectations 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

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

  • ·      a form of pre-arrival care, taking place prior to arrival in healthcare setting

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

Expectations in Telephone Ttriage

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 in Telephone Ttriage

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 in Telephone Ttriage

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 understaffing. Clinicians shoulder the burden of 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 teletriage, 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. 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 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. “

Telephone Triage and EBM 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 -- Formalize Telephone Ttriage as 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 Because remote encounters are, by nature, high risk, decisions must err on the side of caution. especially for children and elderly

  • ·     Fully formalize the Nursing Process into training materials and guidelines

  • ·     Institute 4-6 Hour shifts in all High Call Volume clinical call centers to reduce Decision Fatigue

  • Investigate System Error in Teletriage: Expand 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