Roles of Staff Members (Clinical/Non-Clinical)

Q: Telephone Care Providers (TCPs): Who is qualified to provide telephone triage?

• Physicians, physician assistants, and nurse practitioners usually have the skills necessary for providing telephone assessments.

• Registered nurses usually require additional specialized training to become TCPs.

• The standard of care for registered nurses is that they follow written protocols when providing telephone care.

• It is the author’s opinion that medical assistants and LPNs do not have the skills to provide telephone care, even when using protocols. Some offices may use MAs and LPNs to manage calls after special training and under the direct supervision of a HCP.

Q: Non-Clinical Staff: Is there a role for non-nurses in a triage call center?

• It is more cost-effective to use non-clinical staff to front-end incoming calls.

• Clerical staff can collect demographics from callers.

• Calls can then be placed in a call queue and returned (or answered if placed on hold) as telephone care providers (TCPs) become available.

Handling Life-Threatening Emergencies

 Q: How should a call center manage 911 (EMS) calls?

• Do not delay care by giving lengthy care advice. Tell the caller to immediately call Emergency Medical Services (EMS) or 911 (or as directed by your 911 policy). EXCEPTION: If brief advice could be lifesaving (e.g., abdominal thrusts for choking), take 15 seconds to instruct the caller before contacting EMS.

• Reason to involve 911 quickly: EMS can dispatch a rescue squad while a dispatcher helps the caller with pre-arrival instructions (first aid) by telephone, pending arrival of the rescue squad.

• Indications for EMS (911): The patient has a life-threatening condition that may require resuscitation during transport. Examples are severe choking, anaphylaxis, severe respiratory distress, and coma.

• If patient is calling 911 and is alone, call the caller back in 5 minutes to be certain they have called 911.

• EXCEPTIONS: For a suicidal or drug-intoxicated patient, stay on the line with the caller. Have someone else in your call center call 911 to dispatch a rescue squad. Provide support to the caller until help arrives.

Type of Decision-Making Tool

 Q: Are the triage decision-making tools guidelines, protocols, or algorithms?

 Guideline/Protocol:

• The terms guideline and protocol are often used interchangeably.  For example, one online definition defines a clinical guideline as a “best practices protocol for managing a particular condition, which includes a treatment plan founded on evidence-based strategies and consensus statements by peers in the field.”  

• Another definition of a clinical practice guideline that still stands the test of time (IOM, 1990) includes: “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”  

• The Schmitt-Thompson clinical content conforms to these definitions of a clinical guideline/protocol.

The Schmitt-Thompson clinical content is a decision-support tool that:

• Was developed systematically through a survey of the relevant medical literature.

• Incorporates evidenced-based information when available.

• Is reviewed by an expert panel of nurses and physicians.

• Is updated annually based upon changes in the medical literature, feedback from triage nurses, physicians and call center medical directors, input from the Schmitt-Thompson expert reviewer panels, and results from ongoing analysis of outcome and quality assurance information. 

Algorithm:

• One can define an algorithm as a logical sequence of steps for solving a problem that can be translated and loaded into a computer software program. 

• The Schmitt-Thompson clinical content also meets this definition of an algorithm.  The Schmitt-Thompson clinical content is stored in a highly structured relational database and organized algorithmically.

PURPOSE:  Regardless of whether one describes the Schmitt-Thompson clinical content (STCC) as telehealth triage guidelines, protocols, or as algorithms, their purpose is to:

1. Facilitate a safe telephone triage process and sort patients to the most appropriate level of medical care (disposition) based upon the acuity and severity of their symptoms (triaging the right patient to the right place at the right time).

2. Provide decision-support to telephone triage nurses. The purpose of the protocols is to guide the triage nurse’s decision-making process. The triage nurse uses the triage protocols, along with critical thinking and clinical judgment, to determine the best recommendation for the patient.

3. Deliver best practice care and advice based on expert consensus and evidence-based research.

4. Reduce variability in triage practice and provide a standardized basis for referral and patient education.

5. Promote efficient use of resources.

6. Serve as a framework for quality assurance audits and quality improvement.

7. Provide a reference for ongoing nurse education both during and after triage calls.  

Customization of Protocols

 Q: What are the Pros and Cons of customizing triage protocols for a call center?

Some call centers or offices make custom changes to the standard triage protocols.

The pros and cons of making custom changes should be carefully considered when making these changes.

Pros - Reasons to Customize

1. Health care practice standards and health care resources can vary by location. Respecting this variation, local call centers have the right to make minor modifications to the Schmitt-Thompson Clinical Content (STCC) to reflect local healthcare practices and resources.

2. Local Practice Standards. Clinicians in a healthcare network may have developed a consensus standard and identified certain fever thresholds for pregnancy or neonatal fever that require immediate physician evaluation. The drug of choice for treating eye infections has no national consensus and some offices may select a different one for their use.

3. Local Resources. Variation in the availability of health care resources may be a more significant factor than healthcare practice standards. For example, in some rural areas, urgent care centers are rare. In other areas, urgent cares are open 7 days a week with some providing diagnostic testing that rivals small emergency departments (ultrasound).

4. Approximately 10-20% of medical call centers make modifications to the Schmitt-Thompson Telephone Triage protocols. At the majority of call centers these modifications are modest, limited to a few protocols, and approved by the Medical Director or a Medical Advisory Board.

Cons - Reasons Not to Customize

1. Increasingly, national standards should be the guiding factor in clinical decision- making and medical care.

2. The STCC telehealth triage protocols are internally consistent. It is important for clinical care and nursing ease of use to maintain this consistency. A change in one protocol can often make that protocol inconsistent with other protocols. It also may make the pediatric and adult triage or care advice different when they don’t need to be.

3. The STCC telehealth triage protocols have been extensively reviewed by experts from the STCC Pediatric and Adult Review Panels.

4. The content of the STCC telephone triage protocols reflects years of feedback from call centers across the United States and Canada. This feedback process is ongoing and input from medical call center managers and medical directors is actively welcomed by Dr. Schmitt and Dr. Thompson.

5. New telehealth triage protocols are reviewed and tested before release. Updates of existing protocols reflect important and at times critical changes in the medical literature. Updates incorporate the results of call reviews and quality improvement projects.

6.  The Schmitt-Thompson Telehealth Triage Protocols are updated annually. The logistics of synchronizing your customizations with the annual updates increases exponentially with the number of customizations you have made. Mistakes can be made in the process. Call centers also report that this manual synchronization process delays implementation of the annual update.

 Here are our recommendations if your program decides to make modifications to the Schmitt-Thompson telehealth triage protocols:

• For call centers, avoid making customizations for individual physicians or individual physician practices. Instead, research, discuss, and implement customizations so that they are applied to all calls at your call center. This approach to customizations will require active and involved leadership from your call center Medical Director or Medical Advisory Board.

• Utilize policies and procedures. Look for ways to handle changes through your organization’s policies and procedures rather than through changes to the protocols.

• Limit minor changes. Minor changes suggest low clinical significance. The ratio of the benefit of such changes to the challenges of annual protocol synchronization is low.

• Submit your ideas for major changes to the authors. Drs. Schmitt and Thompson welcome input from their triage partners. Managers and physicians can submit recommendations and rationale for content improvement via email. Drs. Schmitt and Thompson will review the recommendation, research best practice, obtain input from the STCC Review Panel members if needed, and then respond to you. If they agree with your recommendation, they will add your changes to the clinical content. This time-tested approach leads to ongoing-yearly improvements in the content that benefits all call centers and office practices.

For office practices, individual modifications can be made to the Schmitt-Thompson telehealth triage protocols based on your group’s physicians’ practices.  

Review/Implementation of Annual Updates

 Q: What is the best way to review and implement the updated protocols each year?

• The protocols are updated each year.

• Most call centers have their medical director review the yearly changes before approval. Offices may have their lead physician review.

• The review process can be labor-intensive if one reviews every single change.

• To expedite this process, it’s recommended that medical directors only review the MAJOR changes in existing protocols and the new protocols.

• Reviewing all the MINOR changes is a time-consuming process and doesn’t serve much purpose.

• Another briefer way to do this review is to target the protocols that the author mentions in the annual “letter to the users” explaining the major changes.

• Some call centers install the updated protocols and use them while the internal review is ongoing. They trust that the updates have already been cross-checked by both authors and other experts in the field.      

Examples of MAJOR Redline Revisions are:

•Addition or deletion of triage assessment question 

•Any movement of a triage question to a different disposition level

•Substantive care advice changes

•Substantive background information changes

•Substantive definition changes

Examples of MINOR Redline Revisions are:

• Addition / deletion of references

• Re-ordering of triage assessment questions within the same disposition levl

• Minor wording changes throughout

• Spelling, grammar, punctuation

• Any Search Word change
  
  

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