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Are Telephone Triage Guidelines Safe & Reliable ?

How to Evaluate Telephone Triage Guidelines and Protocols

It is safe to say that telephone triage guidelines are still in “early days”.  No independent, peer-reviewed, comparative study has found one guideline system to be safer than all others.  In fact,  errors and delays in care still plague telephone triage. According to the Institute of Medicine, error is defined as the “unintended use of the wrong plan”, as well as “the failure to use any plan”.  Whether in paper or electronic versions, Telephone Triage Guidelines are an important component of the Telephone Triage System (as plan), also composed of qualified staff, an EMR, Standards and Training Program.

Decision-Support versus Decision-Making Software

In the world of telephone triage, there are two distinct philosophical approaches to computerized decision support systems (CDSS). They are either  decision support or decision making tools.  Decision support  systems are defined as “an expert system which reminds experienced decision makers of questions or information that s/he once knew, but many have forgotten”.  Decision making systems are defined as “expert systems which allow an unqualified person to make a decision that is beyond his/her level of training and experience”.  Experts believe that the experienced, trained clinicians’s judgment is the bottom line, and the decision support software is an aide.

This differentiation is important, since current guidelines on the market often lack transparency, making it difficult to ascertain how the product actually operates, or where the user is being lead by the algorithm. Thus, some electronic software is described as decision support software, but in reality acts as decision-making software.

Looking “Under the Hood”  With CDSS, start by asking the software vendor:

  • How long have the guidelines been in use and in what settings?
  • What are the guidelines designed to do?  Make a Diagnosis or help clinicians to Estimate the Urgency of Symptoms?
  • Are there malpractice lawsuits related to the guidelines?
  • Who designed the CDSS?  Practically speaking, expert clinicians (usually nurses) who actively practice telephone triage (and appreciate the difficulties of the task as well as the benefits of user-friendliness) are the best “real world” guideline designers. Physicians should consult, review and approve CDSS for accuracy.
  • Were the guidelines developed by a single clinician or a multi-specialty Task Force?
  • What were the qualifications and experience of the task force members?  Physicians who are familiar with and supportive of nurse telephone triage are the best consultants and reviewers.

See also other Frequently Asked Questions.

Begin the process by obtaining print-outs of: 1. Table of Contents; 2. Three representative guidelines (Abdominal pain; Nausea and Vomiting; or Respiratory Problems); and 3. EMR

  1. TABLE OF CONTENTS  The table of contents is essentially the “search engine” . Remain alert to lists of titles that are confusing, inconsistent, extremely lenthy or redundant. Lay language commingled with medical terminology is user-unfriendly, time-consuming, frustrating and confusing to the end-user.   Is there a consistent approach to titling? For example, are the protocols listed consistently alphabetically in an anatomical site or symptom- based approach? Or are they a confusing mix of both? Poorly organized titling results in user unfriendliness, frustration, user non-compliance and slows the interaction.  Symptom-based titles should be differentiated from  Supplemental Information titles for ease of use.
  2. SCOPE What is the scope of the collection? Too many or too few guidelines create  “user unfriendly” CDSS. Too many guidelines (400+) may result in excessive cross indexing, screen changes, title confusion and slow the search process, whereas, too few guidelines result in – “No Protocol Found” — also a problem.  These guidelines (40+) address 1,500 possible common diagnoses, including predictable, but infrequent emergencies.
  3. AGE-BASED Ideally, CDSS should be age-based —  customized to a specific age group, such as Infant-Child, or School-Age or Adult populations.
  4. PATIENT-CENTERED Patient-centered refers to the literacy level of instructions and symptom descriptions.  Ideally, instructions written in 5th-8th grade literacy level work best.  Written in a conversational way, clinicians can either read content directly to caller, or summarize content already “translated” from medicates to lay language — saving clinicians time, reducing stress and making instructions consistent.
  5. CLINICAL CONTENT DEPTH and BREADTH CDSS are reference tools designed to be consulted for brief interactions with patients — containing essential information to safely triage, advise and provide for  dispositions.  Some CDSS suffer from “content bloat”– inordinate amounts of content cluttered with non essential tutorials and extraneous information that clinicians should already know.  Simple, consistent formatting with brief illness descriptions and home treatment instruction in lay-language make for user-friendliness. A User’s Guide provides instruction for operating the CDSS.
  6. EMR or EHR   The EMR facilitate the problem-solving activity — an example being the nursing process — assessment, impression (“working diagnosis”), treatment plan (disposition) and self-evaluation instructions, as appropriate.
  7. TEST DRIVING: Do the guidelines “make it easy to do the right thing”  (Institute of Medicine)?
    Once you have narrowed the selection down to two or three CDSS, have front-line clinicians use 2-3 patient scenarios  (Abdominal pain, rash, nausea and vomiting)  and then compare results. How do the CDSS perform within the “real world” time frame of 10-15 minutes per call?
  8. TRAINING Current research has found that  electronic software (guidelines)  have not eliminated delays in care or error. Training on how to operate software does not supplant training in telephone triage assessment and decision making skills, critical thinking, risk management.  For best results, comprehensive clinical training is key, affording staff the opportunity to achieve buy-in and appreciate the design.  Training will reduce “protocol bias” ( favorable bias towards previously used CDSS),  shorten the learning curve and facilitate user compliance — and patient safety.


Written by Sheila Wheeler (15 Posts)

SHEILA WHEELER, RN, MS, is acknowledged as an international expert in the field of telephone triage. She has practiced nursing for over 30 years, primarily in critical care, emergency department and clinic settings. An accomplished writer, educator, researcher and consultant, Ms. Wheeler is currently President of TeleTriage Systems in San Anselmo, California.