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Telephone Triage in Year 2000

Past, Present, Future

Experts project that in the near future, telehealth will subsume telephone triage, with telemonitoring and visualization of all patients from home. Disease management will grow as home health assessment includes heart, lung, and bowel sounds, blood pressure and pulse readings, gait, neuro exams and mood assessment.

Training programs will grow to 40 hours and will include internet-based training based on “real life” problems. Sophisticated training programs will provide simulations with “patients” calling from off site and nurses utilizing telemetry and computerized protocols.  Telephone triage will be an international phenomenon.  Within the next ten years, experts from the Europe, the United Kingdom, Australia and South America will converge to network and share solutions and expertise from a multi-national and multicultural perspective.

Job Qualifications: 1970s to 1990s

In the early 70’s, telephone triage had few job qualifications– most nurses were felt to be qualified. As the field evolved into a recognized subspecialty, managers discovered that the high-stakes, high stress work required seasoned RNs with many years of “bedside” decision making experience. Thus, new graduates were not considered the best candidates for the task of telephone triage. Certainly, there are exceptions to this rule. However, we know that less experience results in over triage (Patel, 1996), while increased experience results in more appropriate decisions. The new RN, with little or no bedside decisionmaking experience will require time to build up these skills. Whether in the clinic, office, hospital or in the emergency department setting, five to ten year’s experience provides the foundation necessary for good decision making by phone–a considerably more difficult task.

RNs are considered the best choice not only because they are autonomous professionals, but they are also “the least paid person who can safely do the job” (Schmitt, 1980). Telephone triage requires excellence in interpersonal skill or “telephone charisma” (articulate, personable, resourceful, dedication to service). There must be a good match between the work–high volume, high stress decision making under conditions of uncertainty and urgency -and the practitioner’s temperament– calm, mature and patient. Computer literacy is desirable.

In the 70’s most training was “on the job”, essentially “see one, do one, teach one”. Each new advice nurse had to learn through trial and error, essentially “reinventing the training wheel” with each new employee. In the 90’s, formal training programs emerged. Currently, the best training programs have a minimum of 40 hours. Orientation addresses an overview of the field and the nursing role, the nursing process, communication aspects, history taking, interview and documentation skills, protocol use and medical legal aspects.

Two types of training and education currently exist–in-house and national conferences. In house trainers employ a variety of methodologies, since research demonstrates that individuals learn differently and learning happens best when all senses are utilized. In-house training techniques include reading, lecture, discussion, “shadowing”, written exercises in interview and documentation, audiotape analysis/critique, preceptor programs and role play of mock calls. Role play is an excellent method to cumulatively integrate the new skills and tools (protocols and documentation form) and to simulate the actual task. Preceptors can support and counsel the new advice nurse in the first three to six months.  National conferences provide a broad perspective and opportunity to network and problem solve. Since 1994, conferences on telephone triage have provided a national forum for manager and practitioner alike to network and share experience and expertise. The final step in formal education will be accreditation–not yet a reality–but anticipated within the next five to ten years.

2020: Virtual Call Centers, Telehealth Nursing

Job Qualification for the tele health clinician of the future: “Part-time positions in high volume, high tech, 24/7 hour,  clinical telehealth call center. Clinicians (RN or NP) with minimum of ten years nursing and five or more years telephone triage experience. Eligible candidates must be able to word process at 40-50 words per minute, computer literate, culturally sensitive, with excellent written and verbal communication skills, excellent and maturity. Requires expert level clinical decisionamaking, critical thinking and negotiating skills. Experience with telemetry required. Must be certified through International  Society of Telehealth Clinicians (ISTC)  within the last five years. 80 Hour full-time orientation is required. Bilingual nurses (esp. Spanish, Cantonese, Mandarin) highly desired. BS/MS in Psychology or Sociology a plus. Please designate specialty area: Pediatric, Adult/Geriatric, OB/GYN, Medical Crisis Intervention, Behavioral Health, or Case Management.”

In the future, some clinicians may work from home-based systems, while the majority will practice from huge national call centers. In these “virtual mega-call center” nurses will serve as the coordinator from the “hub” of an integrated computer and phone system–a network of phone-based health care services, calls ranging from crisis level to information-based and from telemedicine and internet based service to “POTs”–“plain old telephone” lines.

As coordinators, clinicians will manage and triage calls to Poison Control, 911, Suicide Prevention, the emergency department, office, home health, case managers and community hot lines. Rotation through these crisis level call centers will be commonplace as nurses learn how these agencies operate and manage calls. As part of the “community sentinel system” advice nurses will both monitor the community and alert appropriate agencies, such as 911, public health agencies or EDs, during community-wide seasonal health threats, such as heat waves, disease outbreaks and related media scares. As case managers, they will routinely perform disease management by phone, pro actively managing populations of callers with CHF, asthma, and diabetes. All staff will be cross trained for telemetry, as nurses monitor blood pressures and weights for home health clients, uterine activity for high risk mothers and intermittent cardiac arrhythmias to identify, diagnosis and treat some cardiac problems.

Telehealth will subsume telephone triage, with the addition of visual display of patients from home, telemetry and internet access by both nurse and patient. For example, home health assessment will include heart, lung, and bowel sounds, blood pressure and pulse readings, gait, neuro exams and mood assessment.Training programs will be a minimum of 40 hours and will include CD programs and internet-based training based on “real life” problems. Sophisticated training programs will provide simulations with “patients” calling from off site and nurses utilizing telemetry and computerized protocols.

Because telephone triage is an international phenomenon, conferences of the future will be international. Within the next ten years, experts from the Europe, the United Kingdom, Australia and South America will converge to network and share solutions and expertise from a multi-national and multicultural perspective.  Accreditation in the future will be be 80 hours of formal training through a regulatory agency, like AAACN. Core content will include tele health and telemetry, informatics, competency training, medical decision-making theory, legal aspects, specialized communication and negotiation training, psychology, community health systems and cultural sensitivity. Advice nurses will be experts in chronobiology, the science of how the biorhythm affects our health, prompting predictable seasonal, diurnal and nocturnal “surges” of such conditions as allergic reactions, heart attacks and strokes. Certified trainers from 911, suicide prevention, poison control and sexual assault response teams will provide specialized training as part of this program.

Used with the permission of Telephone Triage Times. Written in 2000 by Sheila Wheeler   

Please note: The material in this article is copyrighted by Sheila Wheeler. It may not be used for other commercial purposes: i.e. resale, or incorporation into paid seminars. It is limited to individual educational or research purposes.
Written by Sheila Wheeler (14 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.



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