Nurse-led telephone triage

MPS Educational Services carry out clinical risk assessments of out-of-hours providers and the following is an example of a typical scenario.

A nurse-led triage system at an out-of-hours provider had been described by various duty doctors as “dreadful and shocking”. Many GPs were losing confidence that the regime was clinically safe and effective.

Many urgent calls were being classified as routine and conversely there was evidence of unnecessary home visits, inappropriate use of the ambulance service each contributing to additional pressures on the local health care delivery system. It was reported that if Nursing Home staff called regarding an ill patient no symptoms or conditions were recorded on the outcome sheets (Adastra). One antenatal patient was given an appointment at a walk-in centre rather than an immediate referral to the maternity hospital.

During the risk assessment it was established that there were no call handling protocols available, algorithms or decision making software were not used and thus no quality assurance of decisions made by call centre staff.

Comments

The triage nurse must assess the patients’ symptoms and guide them to the appropriate level of care. Telephone triage is difficult and good communication skills are essential; triage nurses must have excellent listening skills to notice non-verbal clues the patient is giving regarding pain, anxiety and level of comprehension. Decision making tools can be of significant assistance in determining most appropriate pathway for the patient.

A publication by T. Males¹ was suggested as a resource. Males states on pages 87 and 88 that “the use of clinical decision support software ‘increases the safety and efficacy of consultation through facilitation, rather than imposition’. Structured questions or lists of points to cover are helpful to improve safety and effectiveness”.

Recommendations

The organisation was urged to swiftly introduce decision making software which would assist them in providing a quality assured triage service.
Before introduction of the chosen system triage staff should be provided with adequate training and their competencies assessed.
Performance should be audited on a regular basis i.e. monthly then extending to every two months when staff are fully conversant with the system.
On-going training to be provided for staff that experience difficulties.

References

Males T (2007) Telephone Consultations in Primary Care. Royal College of General Practitioners publication 2007 ISBN 978-0-85084-306-4.