2020 Nurse Triage Benchmarking Report — Schmitt-Thompson Clinical Content

About the Nurse Triage Benchmarking Survey

During May and June 2020, Schmitt-Thompson Clinical Content (STCC) requested feedback from nurses who work in a telephone triage environment, whether a call center or provider office/clinic, about their services provided and metrics from their call center. We received 56 responses from nurses and nurse managers across the country. Some of the same questions were asked as part of a 2017 Medical Call Center Survey. Where relevant, the 2017 results are included for comparative purposes.

2020 Nurse Triage Trends

In general, there haven’t been substantial changes to the services provided or operations of nurse triage call centers (i.e., same type of services provided, call length, and calls per hour). A couple areas where there was some significant change was in the areas of (1) providing more after care instructions, (2) fewer call centers providing second level triage and (3) an increase in the call center serving as an access point for telemedicine/video visits. Detailed statistics and comments are provided for each question below.

Note: The timing for the survey coincided with the international coronavirus (COVID-19) pandemic. We have tried to address changes from the 2017 survey that may have been impacted by COVID-19.

2020 Nurse Triage Benchmarking Survey Results

Question 1: Which of the following responses best describes the population managed by your call center?

For those call centers that manage both pediatric and adult, 75% of respondents, the majority (two-thirds) of the patients served are adult.

Question 2: Which of the following responses best describes the population managed by your call center?

What type of calls are managed by your call center? (Check all that apply)

There appears to be a slight increase in call centers that provide daytime office triage. This slight increase may be due to the mix of survey respondents in 2020 compared to 2017.

Comments related to “Other” types of calls included: answering service, physician referral, firefighter shift call offs, low level acuity for 911 dispatch, population health calls, reporting culture results to a patient or caregiver in partnership with emergency department, transfer center calls, and worker compensation symptom calls.

Question 3: What call intake strategy do you deploy in your call center?

Some call centers may employ several of these options leading to more than 100%.

“Other” responses included:

· The best practice is for the nurse to answer directly, but the other two options are available if the nurses are currently on the phone.

· Non-clinical personnel can answer the call and it is placed into the call back queue without any acuity rating.

· Non-clinical staff answers the call, collects demographics and transfers to the RN as necessary.

· We send calls to a queue for RNs, except for potentially life-threatening calls; we have a mechanism in place to immediately warm transfer them to a RN.

Question 4: What is the average triage call time (the time it takes to complete a call including documentation and after-call work)?

In both 2017 and 2020, the highest range of call times was 11-13 minutes and 14-16 minutes. However, the responses for the 2020 survey seemed to shift somewhat to a longer call length. This is seen in the increase in percentage of responses for the 14-16 minute range and the 17-19 minute call length range. Depending upon when respondents pulled data from to complete the survey, the longer call length in 2020 may be a reflection of the COVID-19 pandemic during the spring of 2020.

Question 5: What type of additional after-call activities are included in your average triage call time? (Check all that apply)

Between the 2017 and the 2020 surveys there was a substantial increase in the number of organizations who send after care instructions to a caller after a telephone triage encounter. This might be a reflection on the types of survey respondents. However, it is also possible that call centers are providing this additional service to improve caller satisfaction. There was also an uptick in copying documents into the patient’s electronic medical record.

“Other” responses included:

· Calling report to ED

· Consulting MD and calling patient back

· Consulting with emergency department MD's on higher acuity calls with dispositions of 24 hours or less

· Contacting physician

· Coordinating referrals

· Deploying resources to meet member's needs at home

· If during business hours we can offer to transfer the caller to their medical provider

· Involving interpreter services

· MD consults for all dispositions of 24 hours or less.

· Outcalls to family, docs, nurses, transport, scheduling etc.

· Paging on call physicians and handling the callback from the PCP.

· Sending notification to manager if a patient c/o, sending notification to social work if necessary

· Transferring back to scheduler for appts, sometimes conferencing back to 911 or specialty provider

· We have the option to Fax a copy of our interaction with their PCP- I usually do this

Question 6: How would you compare your average triage call time today to your average call time three years ago?

Question 7: Why do you feel there was an increase or decrease in call times?

Why do you think there was an increase in call times?

Responses included:

· Additional services provided; providing medications for certain conditions; ordering COVID testing, scheduling appointments, telemedicine

· Calls are more complex/higher acuity patients (7 mentions)

· Adding more documentation elements to each call

· Changes in nursing scope; fewer standing orders, more calls to providers

· Clients requesting more data collection

· Creation of new medical records and capture of demographics

· More paging physician and pharmacy calls

· More reporting/tracking request of nurse

· Hold times for pharmacies and answering services are longer

· Blocked call lines from patients

· Doing more for callers; drug/lab protocols, scheduling appointments, connections to behavioral health counselors, MD consults

Why do you think there was a decrease in call times?

Responses included:

· We have a better knowledge base

· More streamlined demographics

· Call type – more information calls vs triage calls

· Use of translator line

· More nurse training

· Utilizing metrics for the nurses

Question 8: How many calls does a nurse at your call center take, on average, per hour?

Between 2017 and 2020, there was a big jump in the number of respondents who only take two calls per hour and a decrease in the number of respondents who take five calls per hour. This is consistent with the prior two survey questions that showed that the length of call has increased due to complexity of caller needs and the other reasons.

Conversely, there was a substantial increase in the number of respondents who stated they take eight or more calls per hour. The comments from Question 7 suggest that this may be due to call type, more or better training and a better knowledge base. All of these factors could promote higher nurse efficiency.

Question 9: Does your call center offer or use second level triage (MD provides triage or consultation for certain types of calls)?

There was a fairly substantial decrease in the number of call centers that provide second-level triage between 2017 and 2020. This may be due to a rise in the availability of telemedicine options.

Question 10: If yes, how do you manage 2nd level triage?

For those that do provide 2nd level triage, the majority will consult with the on-call provider and the triage nurse will then call the patient back.

“Other” comments from the 2020 survey on how 2nd level triage is managed include:

· All three scenarios depending on circumstances

· Either transfer to provider or consult with provider and then conduct a call back

· Encounter is sent to the provider, they respond and send back to the triage nurse

· In-basket messaging through the EHR and the provider makes the outbound call to the patient

· We can call the on-call physician or send the patient to the ER if needed

· Sometimes we refer to the managed care or group home

· Caller can call telehealth if escalation is appropriate

· Text message is sent to the provider along with a copy of the chart

· The nurse may route a message to the MD regarding the need for antibiotics for a UTI. The physician will message the nurse back with the answer and we call the patient back

· We typically put the call on hold and consult with the provider but some of these result in a real time video visit or phone call directly between provider and patient depending on situation

For those organizations that indicated they provide second level triage, it is used, on average 12% of the time (Q11). Actual responses range from a high of 40% down to a low of 5%.

Question 12: Does the triage nurse have access to the patient’s electronic medical record at the time of the call?

The data indicates that it is becoming more common for the triage nurse to have access to the patient’s electronic medical record at the time of the call.

Question 13: Does your call center use a specific method to prioritize triage calls and, if so, how well does it work for you?

In the 2020 survey, more respondents indicated they use a specific method to prioritize triage calls and that method appears to be effective.

Responses below describe some current methods of prioritizing calls:

· Call type for front ended calls is used.

· Calls are assigned an acuity level based on chief complaint. The higher acuity levels go straight to a nurse.

· Certain calls that are likely to end up with a 911 outcome are labeled “hot” and must be responded to by an RN within 60 seconds.

· Emergency, urgent and regular.

· Emergent calls come to the call center on a separate phone line. The staff in the clinic have red flag symptoms that will initiate an immediate call to the nurse for a warm handoff.

· Intake agent prioritization training.

· List of common complaints or conditions under emergent symptoms/concerns, urgent symptoms/concerns, semi-urgent symptoms/concerns and routine symptoms/concerns. The charge nurse regularly reviews calls in queue and re-prioritizes as necessary.

· Nurse judgement based on reviewing call information in the queue.

· Our non-clinical staff utilize a red flag list to prioritize calls which works very well for us.

· Our phone staff have guidelines that flag a call high priority vs normal priority.

· We have a red flag call list defined by physicians. Symptoms are reviewed by call center agent and routes to red line, all other calls to blue line for nonurgent symptoms.

· Using good judgment, for example, pick up a chest pain call before a refused med call.

· Using key words.

· We do both nurse triage and transfer center calls. Transfer center calls are priority over nurse triage due to the critical nature of these calls.

· We had a "Trigger Word" sheet for the non-medical staff that were the first person to get the call. Based on what the patient said, the call would be routed either High Low Priority. This wasn't always the right way because the screeners didn't always know to ask particular questions.

· We have a lead who oversees the queue and assigns based on ESI scoring.

· We have a Priority List that is used to prioritize non-urgent, urgent, emergent - 3 priorities.

· We prioritize utilizing a number system. Most calls are a 1 for regular acuity. If a caller calls back, they are given a number of 5. Our RN's and Answering service representative are trained on a "Red Flag" list that describes the highest priority number (10). Once entered into the queue, the Charge RN's also have the ability to change a call to a 10 using their nursing judgement.

· We use the Schmitt prioritization tool.

· We use a symptom driven tool for our unlicensed staff to follow showing urgent/emergent symptoms. It is a long list which is the overwhelming part of this method. It does allow a reduction in calls that they transfer direct to an RN vs place them in the queue for urgent callback or as routine.

· We use the guidelines to create a four-level system of prioritizing: 911, emergent, urgent, low priority.

· Yes - we have a list of potential 911 symptoms and ED symptoms that we classify as Hot or Urgent respectively. If it is HOT they must speak with an RN within 60 seconds, even if the RN has to get off of a call they are on to handle. The urgent calls need to be taken as soon as an RN is available. It works pretty well but we would be interested in continuing to improve this process.

Question 14: Does your call center take calls for any medical specialty services practices?

Virtually identical responses in 2017 and 2020.

Below is a listing of responses to the types of specialty services/practices that are serviced through the call center and the percentage that require 2nd level triage or consultation with a medical provider:

· All hospital employed providers including all specialists. 6%

· Community Pediatric offices; Org Hospice and Home Health

· Cardio 20%, neuro 20%, urology 20%, ENT 20%, spine 20%

· Cardiology, endocrinology, plastics, breastfeeding, home health, hospice, dental (public health)

· Cardiology, ID, GI, Ortho, Surgery

· Cardiology, Orthopedic, OB/GYN, Urology and Oncology

· Cardiology, Pulmonology, Surgery, Endocrinology, OB-GYN

· Cardiology - We transfer an average of 24%

· Endo, Neuro, Home Health, Gender Health, Ortho,

· Endocrine - Diabetic population; ENT, Cardiology, Pulmonology, Allergy, Concussion - CF and Neurology in the works.

· Endocrinology for one group system - less than 1% of calls

· GI, CV, Cancer, Women's Health, Prenatal/Postnatal - 25%

· GI, Endo & Neuro for one health system only. Almost all of these calls require 2nd level triage.

· Lots of different specialties!!

· Ob-50 %, ONC-10%, Urology-5%, surgery- 5%.

· Ortho 20%, Podiatry 15%, Surgery 15%.

· Ortho, GI, surgery, allergy, ENT, neurology, urology.

· Pediatric endocrinology 90%, cardiology 10%, obstetrics 5%.

· Pediatric Neurology, Pediatric Endocrinology, after hours all specialty care except Ortho and OB.

· Pediatrics, Primary care 5% are sent to 2nd level.

· Peds neurology.

· Primary care, cardiology, general surgery, GI, plastics, orthopedics, oncology, OB/gyn, ENT, endocrine, allergy, psychiatry, chiropractic, dermatology, colon/rectal surgery, infectious disease, occupational medicine, nephrology, neurology, neurosurgery, ophthalmology, pulmonary, rheumatology, podiatry, urology, vascular surgery.

· Some women’s health.

· Surgical consults - unknown %

· Urology, BH, many due to having a PCP in the system but also have specialist care.

· urology, surgery, OBGYN, podiatry, psychiatry - unsure on percentage.

· We don't do 2nd level triage.

· We handle calls for all medical specialties (ortho, neuro, endocrinology, oncology, women’s care, special needs peds, etc.) We also handle calls for special populations (LGBTQ including pre/post of gender confirming surgeries, homeless, foster care). We do not have any data to pull for 2nd level on this, but I would imagine it is similar in percentage to our overall 2nd level triage of 23%.

· We have OBGYN, dental, and behavioral health in our health centers along with our primary care services. 2nd level triage is about the same.

· We have our medical group set up so that any patient calling the operators with symptoms be forwarded to the nurse triage line. They reside in the same call center sitting in the same area.

· We provide a Lactation line, Medical Assistance in Dying registration and matching program and palliative support line.

· We take call for a complex care clinic/pediatrician practice. We contact the provider on 90-95% of these calls.

· We take calls for all of our hospital’s specialty practices like ortho, neuro, peds, women's care, dermatology, heme/oncology, etc.

· We take calls for many specialties and are not tracking that percentage.

Question 15: Does your call center take calls/serve as an access point for telemedicine providers or doctors who provide virtual patient visits?

There was a big jump, from 24% to 54%, in respondents, whose call centers now serve as an access point for telemedicine or doctors who provide virtual patient visits. It is unclear if this is a trend or a temporary response to the COVID-19 pandemic this past spring.

In the follow-up question, Q16, the question was asked if a nurse can transfer a caller directly to a telemedicine provider or schedule an urgent telemedicine appointment. There was little change between 2017 and 2020. In 2017, it was 47% yes and 53% no. In 2020 it was 49% yes and 49% no.

Below are specific responses regarding the transfer of telemedicine calls:

· Nurse transfers call back to scheduler, who determines if a telemedicine appt is appropriate.

· We can schedule appointments.

· We schedule urgent telemedicine appointments.

· Nurses direct callers to the website to activate a visit with a provider via telemedicine.

· We developed technology with Cisco to be able to convert a call to telehealth in real time.

· We enter patient info/medical record #/symptoms in TigerText and it is scheduled with the medical assistant.

· We give them a number or tell them how they can access telemedicine options.

· We have developed a telehealth program that can convert a phone call to a video visit in real time and do our telehealth calls in our call center with our ED MD's working in the nurse line.

· We transfer these callers to our Urgent Care for the appointment to be made as telemedicine if applicable.

· We will move towards this in the near future.

· Providers have just started telehealth. If we triage and feel that a visit is appropriate, we transfer to the appt scheduler with directives.

Question 17: Do your nurses call in or electronically send prescription orders per approved standing orders/protocols for certain conditions?

There was a slight increase, from the 2017 to the 2020 respondents, in the number of call centers allowing nurses to send prescription orders per standing orders.

Below is list of the types of conditions for which some call centers have standing orders:

· 5-day supply of necessary meds, refills for puffers and neb solutions, spilled antibiotic refill, diflucan if uncomplicated yeast infection.

· Asthma, suspected swimmer’s ear (tubes and no tubes), ear drainage with tubes, suspected bacterial conjunctivitis, suspected thrush in infant.

· Asthma, swimmer's ear, ear drainage from ear tubes, thrush, pink eye.

· Asthma, thrush, conjunctivitis, lice, Impetigo, acetaminophen, ibuprofen.

· Conjunctivitis, thrush, albuterol refill, yeast diaper rash, positive strep cultures.

· Depends on the provider, not all do.

· Lice medication, conjunctivitis, UTI after culture, strep after swab.

· Lice, pink eye, strep throat.

· Lice, pink eye, yeast infection, some refills, etc.

· Limited "emergency" medications by standing orders only.

· Nausea/vomiting; diaper rash; thrush; conjunctivitis.

· Prophylactic dental abx, vaginal yeast infection, routine medication refill standing order.

· Uncomplicated adult female UTI's, conjunctivitis (adult/peds), nausea/vomiting in pregnancy, nausea/vomiting in adults, emergency contraception (Plan B and Ella), scabies, lice, OTC meds, Diflucan for vaginal yeast infections, influenza and we are now handling ordering COVID tests for patients.

· UTI, influenza, emergency contraception, liver, scabies, yeast infections, conjunctivitis, nausea/ vomiting in adults, nausea/ vomiting in pregnancy and we are writing one for herpes flare ups.

· UTI, yeast infection, mastitis, conjunctivitis, diaper rash, swimmer's ear, thrush, nausea & vomiting in pregnancy.

Question 18: How does your call center handle requests for urgent prescription renewals after-hours? (Check all that apply).

Based on the 2020 responses, one in four call centers do not provide urgent after-hours prescription renewals. For those that do, most consult an on-call provider for a prescription order.

“Other” responses to handling requests for urgent prescription renewals after hours include:

· We advise the patient to ask for bridge dosing with pharmacy.

· Based on provider standing orders.

· Consult with pharmacy.

· Depending on client guidelines may refer to portal etc.

· Non-urgent requests sent to the clinics for fill the next business day.

· We send a task to the provider.

· These calls go directly from answering service to the provider.

· We do not call for all medications after hours, particularly controlled substances - difficult to define urgent at times

· We utilize the Medication Question Call guideline.

Question 19: Do you have staff nurses who work remotely?

Not surprisingly, the percentage of staff nurses who work at home has increased over the past three years. Again, some of this increase may have to do with the COVID-19 pandemic, but we believe the increase is thought to be more of a sustained shift based on responses to the follow-up question (Q20), if yes, what percentage of your staff is set up to work remotely? If a respondent’s work at home percentage went up due to COVID, it was most often clarified in their comments. For those organizations that have nurses working remotely, on average 86% of staff are set up to work at home. The average amount of time remote staff are required to work on site (Q21) was 2%.

Question 22: How many weeks, on average is a new triage nurse at your call center in orientation?

The average number of weeks is seven. The mode, or number(s) that appeared most frequently in this data set, was five weeks and 12 weeks. Some respondents made the distinction between orientation and onboarding, which could take 6-9 months.

Question 23: How many years of nursing experience are required for employment as a triage nurse?

The average number of years of nursing experience is 3.5 years. The mode (numbers that appeared most frequently in this data set) was two years, followed by three and five years. Some call centers also require a minimum experience in acute care, ED/ICU, or hospital pediatrics.

Question 24: Does your call center record triage calls?

It was interesting to see a drop in the number of call centers who record triage calls. It is unclear the reason for this change. Perhaps the decrease was due to expense or effort involved in reviewing the calls.

Question 25: If yes, how often are recorded calls reviewed for each RN?

As a follow-up, Q25 asked how often recorded calls are reviewed for each RN.

Responses/comments include:

· 1 call per week

· 100% of calls after recorded

· 15 per month after successful orientation period

· 2 per month per RN

· 3 calls/month

· 37%

· 5 calls per nurse completed monthly

· 5 live calls and 5 closed calls per quarter

· About 2-3 calls/month are reviewed for each RN. New RNs within their 1st year have more calls audited.

· Daily

· Each nurse gets a minimum of two scanned calls per month.

· The goal is 10 calls per month per nurse.

· Minimum of 7 audits/month (mix of QA and Peer Reviewed calls) plus any complaints/issues or high-risk calls like suicide/child abuse.

· Monthly (3).

· Monthly and PRN as needed for review/outcome of call.

· Monthly and quarterly.

· Monthly or as issues arise.

· Monthly QA audits, frequency depends on years of service and history of call handling.

· Monthly, three calls are audited including self, peer, and administrative.

· QA is done 3 calls per month.

· Quarterly at minimum; monthly for new triage nurses.

· Rarely-only if there is a patient complaint or if there is a concern.

· Triage calls are randomly audited for quality control.

· Twice monthly per nurse or more often as needed - new employee, performance issues, etc.

· Using QA form, more are done when nurse is new or if QA below standards.

· Varies, at least one per week after the orientation period.

· We have a QI process for review of recorded calls. The number of calls per month vary depending on number of hours worked/FTE. RN's in their first year with the department typically have 4-5 calls per month reviewed by a peer/staff educator.

· We try to do 1-2 a week or as needed for training or concerns brought by the clinic.

· Weekly and monthly.

Question 26: How does your call center measure patient/caller satisfaction? (Check all that apply)

There was a slight increase in the percent of respondents who send out satisfaction surveys via email in the 2020 survey: otherwise, not much change.

Listed below is the detail for “other” responses.

· A survey link is sent to any patient that receives after care instructions.

· After call survey (3).

· Asking caller if they have any other questions and making sure they are satisfied at time of call.

· Company sends out general surveys which cover my department.

· Follow up calls for those with disposition of 911 or see ED immediately.

· Just started the process.

· Link to a survey is included in After Care instructions emailed to a caller.

· None (7).

· Phone call with client.

· Post-call survey provided on call.

· Press Gainey.

· Sent via text.

· We didn't follow up but at the end of the call, we would ask what the patient would have done and if they felt good about talking to the triage nurse. Usually they were appreciative that they actually were able to talk to a nurse.

· We do follow up calls independently to check on patients that we've spoken with just to see how they're feeling. Hoping to implement satisfaction surveys in the future.

· We have surveys quarterly for all patients who come into health centers, all of whom would have had some interaction with the triage nurses.

· We hire a company to callback patients to ask a specific set of questions for both our intake and RN service delivery.

Question 27: Does your call center accept videos or photos sent from callers as part of the triage workflow?

Only a slight increase in the numbers of call centers who accept videos or photos as part of the triage workflow over the past three years.

Question 28: Do your triage nurses send any information to callers after a telephone interaction via email or text messaging?

There was a significant increase in the number of call centers who send follow-up information to callers via email or text between 2017 and 2020. Enough of an increase that it might be related, again, to the COVID-19 pandemic and the need to provide callers with more information and care advice.

Specific comments regarding a description of what’s sent is below.

· ACIs (after care instructions) sent, if necessary, via email.

· We use both email and text.

· Care advice (10).

· Care advice handouts or lab results and information via secure patient portal.

· Education can be sent through EMR. COPD and stroke information can also be mailed out to patient.

· Education materials can be sent via email.

· email care advice to patients, educational material to patients.

· email healthcare information.

· Facility information sent, as well as self-care advice.

· Follow up instructions sent by texting.

· I think our teaching will be able to be sent to their email address soon.

· Patient education from Krames or Schmitt Thompson Care Advice Handouts.

· Triage routes to Mychart automatically.

· We are able to email care instructions and we can text message COVID-19 information and link to telemedicine app for phone.

· We have some patient information that we can email to patient.

· We offer patient education if the caller is interested.

· We plan to institute this within the year.

· We require the RN to offer to email or text care advice/info on all calls that have a disposition of less than 24 hours, but it is strongly encouraged to send to patients whenever possible.

· We send the Schmitt ACI's (after call instructions) or other health care information we have created.

· We use the email/ text function to share info with patients.

Question 29: Do the nurses at your call center use online nurse chat with callers/patients?

No significant change in the number of call centers using online nurse chat from 2017 to 2020. Comments include: (1) other than patient portals, no other chat is allowed, and (2) two individuals stated they expect to have this capability in the next year.

Question 30: Does your call center charge for your nurse advice services and, if so, what is the charge per call?

Interestingly, there are fewer call centers, at least based on our survey respondents, who charge for their nurse advice services between 2017 and 2020. The average charge for nurse advice call is $17.00; with some charging as low as $8.00 and others as high as $35.00. Only 34% of respondents who indicated they charge for the service (Q31) stated that fee covers the actual cost (e.g., salary, benefits, overhead) of the call.

Question 32: What other services does your call center offer? (Check all that apply)

From 2017 to 2020, there appeared to be a trend, at least from the 2020 survey respondents, for their call centers to partake in more patient engagement-type strategies such as discharge follow-up, disease management and health coaching.

In 2020 there were also more provider engagement strategies offered, such as hospital placement/patient transfer and physician-to-physician referral.

Additional services mentioned under “other” included:

· Answering Service.

· Answering service for specialty services in hospital after hours.

· Physician referral and new patient appointment scheduling. Plain answering service with paging of providers. Send documentation of calls to office daily.

· Post discharge follow up.

· Primary care physician referrals; prescription refill.

· Provider referral.

· Specialty Clinic after hours parent calls coverage Clinic lines come to us if parent wants to talk to an on-call provider.

· The MDs in our clinics can send messages to our in-basket for us to call patients regarding lab results, follow up calls from visit, whatever the MD needs help with that would require any RN teaching.

· We are also the transfer center for the health system so the nurses are cross trained and in the call queue for both nurse triage and transfer center so get both kind of these calls 24/7.

· We do education especially if we are advising home care so that they know what to watch for if they get worse and when to call back.

· We provide health advice/general information.

· We work with the ED PNPs to monitor lab results for patients seen in our ED. Our RNs will call patients with results, provide education as necessary and call in prescriptions per standing orders. We are also working on developing an ED follow-up call program and an asthma post-discharge phone call program.

For more information, please reach out to info@stcc-triage.com.