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Standards-Based Criteria for Telehealth Guidelines

Standards for Telehealth Guidelines

In Clinical Practice Guidelines We Can Trust (2011), the Institute of Medicine (IOM) sets forth seven criteria required for appraising Guidelines (p 213, Appendix C). IOM recommends that developers set forth design standards for the assumptions, analytic methods, and rationales used in any guideline development.While such design standards apply to all telephone triage guidelines, no developer has produced evidence that their guidelines meet such standards.

TeleTriage Systems currently seeks to affiliate with like-minded companies (AI, Patient Wearables) to create the next-generation evidence-based Guidelines that meet IOM standards.

Are Current Guideline Designs Safe?  To date, no independent research has demonstrated that current electronic guidelines, based on an algorithmic medical model (symptom diagnosis using automated reasoning), is either safe or reliable (Wheeler, 2015).   Furthermore, the approach for this type of guideline does not lead to triage decisions — but rather leads to a wide range of outcomes —  both diagnostic and deterministic. This design approach lacks clear triage acuity categories and clear directives for dispositions (i.e. when, where and why patients should be further evaluated).

Telephone Triage is defined as “making good clinical decisions under conditions of uncertainty and urgency” (Patel).  Assessment by phone of an invisible patient, who is an untrained lay observer, complicated by the variability of symptom presentations, communications and process is challenging.  A pattern recognition approach produces safer and more reliable outcomes — timely, appropriate referrals.  This approach requires thorough symptom and patient history assessment (step one of the nursing process).

Assessment is the most critical and substantive step of telephone triage, since pattern recognition is dependent upon the systematic collection of data. A thorough preliminary assessment is also the first step of the nursing process. By using detailed questioning, thorough assessment helps to guide nurses to select the most appropriate guideline or protocol. Preliminary initial questions also help to “rule out” life-threatening or potentially serious conditions. Inadequate questioning and/or failure to ask specific follow up questions can result in inadequate assessment. It may lead to under referrals and delay in care.

These guidelines are based on evidence (Goodman & Perrin, 1978; Patel, 1995) related to a clinical pattern recognition strategy (by nurses and nurse practitioners) in telephone triage. They are also derived from a 5-Tier Triage approach and categories and descriptions  established by ACEP. Since 1995, clinicians have used these guidelines to manage calls without any reports of malpractice or patient harm.  They were specifically designed to meet and/or exceed the following criteria:

  1. Validity – if guidelines are followed, it will lead to one of 5 Level dispositions
  2. Reliability/reproducibility – given the same data and using the guidelines,  another  set of nurses would produce the same results or expected outcomes
  3. Clinical applicability – explicitly states the populations  to which they apply
  4. Flexibility – identifies exceptions to their recommendations
  5. Clarity & Transparency – unambiguous language, precisely defined terms,  easy to follow mode of presentation
  6. Scheduled Review
  7. Multidisciplinary Process

1) Validity and Reliability/Reproducibility

If followed, valid guidelines should lead to expected outcomes.  Reliable: given the same data, another set of nurses using these guidelines would produce the same outcomes.   Validity and reproducibility are feasible only if qualified nurses — with adequate clinical training — operate them.

These guidelines have been in use or field tested as a paper product since 1995.  During that time, there have been no reports of adverse outcomes of any kind, nor have there been any threats of or actual  malpractice lawsuits.  TeleTriage Systems welcomes opportunities to perform research on the guidelines to document validity and reliability.  Please contact Sheila Wheeler if you are interested in this prospect.

2) Clinical applicability

Guidelines were designed to explicitly address three distinct populations: adults (Age 18+),  school age (Age 6-18), and  Infant Child age groups (Birth to Six years) of all risk levels, socioeconomic status and literacy levels.

3) Flexibility

The Users Guide identifies exceptions to guideline recommendations, rules or provisions for situations, which do not fall into typical presentations. Some examples include:

  • When dealing with high-risk patients, atypical symptoms  or situations
  • When in doubt about what is the right decision
  • When the nurse wishes to upgrade or downgrade
  • A robust Generic Guideline, used as a “go to” or “fall back” guideline for situations where no specific guideline seems to apply.

4) Clarity

The authors of the protocols made every attempt to achieve the goal of clarity. As recommended by the Manchester Triage Group (2016), we worked tirelessly to create a product with unambiguous language, precisely defined terms,  clear operating instructions and a consistent and user-friendly presentation.  We used 5th – 8th  grade level language, so information could be read directly to the caller, rather than risk introducing error by having to “retranslate” it from medical jargon or college to 8th grade level. We simplified the format to streamline the process and to direct the eye through the guideline. Abbreviations are included.  In general, the Table of Contents are Site-based for ease of locating the correct title.

Guideline dispositions are based on the 5-Tier Triage model, which provides complete instructions for when, where, and why patients should be seen for each level of acuity: life threatening, emergent, urgent, acute and non-acute.  The guidelines have been 5-Level since 1995 — when first published — 21 years ago.

5) Transparency

By their very nature, books are transparent.  Similar to the classic Merck Manual reference, which describes symptom patterns, these guidelines are in a reference book format.  In addition, the 40-page User’s Guide has full instructions.  The reader can easily see how the manuals operate.  These are the most user-friendly, consistent, fast and practical guidelines available.

And these protocols are available with standards-based  On-site Training Programs or On-line Training Programs — an integrated component of complete telephone triage systems (Guidelines, Documentation, Training and Standards).  Practice Standards are included in the Appendix section of the User’s Guide.

6) Scheduled Review

Select guidelines were last updated by the author 2005.  Institutions who use TeleTriage Systems Guidelines are responsible for scheduled review, revision  and customization of them per that institution’s own standards.

7)  Multidisciplinary Process

These guidelines were developed over a 2-year period by a group of 20+ expert-level Nurses and Nurse Practitioners under the direction of Sheila Wheeler, Editor-in-Chief.  Three physicians reviewed the guidelines.  Additional Nurses and NPs have served as contributing authors to revise various guidelines over successive years.

Adult Telehealth Guidelines

Pediatric Telehealth Guidelines (School Age)

Pediatric Telehealth Guidelines  (Infant-Child)

Telehealth Guideline Table of Contents

Telehealth Guideline Development:  Evidence-based Structure and Process

“Clinical Systems to Help Clinicians Get Patients to the Right Place at the Right Time for the Right Reason” TM

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