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FAQ: Telephone Triage & Telehealth

What is Telephone Triage?

How is telephone triage defined?  Telephone triage involves the safe, appropriate and timely disposition of patient symptoms via phone, by trained, experienced clinicians (typically registered nurses).  Nurses use problem-solving strategies such as pattern recognition, clinical assessment, symptom risk assessment and guidelines to formulate a “working diagnosis” or “nursing symptom risk diagnosis”. They elicit details about symptoms, and patient medical history and make timely referrals — right time, right place for the right reason — also known as a disposition.

By assessing unseen patients by phone, nurses and other clinicians estimate symptom urgency, rather than diagnose symptoms.  The essence of telephone triage is the ability to make safe clinical decisions under conditions of uncertainty and urgency (Lephrohon). Nurses use assessment and communication skills as well as pattern recognition, identified by experts as a decision-making skill. The over arching goal is the safe, timely, appropriate disposition (referral) of patient symptoms (Wheeler). In other words, the purpose of telephone triage is to “get the patient to the right place, at the right time, for the right reason”. TM

One expert that triage “requires professional judgment, since ruling out urgency is more difficult than identifying it”(Champagne, 1995). To rule out urgent symptoms, (or to estimate symptom urgency) requires clinical assessment — a prelude, but not synonymous to, asking questions from the guideline or protocol.  Assessment is the pro-active elicitation of information from the patient, to gather a relevant symptom history, details and context. It also requires the ability to  perform clinical prioritization and to clinically interpret patient responses to questions.  The passive solicitation of yes/no answers from a list of questions, (or placing the entire burden of providing information on patients) does not qualify as clinical assessment.

How long has telephone triage existed?  Telephone triage is as old as the telephone — and has been practiced informally for over 100 years.  Formally, nurse telephone triage has been practiced since around 1989.  Although this new field is more than 35 years old, Telephone Triage is still considered an emerging clinical subspecialty in that some aspects of it are still underdeveloped.

How is telephone triage performed?  Clinicians typically use specialized electronic (or paper)  guidelines to determine when, where and by whom patients will be seen (the disposition).   They also typically document calls, using an Electronic Medical Record (or paper or audiotaping). Clinicians are usually clinically  trained to perform thorough symptom assessments and to use a process to determine whether symptoms are life threatening, emergent, urgent, acute or non-acute.

What are the qualifications to perform this work?  Clinicians are qualified by clinical education, training and experience to identify, estimate and rule out urgent symptoms and to provide safe, timely dispositions — “right time, right place, for the right reason”.  Nurses are qualified to advise patients to call 911,  to go to the emergency department,  to make a same-day or future appointment and/or to carry out home treatment advice.

What is the purpose of telephone triage?  From the patient’s perspective, they typically contact the clinical call center because they are uncertain about how serious their symptoms are. Systems are marketed to lead patients to expect safe, timely access to nurses who can assess their symptoms and recommend on-site care and treatment, or home treatment advice via phone.

From the institutions’ perspective, the purpose of telephone triage (and telehealth) is to help the healthcare system operate more cost effectively:  to reduce innappropriate Emergency Department, Office and Clinic visits, by serving as an “access facilitator” for patients.

What is a Delay in Care?   A delay or denial of care occurs when  symptons worsen, and the patient is not adequately assessed and advised to seek treatment in time to prevent injuries or even death.  Problems arise when institutions use the service more as a gatekeeper than access facilitator.  Delay in care may lead to nursing or medical malpractice, and may be caused by institutions’ overly restrictive access policies.

Other polices leading to delays in care include:  clinician understaffing,  inadequate call processing times (leading to inadequate assessments), and inappropriate use of non-clinicians to pre-screen symptoms.  Some facilities appear to expect the patient to provide all needed information (or even self triage), instead of placing the responsibility and duty of eliciting and communication significant information on the clinician.

Can non-clinicians perform telephone triage?  Symptom-based calls require clinical assessment and clinical decisionmaking by medically-trained, licensed and experienced clinicians.  Non-clinicians are only qualified to take messages for clinicians.

What is a telephone triage system?  A telephone triage system is typically composed of five components:  qualified staff (clinicians), guidelines, documentation, training program and standards (policies and procedures).  When these components are inadequate (the responsibility of the employer), system error may occur.

What is a Computerized Clinical Decision Support System (CDSS)?   Computerized Decision Support Systems are expert software systems (containing protocols or guidelines for a range of symptoms) that remind experienced decision makers (like physicians and nurses) of issues to consider that s/he once knew but may have forgotten

What is a Computerized Clinical Decision Making System (CDMS)?  Computerized Decision Making Systems are expert software system (containing protocols or guidelines for a range of symptoms)  that allows an unqualified person (non-clinicians, like emergency medical dispatchers) to make a decision that is beyond his/her level of clinical training and experience.

What is Telehealth?  

Telehealth is a broad term that refers to technological expansion (using video, bioteletry, telemonitoring, patient wearables) of remote contacts.  Telehealth also refers to the clinical practice of pre-hospital assessment of symptoms utilizing all of the technologies noted above.  Telehealth emerged nearly overnight during the 2020 COVID-19 pandemic, when remote tele-visits became mandatory during the lock-down. Telehealth is here to stay, and soon telehealth will subsume telephone triage.

Telemedicine is defined as “telephonic medical diagnosis of patients’ problem and their medical treatment”  (Reisman). Telemedicine is typically performed by physicians, whereas telephone triage and telehealth may be performed by RNs.

According to Wikipedia, Telehealth is the “delivery of health-related services and information via telecommunications technologies”. Telehealth,  unlike telemedicine (which narrowly focuses on the diagnosis of symptoms) focuses on pre-hospital symptom assessment and evaluation to prevent delays in care and treatment.  A key function of telehealth (and telephone triage) is that of access to appropriate and timely care.  Both are a form of pre-hospital care and the patients’ initial contact in the health care continuum.

Key Telehealth Trends?

Two recent articles in the Journal of Telemedicine and Telecare (JTT) point out emerging trends that affect sustainable telehealth post-pandemic.   One study noted that reimbursement for telehealth services will significantly affect the future of nurse-based telehealth practice. According to Watkins and Neubrander (2020), “Federal legislation has responded to emergent public-health needs by removing barriers that have impeded widespread adoption of telehealth modalities. This legislation has omitted professional registered nurses (RNs) from delivering reimbursable telehealth services, which is problematic for primary-care practice. RNs historically have led telehealth service delivery and should therefore be included in new legislation as eligible health professionals permitted to provide reimbursable telehealth services.”  

A second JTT article highlights five key requirements for the long-term sustainability of telehealth. These include: (a) developing a skilled workforce; (b) empowering consumers; (c) reforming funding; (d) improving the digital ecosystems; and (e) integrating telehealth into routine care.

Do Telephone Triage and Telehealth Require Similar Standards of Care?

Yes, standards for both clinical practices will be similar.  In addition, both telephone triage and telehealth will require complete, evidence based systems — Qualified staff, clinical training, guidelines, policies and procedures, documentation — evidence of the quality of care.  Telehealth technologies will need to be reliable and valid.

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