LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Define telephone triage, its participants, and its settings.
• Describe best practice as it relates to telephone triage.
• Discuss current controversies in telephone triage.
• Identify common pitfalls in telephone triage.
• List the elements of real-world decision making in telephone triage.
• Summarize the essential aspects of good communication.
• Explain how the telephone triage process is related to the nursing process.
• Define red flags, rules of thumb, and red herrings.
• Describe three systems for rapid identification of high-risk patients or symptoms.

Telephone triage is commonly defined as the safe, effective, and appropriate disposition of health-related problems by trained RNs using guidelines or protocols (Wheeler, 1993). As a new subspecialty, there is still controversy about terminology. For example, some nurses refer to telephone triage as telephone advice and consider themselves "advice nurses," whereas other nurses use the words telepractice or telehealth. Telephone triage interactions generally requires assessment, patient education, and crisis intervention.

For the purposes of this course, telephone triage is defined as the interaction between patient and nurse that takes place exclusively by telephone. Thus, we will not address such topics as telemedicine or telehealth. The focus is on symptom-based calls rather than message taking. While message taking is a current practice in some settings, most state boards of nursing support using a professional nurse as an active participant in decision making. The message-taking role is more appropriately relegated to unlicensed assistive personnel.

Telephone triage does not involve making diagnoses—nursing or medical—by phone. Telenurses do not diagnose but rather collect sufficient data related to the presenting problem and medical history, match the symptom pattern to the protocol, and assign acuity, thereby providing for a safe, timely disposition. Telephone triage aids in getting the patient to the right level of care with the right provider in the right place at the right time (AAACN, 2007).

THE CALLERS

Over the last thirty years, researchers have identified predictable caller populations (eg., by gender, age), call patterns, and peak call periods. Armed with this knowledge, staff in offices, HMOs, and emergency departments need to be prepared with specialized training and protocols and staffing must be adequate for predictable high-volume periods.

Not surprisingly, frequent callers are often in high-risk age groups: the very young, the very old, and women of childbearing age. In internal medicine, women called twice as often as men. The percentage of calls made about children less than 4 years of age tends to be disproportionately large compared to the number of children in a given pediatric practice.

Research consistently identifies older adults as relatively frequent callers. In internal medicine practices, researchers found that clients over 65 constituted 29.3% of those receiving telephone care, the largest proportion when compared to other age categories.

Call Patterns

In family practice settings, peak calling time was between 10 a.m. and noon, with the majority of calls occur Monday through Friday. Of those coming in during the week, there is a pattern of late afternoon calls during the week in a family practice setting. Researchers theorize that clients become aware of their own symptoms after the demands of work are finished. When calling about their children, parents notice that the children are not well when they are reunited with them after work. In both the ED and office settings there is a substantial volume of calls on weekends, holidays, and after hours, when offices are closed and access to healthcare is limited. Half of all after-hours calls in a family practice occurred on weekends.

Call Motivations

Not surprisingly, in the primary care setting a few complaints make up the bulk of calls. Most common were upper respiratory infections (URIs), fever, gastrointestinal (GI) problems, viral infections, minor trauma, back pain, anxiety, otitis, and urinary infections. In pediatric practice settings, 85% of the calls are about respiratory problems, fever, GI problems, skin and infectious diseases, and trauma. Thus, about 25 common complaints made up 80% of calls in primary care settings. In the ED, the top presenting problem categories (44% of the total) were GI, respiratory, OB/GYN, and trauma.

Patients value the care that they receive. In fact, one study showed that they felt that reassurance was more important than the relief of symptoms (Wheeler, 1993). Clearly, reassurance and thoughtful attention to client concerns, whether medical, informational, or even administrative, meets patients' needs and satisfies them. Telephone encounters, if handled sensitively, can reduce inappropriate appointments, reduce anxiety, educate clients, and increase client satisfaction levels as well as reducing risk when there are medical complications.

THE TELENURSE

Patricia Benner (1984) first defined nursing expertise in From Novice to Expert. Through her research she identified key domains of nursing expertise; with minor modifications, most of these domains apply directly to telepractice:

• The helping function. In telephone triage, the key functions of the helping role are creating a healing relationship through (1) attending to (listening) or "presencing" (i.e., being present), (2) maximizing clients' control, and (3) providing comfort through the voice (rather than touch).
• The diagnostic function. Strictly speaking, telephone triage is not intended to provide diagnoses. However, within limits, nurses can detect and document significant changes in the client's condition, perform pattern recognition and matching, anticipate problems, and formulate treatment strategies.
• The crisis intervention function. Nowhere else is the "instant grasp of rapidly changing situations" (Benner, 1984) more vital than in crisis intervention by phone. Telenurses are often inadvertently cast in the role of first responder as they field calls regarding imminent births, trauma, suicide, and ingestions. Not all communities have fully developed 911, suicide prevention, or rape crisis hotline systems.
• The monitoring function. Currently, most telenurses advise and monitor simple home treatment interventions and instruct clients in self-evaluation. In the future, the newly emerging area of disease management will make telemonitoring a standard function of telepractice. As technology and the field of telehealth continue to grow and expand, the trend toward telemonitoring will grow, allowing more clients to be treated at home.

BEST PRACTICES

Best practices are defined as the most efficient and effective ways of accomplishing a task while achieving the best results. Best practices are based on repeatable procedures that have proven themselves with large numbers of people over time. The concept of best practices derives from the belief that proper processes, checks, and testing can produce a desired result with fewer problems and unforeseen complications. Best practice is the assertion that there is a technique, method, process, or activity that is more effective at delivering a particular outcome.

In the world of telephone triage, best practices translates to employing the best human elements (staff), utilizing the best critical thinking strategies and processes (nursing process), and using the best tools (standards-based protocols and forms). Thus, best practice depends on adequate numbers of experienced, qualified staff with solid communication skills, both written and spoken. Several developments in the field of nursing and medical decision making have brought telephone triage to this level of development.

In the mid 1970s, numerous researchers identified key assessment failures. This led to the development of methodologies to help ensure adequate data collection (Wheeler, 1993). The nursing process—a proven problem-solving methodology utilized by nurses for more than 30 years—was incorporated into telephone triage practice. Earlier we noted that Patricia Benner (1984) pioneered in identifying the characteristics of the expert nurse. Later, medical decision researchers identified methodologies that expert nurses utilize to make telephone triage decisions, including rules of thumb, context, and pattern recognition (Lephrohon & Patel, 1995). This research prompted leaders to design better training programs and protocols.

Currently, the Institute of Medicine (IOM) is focused on reducing medical error. The IOM sees healthcare as a system comparable to the airline industry (Langweische, 1998). Through research and policy development, the IOM seeks to reduce system error (IOM, 1999). Systems, combinations of related elements organized into a complex whole, are the next level of best practice. Telephone triage programs are systems with integrated elements—staff, training, protocols, documentation forms and standards—that work together to provide safe, timely delivery of care or access to care.

Researchers have not yet determined which protocol system is best; however, it is safe to assume that protocols and forms based on the nursing process and related research, with built-in fail safe systems, offer the best decision making support for telenurses. In addition, to the degree that protocols are standards-based, they can reduce ever-present risks related to decision making errors. Wheeler (2005) has adapted standards for telephone triage protocols, based on those developed by IOM, for decision support systems:

• Validity. If followed, it will lead to expected outcomes.
• Reliability/reproducibility. Given the same data, other groups of nurses would produce the same results.
• Clinical applicability. Explicitly states the populations to which they apply.
• Flexibility. User's guide with complete operating instructions, including underlying assumptions and exceptions to recommendations.
• Clarity/user friendliness. Written in unambiguous language, using precisely defined terms in an easy to follow mode of presentation. (Wheeler, 2005)

Minimal best practices for protocols include an annual review and updates, comprehensive coverage of presenting problems, and integrated forms. This course does not claim to be the final word; it is a basic rather than a definitive treatment of best practices in telephone triage. It presents key elements of best practices with examples related to each.

PRACTICE SETTINGS

Currently formal telephone triage is practiced in three major settings: health maintenance organizations (HMOs), office and group practices, and emergency departments (EDs). Occasionally, telenurses encounter crisis-level calls, such as ingestions, domestic abuse, rape, cardiopulmonary resuscitation (CPR) coaching, or threatened suicide. In many communities, nonmedical personnel with specialized training staff crisis lines such as poison prevention, rape crisis, and suicide prevention, and customarily manage such calls. Finally, 911 medical dispatchers perform high-level telephone triage and coach callers in first-aid treatment, CPR, and the Heimlich maneuver until paramedics arrive.

Managed Care Call Centers

In the 1970s, HMOs recognized telephone triage as a separate subspecialty. Since then protocols, training, and standards have, generally speaking, kept pace with technological advances. When high standards are maintained, telephone triage in the HMO setting is a successful, highly appreciated, and integral part of the larger system. HMO call volume can be extremely high, making the work stressful. Telenurses usually have electronic protocols and access to patient demographic information via an electronic medical record (EMR) on which to rely. Typically, demographic information includes previous medications, medical history, and dates of recent visits. The EMR software program creates a paper trail, enables managers to track and trend calls, and creates statistics on call volume, types of calls, and individual staff workflow and dispositions.

Offices and Emergency Departments

Generally speaking, HMO call centers are larger and better organized than most small offices, group practices, and ED systems. In HMOs, electronic protocols are provided, as are formal training programs and standards. Office and ED practices can vary widely in standards and protocol availability. Most offices use paper protocols and pen-and-paper documentation. Training may be on-the-job.

Even when taking calls about high-acuity problems, the traditional sphere of ED activity, the average ED lacks standards and training programs. While emergency nurses openly acknowledge telephone triage as an expanded role, there has been resistance on the part of administrators to formalizing the practice—perhaps due to fear of liability. However, when surveyed informally, many ED nurses admit to performing telephone triage even in the face of administration directives forbidding it. Most ED nurses are torn between providing by phone what they consider reasonable and prudent care despite the legal consequences, and not providing care at all.

Crisis Lines

Obvious examples of crisis intervention lines are poison prevention, suicide prevention, rape crisis, and 911. Emergency medical dispatchers (EMDs) are nonmedical personnel or paramedics who respond to 911 calls for ambulance, fire, or police. They assess by phone the need for emergency service and are responsible for dispatching medical rescue vehicles to victims. Most medical dispatchers are high school graduates, two-thirds are female, and most have no previous medical training. In the late 1970s, physician Jeff Clawson created a 40-hour training program for EMDs that covered coaching techniques for a range of commonly encountered crisis-level medical problems (Clawson & Dernocoeur, 2004).

RISK MANAGEMENT

In the current managed-care environment, which seeks to contain costs by reducing inappropriate ED (with paramedic transport) and office visits, telenurses are sometimes forced to act as gatekeepers. As a result, nurses and receptionists may unwittingly be caught in a bureaucratic trap. With the nurse or the physician, two specific risk management issues—delay and denial of care—can haunt every decision made. That is because telenurses provide access to appointments and entry to the ED. Delays or denial of care can result in harm to the patient. In the following case, delay in getting an infant to the nearest ED had tragic consequences.

Patients themselves may contribute to delays through their own reluctance to call 911. A recent study found that people who are charged for emergency services were less likely to call 911. In the study, researchers found that although 89% of people surveyed said they would use EMS services to go to the hospital, only 23% of patients arrive by ambulance (Brown et al., 2000). The following case illustrates this.

The telenurse must focus on how to ensure patients' timely access to emergency services rather than who will pay for paramedics. The nurse should always be alert to the possibility of patients' concern with payment issues. This issue may be a "hidden agenda," leading the caller to minimize symptoms in order to avoid incurring the costs associated with paramedic transport. Detailed written policies and procedures should clearly address the access issue and the correct procedure to follow.

Bureaucratic obstacles can be subtle. While a high volume of malpractice claims from traditionally high-risk populations (pediatrics, geriatrics, and women of childbearing age) have not changed, what has changed is that many claims from high-risk populations are now related to lack of timely access to specialists. Due to cost-containment strategies, callers often need to be screened by their primary-care provider prior to seeing a specialist. This policy may dangerously delay access to the patient's OB/GYN, pediatrician, internist, or oncologist.

CURRENT CONTROVERSIES

Who Is Qualified?

A hotly debated issue centers on who should perform telephone triage. Should it be a physician, a nurse practitioner, an RN, an LVN, or a receptionist? Physician Barton Schmitt, a pioneer in telephone triage, suggests a good rule of thumb might be to use "the lowest paid person who can safely do the job" (Schmitt, 2004). In may cases the RN may be best suited to this role. Sample job qualifications for telephone triage are presented below.

Employing secretaries, unlicensed assistive personnel (UAPs), LVNs, and LPNs to manage calls prompts several questions: How much legal risk is there? Are they qualified? Can physicians or nurses delegate the important task of telephone triage to them? Can unlicensed personnel perform limited telephone triage with a "list of emergent symptoms" or some kind of abbreviated protocols? In the managed-care environment (with a goal of managing patient access and demand), could even appointment making, without an initial assessment, be a form of unacknowledged triage and thereby an exposure to risk?

Most experts agree that using UAPs to perform telephone triage is risky (Mahlmeister, 2005; Smith, 2005). It is one of the most problematic issues confronting telephone triage. This is controversial because it is still an ill-advised but not unusual practice in small offices and group settings. Moreover, some employers don't distinguish between skills required for message taking and appointment making and symptom assessment or providing advice. The following case studies demonstrate how important these distinctions are.

In the following case, the patient volunteered no symptoms; indeed, he may not have experienced anything that he would consider a symptom. Especially with older adults, symptoms may be subtle or even silent. Perhaps, in this patient's mind, he was simply calling to talk to his doctor, a trusted caretaker, about the fact that he had been feeling tired. Perhaps he wanted to discuss with his doctor whether he needed an appointment.

Well-meaning but misguided patients often mislabel their own symptoms and attempt to decide for themselves when they need to be seen (appropriately or inappropriately). They may base decisions on what is convenient or reasonable for them. This practice compounds the possibility of triage error, underscoring the need for RNs to elicit symptoms prior to appointment giving. Establishing a policy that all symptom-based calls should be triaged by the RN may seem overly zealous but may actually help systems to run more efficiently and safely.

Protocols vs. Professional Judgment

An ongoing area of confusion and controversy revolves around whether the protocols or the professional judgment is the ultimate bottom line. In other words, what determines the correct disposition, protocols or professionals? While protocols are an important component of the telephone triage system, the bottom line is the experienced, well-trained RN. Current standards of practice stress that RNs should perform the decision making because protocols alone cannot guarantee safe practice (Brillman et al., 2003).

For years, this controversy has gone unresolved. If the premise that protocols are the bottom line is true then the nurse doesn't really matter. Professional decision makers become irrelevant, the next step being to simply do away with training and standards and replace them with protocols operated by "medical technicians." In fact, one expert maintains that information technology can potentially transform nurses from active decision makers into passive "system operators." Some experts suggest that protocols may actually interfere with critical thinking at times (Gladwell, 2005).

Managers should be aware of the risks of relying on protocols to take the place of formal instruction. Over-reliance on the tool can lead to errors in triage. Training for critical thinking in history taking, communications, assessment, and decision making is key to safe practice. Potential problems can be averted through instruction in the correct and safe operation of the protocols and documentation form. Such instruction also prevents "protocol bias," which develops when RNs who have been using one type of protocol must begin using a new one.

Computers are—and always will be—essential to telephone triage as the workhorses for tracking and trending. However, if protocols are given too significant a role, nurses may become passive. What is required is a balance between nursing judgment and protocol. This controversy actually affects the area of protocol design. Are protocols decision making or decision support tools?

Protocols: Decision Making or Decision Support?

Some designers believe nurses should use protocols based on strict algorithms, which tend to be unworkable in the real world of telephone triage. Others see the RN as the true decision maker, with the protocols serving as a decision support tool. Decision making systems allow a possibly unqualified person to make a decision that is beyond the level of training and experience. Decision support systems remind an experienced decision maker of information once known but possibly forgotten. The examples presented here are based on a decision support approach.

Decision making tools are designed to be followed rigidly by answering yes or no to decision tree questions, in order to get to the final disposition. This approach is based on black-and-white thinking, or binary code, which assumes that the information received is both accurate and sufficient in quantity and quality to solve problems.

The decision support tool is based on pattern recognition, encouraging the RN to use critical thinking skills, context, and pattern matching to come to a disposition. This approach mimics the way the brain solves problems by presenting the user with patterns to match with the patient's presentation.

To prevent medical error, tools must meet standards for reliability. In telephone triage, that means the system (protocols, forms, training, standards) has been structured to reduce the prospect of failure, regardless of environmental factors. For example, the protocol and documentations form should be integrated and include built-in fail-safe requirements to follow the nursing process steps and force users to collect adequate amounts of key information (age, allergies, previous medical history and medications, problem, and patient history). This feature forces the practitioner to meet clear-cut standards.

COMMON PITFALLS

For more than thirty years, researchers have continued to identify common pitfalls in telephone triage practice. The most common of these pitfalls include inadequate talk time, insufficient history taking and documentation, stereotyping of clients and problems, second guessing or over-reliance on callers, premature closure, and improper use of or failure to use protocols.

Stereotyping of callers can be avoided by obtaining the age, gender, and medical history. It is easy to mistake the caller's gender or age from the voice. Nurses can avoid stereotyping symptom patterns by careful and sensitive assessment of problem and patient history, and by taking care not to jump to conclusions. For example, burning on urination in an older female cannot simply be dismissed as a urinary tract infection; it may be symptomatic of a sexually transmitted disease. By the same token, the nurse who assesses a teenage girl who complains of abdominal pain without exploring the prospect of sexual activity, unprotected sex, and possible pregnancy, runs the risk of potential delay in care.

Second-guessing is often referred to as the You're Not Sick Until I Say You Are syndrome. Telenurses must avoid making erroneous assumptions by either over-investing in the caller's assessment or being dismissive of the caller's concerns. Callers who claim that the problem is an emergency may have correctly assessed the situation and telenurses should take them seriously.

On the other hand, the caller who has self-diagnosed a problem may lull the nurse into a false sense of security. For example, the caller who begins by saying: "My new medication makes me feel dizzy" or "I was carrying some logs and now my shoulder really hurts" or "I think I have the flu" may have seriously misrepresented the problem. The initial patient description must be set aside while the nurse elicits more details. You cannot simply assume that symptoms are a result of a medication, musculoskeletal injury, or the flu. Those complaints could be related to conditions like stroke, myocardial infarction, or sepsis, for example.

Assuming that the protocols are well designed and ample in number, there are several ways in which the nurse can misuse them: (1) fail to use the protocol, (2) use the wrong protocol, or (3) use the protocol improperly. Failure to use protocols is obviously risky, but easily occurs when the nurse finds that no protocol seems to apply to the presenting problem. This is commonly referred to as the Out of Protocol experience.

Failing to collect enough information can lead to selecting the wrong protocol. This was named the Wrong Train syndrome by Dernecoeur and Clawson (1999), who state, "If you get on the wrong track at the station, no matter how fast you travel, you still end up in the wrong place." Nurses may choose the correct protocol but fail to follow it correctly, by choosing the wrong disposition. This can be remedied through protocol competency training and comprehensive user's guide instructions.

REAL WORLD DECISION MAKING

In the mid 1990s, researchers first described telephone triage as "decision making under conditions of uncertainty and urgency." Lephrohon and Patel's research (1995) on RN decision making in an emergency department focused on how experienced nurses make real-world decisions in telephone triage. They discovered that the nurses used pattern recognition, rules of thumb, and context as major strategies to make decisions. Ideally, the strategies of pattern recognition, rules of thumb, and context can be incorporated into training, protocols, and forms in order to mimic the way the brain naturally solves problems in real-world situations.

Lephrohon and Patel (1995) pointed out that the uncertainty is due to decisions based on partial or inaccurate information and urgency is based on the fact that telephone triage is a high-stakes activity with calls being processed in an average of 7 to 10 minutes.

Patients are complex and symptom presentations may be ill structured, novel and variable. Thus, we need protocols and documentation forms that foster a contextual approach to problem solving. Pattern recognition approaches are similarly complex, yet flexible, while at the same time providing firm support for decisions.

Enhancing Intuition

Researchers have paid a lot of attention to the role of intuition in decision making. They maintain that intuition can be developed, and offer a variety of suggestions. Gary Klein, in Intuition at Work (2003), advises learning to detect problems through emotional cues, that gut feeling when something isn't right. He recommends developing an active stance, so that if something doesn't make sense, it acts as an alarm that is not to be dismissed. Also, become aware of organizational barriers such as rigid procedures or institutionalized inertia. Finally, reframe the situation and don't be afraid to consult with colleagues to review with fresh eyes.

Malcolm Gladwell, author of Blink (2005), says that good decision making relies on a balance of conscious and instinctive thinking. He states that reducing complex problems to their simplest elements aids in decision making. Gladwell warns that too much information can paralyze the unconscious. Remember to keep it simple.

Rosalinda Alfaro-Le Fevre, in Applying the Nursing Process: A Tool for Critical Thinking (2006), recommends improving critical thinking skills by avoiding behaviors such as stereotyping others, resisting change, and seeking conformity. In addition, she suggests reducing barriers to intuition: anxiety, stress, and fatigue, lack of time, feeling judged, and environmental distractions.

Managing Uncertainty

In the beginners mind, there are many possibilities. In the expert's mind there are few.
—SHUNRYU SUZUK, Zen Mind, Beginner's Mind, 2005

In telehealth, critical thinking involves decision making under conditions of uncertainty and urgency. The task is made more complex by sensory deprivation, conflicting goals (call quotas vs. quality interactions), "noise" (irrelevant data, long-winded histories), and multitasking (thinking, listening/talking/questioning, reading, writing, synthesizing information, pattern recognition). The nurse must focus on what is most salient—the meaningful bits of information—and identify patterns to form reasonable working diagnoses. Finally, many of the problems presented by phone are, by their very nature, complex or novel, making critical thinking very difficult. Telehealth nursing is considered a high-stress activity due to its fast pace and potential for crisis-level calls, both of which can interfere with critical thinking. "Under time pressure, people use less information to make decisions, which are often suboptimal" (Lephrohon & Patel, 1995).

Whether known as critical thinking, intuition, or pattern recognition, this mental skill is the core activity of telephone practice. In order to flourish, intuition and pattern recognition require a supportive environment. Working short staffed in a high-volume, noisy environment, without protocols, training, or documentation, will only heighten stress and uncertainty, thereby diminishing intuitive skills. On the other hand, a quiet, moderate call-volume environment with adequate numbers of qualified, experienced, and trained staff who are equipped with guidelines or protocols and documentation forms reduces uncertainty and supports intuition. Written standards are highly desirable as well.

As researchers on decision making point out, human beings tolerate ambiguity differently. Uncertainty adds stress, thereby negatively affecting the ability to make decisions. In the future, managers may use psychological testing to screen prospective staff for tolerance of ambiguity, selecting the best and most stress-resilient decision makers.

Identifying Red Herrings

Salience is defined as being particularly noticeable, striking, or relevant (Merriam-Webster, 2004). A major task in telepractice is to determine what data are relevant and which are not. Data must be collected, considered, weighed and even ignored in order to perform pattern recognition and arrive at proper disposition; for example, key pieces of contextual information—age, gender, previous medical history—are always salient. While key symptoms may be salient, others that are more general and nonspecific may be given less weight.

There will be information that is irrelevant and must be consciously ignored in order to come to safe decisions. Such data might be called red herrings; they are distracters. Red herrings can originate with the patient or the nurse. The patient may deny or misinterpret symptoms; they might miscommunicate. Nurses may be overly focused on a given procedure or policy (cost, for example), thus missing the point of the call (timely access).

Red herrings may also result from the nurse's misinterpretation of symptoms or patient history. For example, a patient who was "seen recently in the ED" may be experiencing new symptoms, which the nurse must re-evaluate. A patient who is "on an antibiotic" should not lull the nurse into complacency; Methicillin-resistant Staphylococcus aureus (commonly known as MRSA, pronounced mersa) may be the culprit. Finally, a post-operative patient complains of severe pain; while you might expect pain following surgery, you need to evaluate any pain carefully that is not well managed by the prescribed analgesic, or is unusual in nature. Red herrings may cause the nurse to jump to conclusions, to stereotype, or to end the call prematurely.

Another useful rule for avoiding red herrings is to "beware the developing disease." Do not be misled by initial presentations that seem nonacute. What starts out as vague abdominal pain with low-grade fever may quickly develop into the classic picture of appendicitis. Follow-up calls should be mandatory for possible developing diseases, and especially for: abdominal pain, respiratory problems, diarrhea, nausea and vomiting, fever, or marked change in activities of daily living (ADLs).

Employing Rules of Thumb

A rule of thumb is a way of proceeding based on experience and sound judgment. Rules of thumb provide a practical method that can generally be relied upon for an acceptable result. Gary Klein, an expert in medical decision-making, studied groups of ICU nurses, firefighters, and others who make decisions under pressure (Klein, 2003). He discovered that when these experts make decisions, they don't logically and systematically compare all available options. In real life that methodology is too slow. Experts quickly size up situations and act, drawing on experience and intuition. Rules of thumb often underlie the expertise and intuition.

The following sections present rules of thumb that represent experts' collective "pearls" of wisdom in telephone triage. They are a body of knowledge that every telenurse should commit to memory. Through study and integration of these rules, novice practitioners can improve their decision-making proficiency and efficiency. This is not exhaustive; add your own "pearls" as appropriate.

CARDINAL RULES OF TELEPHONE TRIAGE

These rules are enhanced by two contributions from Clawson (1998):

• Always err on the side of caution.
• When in doubt, send 'em out! (Clawson, 1998).
• Beware the middle-of-the-night call.
• Be alert to possible atypical, silent, or novel presentation.
• Serious symptoms may present as a single symptom or a complex of symptoms.
• Always speak directly with the client when possible.
• Assume the worst until proven differently.
• Make corrections for your own fallibility.
• The more vague the symptoms the greater the need for good data collection.
• Speed does not equal competence; avoid premature closure.
• Never abandon the caller in crisis.
• Temperature extremes often trigger medical problems (Clawson, 1998).
• All severe pain should be seen urgently.
• Several calls in a short period of time may be an indicator of acuity.
• Beware the developing disease.

AGE-BASED RULES OF THUMB

Age is a major feature in many rules of thumb. In fact, extremes of age can markedly affect the immune response as well as the ability to regulate body temperature, as illustrated by these two key rules of thumb:

• The older (younger) the patient, the greater the risk of hypo- or hyperthermia.
• Assess all sick children and older adults for dehydration or sepsis.

INFANTS AND CHILDREN

• Kids get sicker quicker.
• To avoid night calls, visits, and crises—give day appointments.
• Neonates are at increased risk for overwhelming infection due to prematurity, traumatic delivery, maternal illness, or neonatal stress.
• All confusion in children is considered emergent.
• Always err on the side of caution with children, especially with infants and toddlers.
• Pediatric populations are at greater risk for hypothermia and hyperthermia.
• Under 4 yrs: symptoms tend to be very generalized; over 4 yrs: symptoms tend to be more specific.
• Infants < 3 months with fever of 38°C or 100.4°F—see immediately
• All parents have the potential to abuse their children physically at some time.
• Assume any symptom of STDs (discharge, lesions) in a child to be sexual abuse until proven otherwise.
• Always elicit an immunization history; lack of, or inadequate, immunizations place a child at risk.
• Assess all children with unexplained symptoms for possible unintentional or purposeful ingestion/exposure to toxins, inhalants, and street or prescription drugs.
• Any teenager who is depressed is at risk for suicide.

Teenagers are especially vulnerable to depression and suicide due to several factors: easy access to alcohol and drugs; increased sexual activity; complex societal demands; negative role models; and increased family disruption. The precipitating factor may be: a loss or betrayal of trust; romantic break-up; failure in school or sports; move to a new neighborhood; peer pressures; conflict regarding dependence and independence; poverty; unwanted pregnancy; sexual problems, rape, incest, sexual dysfunction, gender identity problems; peer- or media-emphasized suicide; treatment for mental illness; and/or any legal problems.

OLDER ADULTS

• Symptoms in older adults may be atypical, silent, or late (eg., the patient may interpret fatigue merely as a symptom of pneumonia or infection).
• All sudden confusion in older adults is considered emergent.
• Assess all older adults for dehydration status.
• Older adults are at risk for adverse drug reactions (ADRs). The greater the number of drugs, the greater the incidence of ADRs. Moreover, as the number of daily doses increases, compliance may decrease.
• Assess all older adults with unexplained symptoms for ADRs, "chemical restraints," or possible ingestion (intentional or accidental). Exposures may be due to toxins, alcohol, or overmedication with prescription or OTC medications.
• Older adults may be poor or forgetful historians. Err on the side of caution.
• Elderly white, retired widowers are at highest risk for completed suicide.

SYMPTOM-BASED RULES OF THUMB

Symptom-based rules of thumb include the following:

• Once an ectopic, always an ectopic.
• Any bleeding in pregnancy is considered an ectopic until proven otherwise.
• All severe pain must be seen within 8 hours or less.
• Beware of any pain that awakens the patient or prevents sleep at night.
• Epigastric pain in males >35 and females >45 is considered an MI until proven otherwise (Clawson, 1998).
• Any pain between the navel and the nose is chest pain until proven differently.
• All first-time seizures must be seen.
• All rashes are contagious until proven otherwise.

TRAUMA BASED RULES OF THUMB

Trauma-based rules of thumb include the following:

• Never remove impaled objects.
• With face or jaw trauma, always check for head injury.
• All breaks in skin made by human teeth are presumed to be human bite.
• All snakes are considered poisonous until proven otherwise.
• All chemical and electrical burns are potentially worse than they appear initially.
• Always be alert to unwitnessed accidents and to mechanism of injury (major trauma: MVA, falls >15 ft, blunt trauma).
• Question carefully caretakers' assessments of trauma. They may focus on a minor problem (avulsed tooth) and miss a more serious one (head injury).
• Trauma with suspicious history = possible abuse.

THE EIGHT E's OF MYOCARDIAL INFARCTION

Always be aware of the eight E's of myocardial infarction. They are extremes of:

• Emotion
• Exertion
• Environment (weather)
• Eating
• Era (age)
• Epigastric distress
• Essential hypertension
• Early morning

GOOD COMMUNICATION

All successful nursing care hinges upon communication. In telephone triage, the challenge is to push the limits of what is possible and unique to this specialty. The manner of communication is as important as what is communicated. Nurses must inspire, negotiate, persuade, and engender trust. "Telecharisma" is the personal magic characteristic of telenurses' resourcefulness, expertise, and innovative communications. From the first words of greeting, and from the way the nurse listens, responds, and asks questions, they demonstrate the warmth, caring, and trustworthiness that we identify as charisma.

Successful communication requires a sender, a message, a mechanism, and a receiver. For the message to be complete, information usually has to flow in both directions. Experts have found that too little or too much information impairs critical thinking and diminishes the chances of the message being received and understood. The prospect of too little information is increased due to lack of sensory input and information. Thus, because the "signal" is weak, barriers that in person are not very formidable can become nearly insurmountable. Messages may be impaired by lack of trust, or by unexplored feelings, needs, and biases. Clients' and nurses' beliefs, attitudes, and perceptions of symptoms become obstacles in themselves.

In telephone triage practice, nurses can facilitate communications by closely attending to and receiving messages, clarifying or asking for detail, reflecting, and paraphrasing to check accuracy. At the bedside, speech, smell, touch, sight, and emotional cues paint a rich picture of the client's condition, while, on the phone, communications are limited to verbal and emotional cues. The risk of miscommunication is great. Although it is possible to gain limited tactile and visual information gathered by proxy from callers, nurses receive, analyze, solve problems, and instruct without observing the client. However, careful communications require adequate time.

If the nurse appears "time driven," offers few explanations, and makes no attempt to build rapport with the caller, the risk of communications breakdown is greatly increased. Some callers, dissatisfied with the brevity of the call and lack of emotional support, will fail to follow the nurse's advice. The sections below offer three best practices to enhance critical thinking: adequate time, open-ended questions, and speaking directly to the patient.

Allow Enough Time

When it comes to "talk time" in telephone triage, there are no short cuts. Ineffective communication leads to increased legal liability and risks substandard client care. Adequate time enhances decision making and critical thinking. A landmark study from the New England Journal of Medicine compares performances of pediatric nurse practitioners with pediatricians (Perrin & Goodman, 1978). The authors discovered that pediatric nurse practitioners performed as well as or better than physicians in telephone triage. The nurse practitioners were judged to be warmer and more open to questions and left callers feeling more satisfied. They spent significantly more time per call than physicians (MDs, 3 to 5 minutes; RNs, 5 to 7 minutes). Perrin and Goodman consider that the additional minutes reflected an investment in client education, not inefficiency. Current standards have raised this time frame to 7 to 10 minutes or more, depending upon the type of call and caller.

Use Open-Ended Questions

Open-ended questions provide for better and more reliable data gathering by encouraging the clients to perform the work of describing symptoms. Asking leading questions—a flawed technique often related to being time-driven—simply elicits yes or no answers, thereby yielding faulty data. Resist using leading questions, which cloud the picture by providing the answer in the question. For example: Is the pain severe? Are you having bloody stools? Are you having difficulty breathing? usually elicit yes or no answers. Open-ended questions—Describe the pain, What are the stools like? Tell me about your breathing—eliminate yes or no responses. Always start data collection with open-ended questions.

There are several exceptions to the policy of utilizing open-ended questioning. Exceptions include crisis-level calls and calls from children, frail elders, and poor historians. In such instances, use facilitative questions such as: Is the pain better, worse, or the same as it was yesterday? Is the bleeding dark red or light red? This is a compromise between open-ended and leading approaches that may still yield better data than leading questions.

With the crisis intervention call, where decisions must be made within seconds, leading questions are appropriate. Appropriate questions would be: Is the victim conscious? Breathing? When an immediate disposition is imperative, open-ended questions are too time-consuming.

Speak Directly with the Patient

Many pitfalls can be avoided by talking directly to the patient wherever possible, although with children under the age of 8 years, some older callers, or poor historians, this may not be feasible. Many calls are mis-triaged by not taking the extra effort to speak directly with the client. This strategy will not only improve the quality of information collected, fostering trust and compliance, but it can also expedite the call.

TELETRIAGE AND THE NURSING PROCESS

Critical thinking skills and a systematic approach can remedy the pitfalls just described. The system described "next" acts as a safety net for the telenurse. Another way to envision the system is as "layers of safety," a phrase developed by an attorney, in relation to telephone triage practice:

• Identify what is salient and ignore what is not.
• Apply rules of thumb as a rapid method to make decisions.
• Apply "red flags" to rapidly identify high-risk problems or populations.
• Employ consistent, comprehensive data-collection strategies.
• Use the nursing process, modified for telephone triage.
• Use a documentation form with nursing process embedded.
• Utilize a generic protocol with embedded nursing process.

In telephone triage the four steps of the nursing process—assessment, diagnosis, planning/intervention, and evaluation—are modified slightly. Assessment is the most important and substantive step of telephone triage; pattern recognition is dependent upon the systematic and continuous collection of data. Nursing diagnosis becomes the provisional (or working) diagnosis in telephone triage. This step requires interpreting and analyzing patient data; identifying patient resources, and formulating a working diagnosis.

Planning/intervention involves utilizing the protocol of pattern recognition and matching. Patterns are classified according to disposition of emergent, urgent, acute and nonacute diagnoses; the nurse prevents, reduces, or resolves problems identified by adhering to the protocol disposition and directives. Evaluation becomes patient self-evaluation, wherein the nurse instructs the caller in home care and how to monitor symptoms. The nurse may also monitor progress and self-care activities via follow-up calls to determine if home treatment is sufficient or if upgrading is needed.

Assessment

To determine the right disposition, the nurse must explore the context by building a picture or pattern. The process, then, is to ask enough of the right questions, in the right way to elicit enough of the right data, and to choose the right protocol(s) and right disposition. Assessment often begins with a cursory or global approach.

A GLOBAL APPROACH

Some problems require more thorough questioning, and RNs thus pursue data collection to a greater degree. For example, in the case of chest pain, the nurse quickly elicit the large chunks of information (age, gender, symptoms) and makes a decision. In other cases, such as vague abdominal pain, the nurse may spend more time gathering quantities of detailed information. Problems arise when a protocol design (or a professional) fails to offer options for rapid prioritizing.

Red Flag Populations and Symptoms

The telephone triage process should begin with a rapid prioritization to determine callers who urgently need appointments. Expert nurses quickly build a picture through gathering key chunks of information: the patient's age, gender, chief complaint, literacy or language level, emotional state (determined via the words, tone, pacing of voice), and, sometimes, previous medical history. This key contextual information can quickly identify high-risk patient or problems. This process, while appearing superficial, yields valuable information and often takes as little as 60 seconds.

Research has identified several broad categories of high-risk patients and symptoms. These groups are signified by the acronym SAVED:

• SSevere, strange, or suspicious symptoms
• AAge
• VVeracity problems
• EEmotional distress
• DDebilitation and distance

These five categories are also known as red flags. Red flags help all practitioners to function more effectively. Listed below are examples illustrating each category

Severe, strange, or suspicious symptoms. Patel notes that "it is easier to identify an emergency than to rule one out" (Lephrohon & Patel, 1995). Severe pain (9 on scale of 10), severe bleeding (spurting, bright red) or severe trauma (falls from a height over 15 feet) are conditions that the average layperson could identify as urgent. Strange symptoms include ill-structured, vague, atypical, or unusual presentations, symptoms that only astute professionals might recognize as urgent. Sudden, unexpected, or new symptoms, recurrent symptoms, or a marked change in the patient's condition all qualify as suspicious or strange. Suspicious symptoms include the "big six": head, abdomen, chest, respiratory, dizziness, and flu. These symptoms always require thorough investigation by a professional, primarily because they are often linked to under-diagnosed conditions such as ectopic pregnancy, MI, or appendicitis—all serious diagnoses.

Suspicious symptoms also apply to any situation where the nurse has a "gut feeling" or a hunch about a problem. If the nurse is uncomfortable with the protocol disposition, it is important to upgrade a problem or bring the patient in sooner. When red flags are raised, nurses are encouraged to use their intuition.

Age is one of the most important pieces of data obtained. The very young, very old, and women of childbearing age are always considered high-risk patients. Due to immature immune systems, premature infants and those under 3 months of age are at highest risk. The "frail elderly" (anyone over 75 years of age, or suffering from multiple or chronic diseases, functional disability, or psychosocial problems) are vulnerable due to failing immune responses. The childbearing years, always a high-risk period associated with pregnancy, birth control, and STIs, now extends from age 11 into the 60s! In regard to chest pain, the latest research demonstrates that women over age 45 have the same risks of cardiac disease as men over age 35.

Veracity refers to the ability to reproduce the facts of the situation accurately without communication barriers. Obstacles to data gathering arise whenever there are second-party calls, low-literacy callers, language barriers, extremely young or very inexperienced mothers, or caretakers unfamiliar with the patient.

Emotional status (caretaker and/or patient). Nurses can pick up many cues through careful attention to the words, tone, and pacing of the caller's voice. There may be hysteria or denial; inappropriate affect in caretaker or parent, or a history of psychiatric problems or substance abuse. Anxiety is always a red flag. Frequent calls in a short period of time can be an indicator of both caller anxiety and problem acuity.

Debilitation. Generally debilitation refers to chronic illness. Some chronic illnesses are listed in the box below.

Distance.When timely access is difficult, distance can pose a problem. For example, time may be of the essence but the patient/caretaker is calling from a remote location several hours from hospital, or the patient must take sporadic public transportation at night. In urgent situations, if timely arrival is difficult due to the lack of a car, the nurse must upgrade the disposition.

To summarize, quickly prioritize by using SAVED and the documentation form. Ask questions in any order, or simply let the caller tell their story at first. Use open-ended questions where possible. Unless it is clearly an emergency, follow SAVED with SCHOLAR, PAMPER and ADL (see below) as appropriate.

While performing a global assessment you may quickly assess an emergent situation that requires aborting the assessment process and bringing the caller in for treatment; however, in most cases the call requires a brief problem statement and patient history.

PROBLEM AND PATIENT HISTORY

Researchers have consistently pointed out the need to collect essential information related to the problem and patient history (Wheeler, 2005). The acronym SCHOLAR outlines key questions to elicit data (Box 4), and PAMPER (Box 5) elicits key information about the patient history. These key questions can easily be built into documentation forms as both prompts and question/answer (QA) tools to support nurses. (While PQRST or SOAP may work well for face-to-face assessment, more detail is needed in telephone triage interactions. These two tools are best practice tools and will yield comprehensive results.)

ASSESSING CHILDREN AND POOR HISTORIANS

Activities of Daily Living (ADLs)

With children, some elders, and poor historians, it is difficult to get adequate information for two reasons: (1) the patient is preverbal or a poor historian, and/or (2) the patient has vague or ill-structured symptoms. In these cases, SCHOLAR and PAMPER may be unworkable. Use activities of daily living (ADLs) to elicit and compare the client's current state with their baseline state (see box below).

With children and elders, baseline indicators of current health or illness provide the clearest picture, when symptoms are often vague, ill-structured, or absent. Since toxicity and dehydration are common risks with children, gather this information and then compare it to the descriptors in protocols for Toxicity and Dehydration Assessment. Marked changes in any of these indicators can be a sign of severe illness.

DOCUMENTATION ESSENTIALS

Always start the process with assessment questions and the documentation. The rationale is to use the form and the key questions to sketch an outline of the problem quickly. The next step is the fill in the details using the protocol. Patients often present symptom complaints in erratic and disorganized ways. They may focus on one symptom to the exclusion of other, more important ones. An example might be the parent who is concerned about a child losing a tooth due to trauma, when the more serious problem is possible head injury.

Resist the urge to select a protocol too quickly. Confining the interaction for the "first pass" reduces the risk of jumping to conclusions. As uncomfortable as uncertainty may be, choosing a protocol at any cost may lead you down the wrong path.

Telenurses can form a "provisional or working diagnosis," or impression. Use the patient's chief complaint in his or her own words (headache, nosebleed, vaginal bleeding) then add modifiers or qualifiers to designate the level of acuity; for example, abdominal pain, 9 on scale of 10, sudden onset; ankle pain, 4 on scale of 10, trauma history.

Documenting high-risk patients and symptoms using SAVED can "defend" dispositions. For example the statement "abdominal pain, prev hx ectopic" or "nosebleed, severe, unresponsive to home tx x 30 min" provides information that identifies the problem's severity. In the examples, the severity was due to previous medical history or failure to respond to home treatment, respectively.

The final steps of the nursing process—plan/intervention and evaluation—are addressed in the protocol. The treatment plan, formed from protocol's disposition and advice, is always a provisional one. Evaluation is carried out when the nurse provides patient teaching for self-evaluation through follow-up instructions from the protocol.

The sample documentation form (Wheeler, 2003) is based on the concept of charting by inclusion. Charting by inclusion requires that the RN chart normal negatives (pertinent negatives) as well as abnormal findings. Pertinent negatives are "findings that are normal and significant" (eg., no black or bloody stools). If you are charting by inclusion, pertinent negatives should always be written. In telephone triage, the issue of charting by inclusion or exclusion is still a controversial area, best addressed by in-house counsel and written policies.

Charting must be concise but complete, including accurate, timely observations in the patient's own words and always using approved abbreviations and terminology.

• Quantify where possible, avoid vague expressions.
• Use time frames (8, 16, 24, 48 hr) as related to symptoms or treatment.
• Form "provisional, working diagnosis" or "impression."
• Document advice per protocol name or number.
• Document protocol deviations/override/modifications.

Elicit information in any order that seems appropriate to the caller and the situation. It is not necessary to let the form dictate the order of data collection. In real-world situations, people volunteer information initially when describing their chief complaint. To interrupt and begin mechanically asking protocol questions is counterproductive and may actually lengthen the call. Take notes into the appropriate spot on the form as the caller volunteers information. Then fill in the gaps with follow-up questions from the protocol.

The acronyms SCHOLAR, PAMPER and ADL are incorporated into the documentation form to prompt nurses to ask key questions. Once the nurse has elicited this information, it is time to choose a protocol. In some cases, the nurse will use the generic protocol, a core protocol that serves as "infrastructure" for all other protocols.

Disposition

SELECTING THE CORRECT PROTOCOL

A Generic Protocol

Protocol selection is based on the principle of prioritizing. Choose the protocol that matches the most serious problem or the problem most likely to lead to an appointment. Your agency should provide adequate numbers of protocols from which to choose; however, because of the myriad presentations and the uniqueness of individuals, there may not be enough protocols to cover every condition. This leads to what is commonly known as the Out of Protocol experience; it is remedied by the generic protocol (fallback protocol), which can act as a safety net.

The generic protocol (Wheeler, 2003) is especially useful in two instances: (1) when the nurse does not know which protocol to use, and (2) when responding to calls about infants, elders, or poor historians whose presenting symptoms are vague or ill-structured. It might also be used as a training device for novice practitioners (Wheeler, 2003).

Sepsis and Dehydration Protocols

There are two key protocols that no pediatric manual should be without: sepsis (toxicity) and dehydration. Children are especially vulnerable to these two serious conditions. Both protocols should describe key behavioral patterns related to these conditions based on the parameters outlined in ADL (how is the is the child eating, drinking, sleeping, playing, and eliminating, and how is its color). For example, with possible sepsis, the child may exhibit extremes of behavior: extremely irritable, crying inconsolably, unable to be comforted. At the other extreme, a child who is extremely quiet, not moving, very withdrawn, and difficult to engage presents another pattern of severe illness. Refusal to eat, drink, or breastfeed nearly always indicates patterns of extreme illness in children.

With dehydration, the nurse should elicit and be alert to the combined effect (context) of conditions that can worsen dehydration. These include extreme heat or humidity, exercise, fever, nausea and vomiting, diarrhea, low or no fluid intake, as well as age, chronic disease, degree and duration of fever, patient medical history, depressed thirst response, and medications.

Pattern Recognition and Matching

Patients rarely present with the classic picture of any disease. Human beings are unique individuals; disease presentation vary due to previous medical history, age, immune function, and the timing of the call in relation to the disease process. Thus, telenurses must carefully navigate the myriad of possible presentations. A myocardial infarction may present as one key symptom (like chest pain), a few generalized symptoms (nausea, vomiting, sweating), or the full-blown classic picture (crushing chest pain accompanied by shortness of breath, nausea, vomiting, dizziness, sweating, anxiety). It is up to the RN to determine what constitutes a match.

A cardinal rule in telephone triage is when in doubt, always err on the side of caution. Nurses must rely on their best professional judgment and use every means at their disposal to ensure that patients are treated in a timely manner. Time frames designated on the template are intended as a general guide. When in doubt, have the patient come in sooner rather than later.

Nurses may upgrade dispositions as appropriate (from urgent to emergent, nonacute to acute). However, never downgrade (urgent to nonacute) without physician consultation. If patient is noncompliant, always seek advice from the physician advisor.

FOUR-TIER TRIAGE

While five-tier triage may apply face to face, the limits of telephone triage allow for only three or four disposition categories. Each category is intended as a flexible time frame within which the nurse determines what is safe, prudent and reasonable. Thus, the nurse has the professional responsibility to use best professional judgment.

• Emergent-level calls. Generally speaking, emergent-level calls require paramedic transport. Paramedic transport: Severe, life-threatening symptoms require paramedic transport and must be kept NPO. Whenever possible, try to remain on the line with the caller, or implement a three-way conference call as appropriate (Suicide Prevention, 911, Poison Center, Rape Crisis). Notification of patient arrival: When patients are advised to come to the ED or to labor and delivery, always call and notify the department of your impending arrival.
• Urgent-level calls. Urgent-level callers should come in within 1 to 8 hours. However, some urgent symptoms may need to be seen as soon as possible at the most appropriate site. These patients must be kept NPO and will require paramedic transport if there is no readily available car, or if the driver (caretaker/parent) is alone and/or too anxious to drive. If there is ready transportation and the driver feels safe and confident enough to drive, and can arrive within 1 hour, then the person may drive in.
• Acute-level calls. In this system, acute-level calls are seen within 8 to 24 hours or given a next-day appointment.
• Nonacute-level calls. Generally speaking, nonacute-level calls are directed to come in as appropriate. Nonacute symptoms usually can be managed with telephone advice and/or appointment.

Patient Self-Evaluation and Closure

Always end your call with the final question "Is anything else bothering or worrying you?" That final question is important; the caller may reveal their real motivation. This new information may open the door to a new triage process.

At the end of the call, state the disclaimer and document it. The disclaimer helps to ensure that the patient has given informed consent—in other words, they comprehend the problem definition and proposed treatment with the following understanding:

• This is an impression, not a medical diagnosis.
• The advice or home treatment is based on the impression.
• The final decision to follow advice rests with the patient.
• If patients disagree with the impression, they may have an appointment.
• If symptoms become markedly worse or fail to respond to the home treatment, the patient agrees to call back or come in.
• Patient agrees to the plan.

Elicit and document what the caller plans to do at the end of the call. This will demonstrate that there was agreement to a certain plan of action. Further, it ensures that the patient understands what to do and under what conditions they may need to ask for further help. At the time of the call:

• Make certain the physician is going to follow through; if not, find someone who will.
• Use the chain of command; don't be afraid to go to the next higher level.
• Take continuing education courses.
• Know your Nurse Practice Act.
• Use written guidelines and protocols.
• Obtain copies of your job description, job qualifications, policies and procedures in writing. These are the standards you will be held to in case of litigation.(Stein, 2000; Mahlmeister, 2005; Wheeler, 2005)

SUMMARY

As telephone triage continues to evolve as a subspecialty, best practices will flourish into sophisticated programs. Until researchers identify the best protocols and forms, the best approach is to be reasonable and prudent. Currently, minimal best practices include sufficient numbers of experienced, qualified, trained staff who utilize the nursing process, protocols and forms. A QA program (sample QA form) is yet another way to support best practices.

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