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Telephone Triage Interstate Practice

A Historical View of Interstate Practice of Telephone Triage (Carol Rutenberg, Author)

Joan Ritter is sitting at home in one state taking a call from a patient who is living in or traveled to another state on business.  When she takes that call, where is she practicing?  You might be surprised to learn that most state Boards of Nursing feel that nursing takes place where the patient is (not the nurse) and thus you might be practicing in the state from which the patient is calling.  The question is: Are you licensed to practice in that state?

Telehealth nurses and organizations have been closely following the proposed Interstate Compact for Mutual Recognition of Nurse Licensure (Interstate Compact),first proposed by the National Council of State Boards of Nursing (NCSBN) in 1997.  The need for this compact arose when the provision of care by telephone and thus provision of care across state lines (interstate practice) became common.  The model for this Compact is based on the Driver’s License Model, which holds that a resident of one state may drive in another state, as long as they maintain a valid driver’s license in their home state and follow the driving laws of the state in which they’re driving. While the question of providing care to patients in other states is an obvious concern for many call centers, this is an issue faced by nurses from many venues such as doctor’s offices and clinic settings.  While some call centers have bought multiple state licenses for their nurses, this certainly isn’t occurring universally, and nurses are at risk every day.

Where Are We Now? Since Utah enacted the Interstate Compact in 2000, 17 other states have followed suit and more are sure to follow.  Until then, nurses in non-compact states or those who are talking calls from patients in non-compact states (including “snow-birds” and patients on vacation) may be in a position to be regarded as practicing nursing without a license.

Among states that have not yet signed on, they cite such concerns as loss of revenue (from license renewals), loss of control (directly stemming from nurses in other states practicing in their state), and the dilemma of who would pay for transportation and other costs associated with the disciplinary hearing for a nurse accused of practicing without a license in the state in question.  While it might be desirable for all 50 states to pass the Interstate Compact, it is likely that some never will.  Until such time as the interstate compact becomes universal, nurses who are taking calls from other states are at risk.

What should nurses do?  Many organizations have not taken action to protect themselves or their employees against the allegation of the unlicensed practice of nursing because as yet, the issue has not been tested in court. However, although there is not yet case law pertaining to this issue, it is probably just a matter of time before an interstate practice case makes it to court.  While many organizations have taken a “wait and see” attitude, others have decided to aggressively protect the nurses and the organization by purchasing multiple state licenses for their nurses.
However, until the Interstate Compact becomes a universal reality and until such time as the BONs develop consistent regulations addressing scope of practice in telephone triage, the practicing nurse is apt to remain confused on these issues.  The prudent practitioner in the prudent organization would develop policies and practices that are in keeping with statutory and regulatory guidance provided by the relevant Boards of Nursing in order to assure that they are not stepping over the line.

Other Lines: The Scope Of “Telepractice”; Telenurse Qualifications

Although the question of interstate licensure has been given a good deal of press in regulatory circles, another equally troublesome issue continues to loom large relative to the question of interstate practice. There is confusion because of differing Boards’ rules (or lack thereof) relative to the practice of telephone triage.  In polling the BONs, two issues have surfaced.  These questions deal with recommendation of medications and the differing roles of RNs, LPNs and LVNs (LP/VNs).

In common practice, it is not unusual for telehealth nurses to recommend medications to patients.  Specifically, these medication recommendations fall into three categories: recommendation of over-the-counter (OTC) medications, recommendation of prescription medications, and renewal of prescription medications.  Most call centers limit their medication recommendations to OTC drugs, but nurses in doctor’s offices and clinic settings often recommend medications in all three categories.  States vary widely on their opinion regarding the legality of these practices.  While some states (11 at last count) hold that it is within the scope of practice of an RN to recommend OTC drugs on the basis of her/his own license, others regard this as a delegated medical act and require that a medically approved protocol be in place to support recommendation of OTC drugs.  Still other states regard this practice as being outside the scope of practice of an RN and prohibit this practice under any circumstances.  Likewise, some states allow recommendation and/or renewal of prescription drugs according to protocol, while others prohibit this activity.

A second area of controversy has to do with the use of LP/VNs in telephone triage.  Some states feel that LP/VNs may do telephone triage under the supervision of an RN or a physician, but other states feel that this is outside of their scope of practice.  The basis most often cited for this opinion is the definition of Licensed Practical or Vocational Nursing, which prohibits these individuals from doing independent assessment.

Article by Carol Rutenberg, RN C, MNSc

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.