THE BRAVE NEW WORLD OF TELETRIAGE
The work of teletriage is nothing if not uncertain, and humans intensely dislike uncertainty. However, it is reasonable and prudent to acknowledge the limitations of this work, and to question our assumptions about it. Safer practice and evidence-based tools can reduce uncertainty and improve outcomes.
“Triage (on site) is not an endpoint but a beginning.” American College of Emergency Physicians, 1999. Uniform Triage Scale in Emergency Medicine, Information Paper
"Physician expertise and professionalism alone could not prevent common error.” Killip. (2007),
“All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. They all have at least three common elements: expectation of selflessness; of skill; and of trustworthiness. Aviators have a fourth expectation -- discipline”. (Gawande, 2010)
‘We don’t look for patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point”(Gawande, 2010).
“Any mistake or failure in the diagnostic process can lead to a diagnosis that is wrong, missed or delayed. More diagnostic errors occur in ambulatory settings, but inpatient diagnostic errors tend to be more lethal”. Groszkruger, 2014.
Artificial Intelligence — the Wave of the Future in Teletriage
CDSS that employs AI without a governing framework and guard rails - might produce unsafe outcomes.
Errors of Assessment, Communication, Continuity, Informed Consent and Human Error. (Joint Commission) are Root Causes of unsafe outcomes in teletriage. Malpractice cases in teletriage are typically related to these predictable and preventable errors. Human and system error can be addressed by a system —structure and process — a group of related parts that work together for common goals — patient safety, practitioner safety, system effectiveness.
CDSS that Meets Key Telephone Triage Requirements
1. Practice Management:
a. Clinical Training - Five CE courses
b. Risk Management
c. Standards: Practice & Call Center
d. Pending: Universal Guideline - EBM certified & AI/PA enabled
2. Clinical Trends/Health care Technology: CDSS (in Process)EMR
3. Financial Performance: Tracking and Trending Capabilities
4. Patient Experience:
a. Patient Brochure on how to use Advice Nurse Service
b. Patient Educational Material for Symptom-Based Calls
Patent Pending
Universal Guideline: Multi-Purpose, Multi-Setting
1. Universal Template to develop All-Age hard Copies: Infant-child, School age, Adult
2. Contingency Guideline, when no Guideline seems to apply
3. Pre-emptive Guideline, prior to selecting a specific guideline
4. Standalone Guideline, All-Purpose guideline, used without other guidelines
5. Training adjunct to introduce broad principles and policies, for new staff
6. Face-to-face triage in ambulatory settings (pre-triage in ED, Urgent Care, Offices, Clinics, College Student Health, and a range of clinical or off-site settings).
7. AI/PA-Ready Prototype to integrate Artificial Intelligence (AI), Predictive Analytics (PA)
The Future of Telephone Triage CDSS
Currently, computerized decision support systems (CDSS) for nurse telephone triage lack meaningful evidence that they are reliable or valid. Other telephone triage CDSS are confusing, complicated and unsystematic. Many CDSS designs are too unwieldy for research purposes making it difficult to demonstrate that a given CDSS qualifies as evidence-based medicine (EBM). In general, inadequately tested CDSS may actually interfere with the decision making process (Wachter, 2017).
CDSS designs must be elegant, transparent, user-friendly and seamless. However, guard rails are essential for this emerging subspecialty. Meaningful research on the safety of incorporating advanced technologies into current CDSS is urgently needed.
Generative AI, predictive analytics, advanced EMRs and biotechnology will be standard components of teletriage in the near future. These powerful technologies, require a system within which to operate. Formal subspecialties typically require a system composed of specialized clinical training, clinical practice standards, requirements for experienced, trained clinical decision makers and reasonably safe CDSS and EMR (verified by EBM).
The ultimate CDSS will utilize data from generative AI, Predictive Analytics, and relevant EHR data. Later, data from Biotelemetry and Patient Wearables will augment the process of assessment and decisionmaking. Machine learning and planned error recovery will enhance safety and continuous quality improvement. Reduced uncertainty and feedback will enhance clinician job satisfaction.
A Universal Guideline with embedded standardized components — structure and process — will serve as a virtual History and Physical (H & P). Relevant patient “back story” or history (the EMR) - provide context. Essential assessment questions provide data about the chief complaint. AI and predictive analytics supplant the expert physician advisor at the clinician’s side — supporting, reminding and prompting with additional questions. AI/PA can suggest an estimated symptom urgency level - a triage disposition. This remote High-tech H & P — structure, process, outcome — will be transparent, standardized, valid and reliable.
“Improved Systems improve safety” Giesen et al., (2011), Annals of Medicine
“If you fail to plan; plan to fail” (IOM)
Does your institution or facility have a formal system? Or is it just “bits and pieces”? The Institute of Medicine defines system error as “failure to use a plan; using the wrong plan; or failure of planned action to be completed as intended”. Institute of Medicine, 2000. [PubMed]
CERNO…..I Perceive - -
Discern – Distinguish – Sift – Separate - Bear in Mind – Reckon – Determine – Resolve – Contend - Decide