Telephone Triage Protocols for Registered Nurses

1. Telephone Triage Protocols for Registered Nurses UTMB – CMC-Nursing Services Policy E-37.2

2. TELEPHONE TRIAGE PROTOCOLS for REGISTERED NURSES E-37.2 • ANA Telehealth & Corrections • Telephone triage & Advice lines Rapid Growth • This industry like all aspects of health care pose a medical-legal threat. • Experts agree use of approved protocols reduce the risk in giving advice over the phone. J. Robison 07/18/10; Revised 3/15

3. PURPOSE for POLICY E-37.2 • To provide telephone triage guidelines to the Registered Nurse (RN) providing direction to Security Staff for patients with medical complaints at facilities where medical personnel are not on-site. • Texas Board of Nursing & Tele-health Nursing; Texas Nursing Practice Act J. Robison 07/18/10; Revised 3/2015

4. Policy E-37.2 Protocol Book • Guideline for RNs • 200+ Protocols: symptoms, disorders, & emergencies • ARE NOT DESIGNED to diagnose patients-assess severity of problem J. Robison 07/18/10; revised 3/15

5. Telephone Triage Training & Documentation • Documentation of Telephone Triage Training • Documentation of patient-nurse relationship establishment • Documentation understanding when in doubt err on side of patient safety J. Robison 07/18/10; revised 3/15

6. Protocol Navigation Standard Design for Efficient Utilization • Key Questions • Assessment • Action; Action Plans J. Robison 07/18/10; revised 3/15

7. KEY QUESTIONS PROMPTS the RN to address key areas before proceeding through the protocol. This always includes asking and recording the patient’s name, TDCJ number, age, onset, & frequency of symptoms J. Robison 07/18/10; revised 3/15

8. ASSESSMENT Contains the questions listing the symptoms, conditions, or combination of factors that should be assessed to determine urgency. J. Robison 07/18/10; revised 3/15

9. ACTION/ACTION Options Organized around yes & no answers No go to next questions Yes advice is given Options will vary: “Call ambulance” “Seek Medical Care” “Call Back or Call PCP” J. Robison 07/18/10; revised 3/15

10. Disposition Options • A protocol may be overridden to a higher level disposition if the nurse deems necessary. • A protocol may only be overridden to a lower level disposition if the nurse consults with and obtains an order from the on-call primary care provider. • This order must be documented on the Telephone Triage Documentation form. J. Robison 07/18/10; revised 3/15

11. PROCEDURE • Patient in front of DMS monitor • No monitor, patient speaks to RN directly & follow protocol • If not possible, send 911 to hospital ED • Document on Telephone Triage Form • RN will contact provider • Triage form will be emailed to NM of patient’s UOA • NM of patient’s UOA: ensure follow-up, form to MH if needed, and have form scanned to patient’s medical record. J. Robison 07/18/10; revised 3/15

12. Failure to adhere to the protocols in this book, and the policies and procedures of UTMB CMC and TDCJ Health Services may lead to discipline up to and including termination. J. Robison 07/18/10; revised 3/15

13. J. Robison 07/18/10; revised 3/15

14. Scenario Discussion • In the following slides, five scenarios will be given with varying patient conditions. • Different protocols can be used to address the problems described in the scenarios. However, it is best to use the protocol that most closely matches the presenting symptoms. • For each scenario, complete a Telephone Triage Documentation Form. • Spend only about 5-6 minutes per scenario, as if you were on the phone talking to the caller. • In the space provided at the bottom of each form, describe additional information that would be important to obtain to manage the call appropriately. Not all scenarios provide adequate information to thoroughly assess the problem and reach a disposition. Based on the information provided, indicate your disposition decision. • Remember, this is a learning opportunity. This exercise is designed to help you feel more comfortable with the protocols, applying your assessment skills, and documenting the encounter. J. Robison 07/18/10

15. Scenario #1 • Call received at 2340 by officer Gray and the patient is placed on the phone. Patient Smith is a 32 y/o male complaining of a wasp sting to the forearm that is badly swollen, about 6” across, and is warm and painful to the touch. He has pain in his arm and shoulder. There is no stinger. The incident occurred at 1800 hours today. The patient denies any difficulty breathing, chest pain , rash, or other problems but wants to know if anything else can be done. J. Robison 07/18/10; revised 3/15

16. Scenario #1 Findings • Possible protocols • Bee Stings p54 • Insect Bites p60 • Allergic Reaction p19 • Problem • Non-urgent • Disposition • Instructed the Security officer to issue a pass to the offender patient to come to medical the next day. • Applicable Home Care Instructions • Wash the site with soap and water. • Elevate the extremity to help decrease swelling. • Apply a cold or ice pack to the sting site for the first 24hrs. • Remind patient that acetaminophen is available from Security staff. • Apply underarm deodorant to the site to help reduce itching. J. Robison 07/18/10; revised 3/15

17. Scenario #2 • Call received at 0200 and patient Nelson #12345 is placed on the phone. Nelson is a 19 y/o male complaining of sweating off and on since yesterday and has a cough. He states developing small water blisters all over his body today and is nauseated. He has had a headache for four days and has been dizzy. He describes his rash as 20-30 red-like spots that are flea bite size with blisters in the middle. Some of the spots itch. He does not know if he has a fever and there are no scabs. Nelson can’t remember is he has ever had the chickenpox. J. Robison 07/18/10; revised 3/15

18. Scenario #2 Findings • Possible protocols • Chickenpox p114 • Cough p148 • Headache p264 • Dizziness p172 • Problem • Non-urgent • Disposition • Instructed the Security officer to issue a pass to the offender patient to come to medical the next day. • Applicable Home Care Instructions • Increase fluid intake. • Take a cool shower. • Apply a cool compress or ice pack to forehead every 2 hours. • Remind patient that acetaminophen is available from Security staff. J. Robison 07/18/10; revised 3/15

19. Scenario #3 • Received call at 2030 and patient George placed on the phone. George is a 23 y/o male who was in a fight with another offender 3-4 days ago in the chow hall. He is complaining that his right arm is swollen and very sore. The other guy bit him twice just below the elbow. He has a reddened area about 3”x6” that is very painful to the touch. There is pus in two areas, and the patient thinks he has a fever. He describes the area on his arm as very warm to the touch and very painful. J. Robison 07/18/10; revised 3/15

20. Scenario #3 Findings • Possible protocols • Human Bites p57 • Wound p446 • Wound Healing and Infection p567 • Problem • Urgent • Disposition • A. If the facility being consulted is within a designated HUB area, the RN will instruct Security staff to bring the patient to the HUB for a full assessment. • B. If the facility being consulted is NOT within a designated HUB and a licensed nurse or provider will not be on the facility within 2 hours, Security will be instructed to transport the patient o the nearest local community hospital ED. J. Robison 07/18/10; revised 3/15

21. Scenario #4 • Call received at 0400 and patient Kennedy is placed on the phone. Kennedy is a 29 y/o female who is complaining of abdominal pain and vomiting. She states that she has had severe abdominal pain since noon today. The discomfort started as heavy bloating, then vomiting about 15 times this afternoon. No diarrhea or gas noted, but lightheaded and dizzy for the past 45 minutes. She describes her pain as 8/10 and feels no relief after vomiting. J. Robison 07/18/10; revised 3/15

22. Scenario #4 Findings • REFER TO STANDING DELEGATED ORDERS: N/V has a standing delegated order & is an urgent/emergent issue. • Problem • Emergent • Disposition • Instructions given to security officer to call 911 and transport offender patient to nearest local community hospital ED. J. Robison 07/18/10; revised 3/15

23. Scenario #5 • Call received at 0130 and patient Jones placed on the phone. Jones is a 32 y/o male complaining of intermittent chest pain for the past three days. He denies any radiation, shortness of breath or nausea but states the pain is worse when he tries to take a deep breath. He also reports exercising and lifting weights daily. The patient is adamant that he should go to the local ED. J. Robison 07/18/10

24. Scenario #5 Findings UTILIZE the Standing Delegated Order for CHEST PAIN !!! Notify the Provider!! Even if you believe it is musculoskeletal—let the provider make the decision & diagnosis. J. Robison 07/18/10; revised 3/15

25. Questions? Reference: American Nurses Association. (2013). Correctional Nursing: Scope and Standards of Practice, 2nd Edition. Silver Spring, MD: Nursebooks.org. Briggs, J. K. (2007). Telephone triage protocols for nurses. Philadelphia, PA: Lippincott Williams & Wilkins. Texas Board of Nursing. (2015). BON Rules and Regulations Relating to Telenursing/Telehealth. Retrieved from http://www.bon.texas.gov/faq_nursing_practice.asp#t18 J. Robison 07/18/10; Revised 3/2015