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Telephone triage: Q&A with Sally-Anne Pygall, Nurse Training Consultant

What makes telephone triage different?

Nurses have assessed patients over the phone for decades. However, they may not realise that if they are asking questions in order to give advice, they are triaging!
 
Telephone triage has become more common and takes place in many different settings. Even nurses working in secondary care give ‘follow up’ advice to patients or speak to patients in A&E by telephone.

Nurses and midwives train to physically assess someone’s condition, and give advice or provide treatment. However, skills for physical examination are not immediately transferable to telephone consultation without training.

Missing information

Decision making in telephone triage is complex, not only because the nurse is not physically with the caller, but also because they are relying on the caller’s understanding of their own condition. Vital pieces of information may be missing unless the triager is able to completely and accurately extract it, using only verbal clues.

Communication skills

You need different skills when assessing patients by telephone. Without body language you have to use your tone of voice to convey interest, sympathy, and even control. According to the Chief Medical Officer, communication problems account for one in four complaints in the NHS.

How do nurses and midwives ensure they give good advice over the telephone?

Protocols or systems

Nurses working in NHS Direct and some out of hours providers use a Clinical Decision Support System (CDSS). These systems support decision making and provide evidenced based self care advice. However, in my experience, many nurses using CDSS become ‘system operators’ and rely heavily on the system to suggest the appropriate outcome (level of care advised) or they ‘blame’ the system for inappropriate outcomes if criticised for being risk adverse or mistriaging.

Training, not just experience

Nurses working in primary or secondary care rarely use a CDSS or work to protocols. They rely on their experience of face to face assessments to decide the level of care, and to give advice.

However, accurate assessment by telephone means knowing how to ask the right questions at the right time, and how to engage the caller with the right communication skills.

In many calls, triage is through a third party or without the patient being present! This carries even more risk and requires specialist training to ensure these situations are dealt with safely.

Protocols

Protocols developed in house or bought ‘off the peg’ help standardise advice and outcomes, which can vary depending on levels of experience and training.

Nurses can protect themselves legally by using protocols, exemplary documentation and record keeping, and quality assuring their work (Coleman (1997)). Apart from nurses working for NHS Direct and some (not all) out of hours providers, I have yet to meet a nurse who is working to all of these principles.

Supervision and audit

Alongside training, nurses need clinical supervision. Few nurses have their calls recorded, making supervision difficult, but not impossible. Where calls are recorded, nurses should get an appropriate audit, or at least have a colleague review the quality of their calls. Listening to your own calls is a powerful form of instant feedback!

What happens when telephone triage is not properly audited?

Without proper auditing, using the right people, quality tools and feedback processes, the nurse may be practicing unsafely or arranging face to face appointments unnecessarily.

Audit tools

The Royal College of General Practitioners (RCGP) have an out of hours audit tool for all staff involved in the patient journey. However, in my experience, it does not give details of best practice or benchmarking for improvement. As training is not mandatory for auditors, they might not be able to assess the quality of triage work done by others.

Unnecessary appointments

Face to face consultations  or appointments with a GP or in A&E, come at a high cost. In surgery hours, an 11.7 minute appointment costs about £36.00. A 23.4 minute home visit costs £58.00 (Unit Cost of Health and Social Care 2008). Out of hours, the costs are around £10 per clinic appointment and £20 per home visit.

Not helping patients to help themselves

Failing to empower patients to manage their own care creates a culture of dependency. If a patient is seen unnecessarily, in future they will not be satisfied until they are seen face to face. Poor telephone consultation results in missed opportunities to educate patients.

What are the main challenges facing nurses and midwives working in this area?

Demand and cost

Demand for instant health care is increasing. Telephone access is popular, and as seen with the swine flu pandemic, nurses are ‘drafted in’ to manage increased demand for appointments. Without knowing how to do this safely, competently and with confidence, patients may be seen unnecessarily or, more worryingly, be denied care.

Nurses I spoke to were ill prepared and ill equipped to handle the demand. Many surgeries use nurses as a ‘cheaper’ option to GPs; 51p per minute as opposed to £3.00 per minute for a GP (Unit Costs for Health and Social Care 2008). Often practice nurses are asked to use triage to prioritise requests for GP home visits and manage demand for appointments.

Training and development

Nurses often see this work as part of their role and do not question their ability to do it. If asked to catheterise someone or to take a smear without training, a nurse would refuse in order to protect their registration and the patient. However, when it comes to telephone triage, as they do not appreciate the risks involved, they often undertake this role without additional training.

With little access to clinical supervision, training and development, nurses often have to find training courses and meet the cost themselves. Nurses should also get regular refresher courses to ensure their skills are up to date, but this rarely happens.

Has the use of telephone services changed?

Demand is increasing

Figures from NHS Direct show that millions of people now seek advice from nurses over the phone each year. Surgeries increasingly use telephone triage surgeries to manage demand for same-day appointments. Other services such as Community Nursing, Rapid Response Teams, Occupational Therapy, Mental Health Teams and others are increasingly using the telephone to monitor and treat patients

Managing long term conditions

Telephone consultation is also used for asthma reviews and management of other long term conditions such as coronary heart disease and diabetes. The savings can be enormous. In addition, research shows that people with long term conditions comply better with their treatment programmes if the reviews take place over the telephone rather than face to face.

What should members of the public know about how telephone triage works before they pick up the phone?

Out of hours services commonly do not have access to the patient’s own GP records. People think out of hours services are an extension of their in hours care, and can become frustrated when asked for their medical history.

Created date :

26/03/2010

Modified date :

26/03/2010