Telehealth Triage - Getting to Yes
We’ve all been there. Precious minutes spent gathering pertinent information for our assessment, careful selection of the correct guideline, 2 -3 pieces of vital care advice shared, only to have the patient decline our triage disposition. About 7 out of 10 callers follow our recommendations, what about the other 30%? How can you ensure better alignment? How can you get past no to yes?
Patients have a variety of reasons why they don’t follow our recommendations. Fear, cost, denial, embarrassment, lack of understanding, and unclear triager communication all can play a part in a patient choosing not to follow the triager’s guidance. Here are a few tips that will help prepare you for the next time a caller declines to follow your advice.
Keep an Open Mind
Check your assessment - did you collect adequate information? Clarify vague or potentially high acuity information? Did you make assumptions? Jump to conclusions? Did you consider the guideline “rule out” statements?
Remember to start with an open – ended question and allow the patient to speak uninterrupted for the first 30 to 45 seconds. This will allow the caller to share important information and concerns. It will also help you develop a working nursing diagnosis and clearly understand the urgency of the caller’s situation.
Keep Open Ears
During your initial assessment and guideline triage questions, did you carefully listen to the patient’s responses? Did you hear what the patient was saying “between the lines?”
Some clues that may suggest the caller feels a concern was not heard:
Caller makes a request several times
Caller suddenly becomes quiet
Symptom(s) are repeated several times by the caller
Utilizing active listening skills is key. Ideally, a triage call should be a collaborative partnership. The patient and nurse work together to clarify symptoms and develop a plan.
Check for Understanding
Does the patient understand the consequences of not complying with your recommendation? Denial can be powerful. Denial can be used as a coping mechanism. It can also prevent a patient from seeking necessary care or treatment in a timely manner. Questions or statements such as “do you think that is really necessary?” or “I know my body. I’m sure it’s not my heart” can tip you off to investigate further.
Note: If a caller is cognitively impaired, the triager will need to advocate on the patient’s behalf. This would include getting the patient the appropriate level of care (e.g., call Emergency Medical Services, EMS 911, on their behalf.)
Recognize that High Acuity Symptoms Can Trigger Feelings of Fear or Denial
It is helpful to quickly identify high risk symptoms and be prepared for a caller’s objections, should a caller decline your recommendation. Preparation can aid the triager in minimizing delay of care and being caught off-guard by a reluctant caller.
Know and be prepared for objections in high acuity situations (activating EMS 911). Here are some examples of objections you might encounter, as well as potential responses:
“I can’t afford this” – “In most regions, EMS 911 is tax payer funded, and EMS evaluation is a free service. EMS can tell you if it is safe for you to be driven somewhere for care, or if ambulance transport is needed.”
“What will the neighbors think?” – “The neighbors will know that someone needed help, and that help has arrived quickly”.
“Is this really necessary?” or “I’m going to wait and see” – The triager can briefly summarize the symptoms and their concern. “Based on what you’ve told me, I’m concerned for your heart. I would like 911 to come and evaluate you. Will you call them now?”
“Can’t I just drive myself/my loved one?” – “What if something happens to you on the way? You may be endangering yourself and others.” “What if something happens to your loved one on the way? You will not be able to help them and drive at the same time.”
“Can’t I go to the fire station?” – “The medics/EMTs may be out on a call. Dispatchers will send a unit that is closest to your location at the time of your call. It’s quicker for them to come to you.”
“Can’t I just go to the Urgent Care?” – “Urgent cares are a great service, but they don’t have all of the services or tests that an emergency department has. For your particular symptoms, the emergency department is the most appropriate place.
“Do they have to turn on the lights and sirens?” – “You can request that they don’t put lights and sirens on in your neighborhood.” (Note: Lights and sirens will be used on main arterials and streets when en-route, for everyone’s safety.
“I don’t want to take the chance of exposure to COVID” – “EMS and hospital emergency rooms take the utmost precautions to provide for your safety.” A care advice statement from the COVID guideline can be helpful. “If you or your child needs to be seen for an urgent medical problem, do not hesitate to go. ERs and urgent care centers are safe places. They are well equipped to protect you against the virus.”
Be specific. Be direct. Be brief. If the patient is then agreeable to the plan, give clear, concise, short instructions to the caller. (e.g., You need to hang up and call 911 now). If needed, help the caller with a brief summary of symptoms to give to the dispatcher (e.g., I’m having chest pressure).
Note: Some call centers may call on behalf of the caller. It is preferable for the caller to call EMS directly. This will connect the patient to the correct EMS system and can give EMS the caller’s address/phone number automatically. Follow your contact center policy.
If the patient still declines your recommendation, briefly restate your recommendation and rationale, and then ask the patient’s intent. “My recommendation is still that you call 911, I am concerned about your heart symptoms. What are you planning to do?” If the patient is seeking a different level of care (e.g., driving to ED), notify that facility if possible. State your recommendation clearly, calmly, and concisely. Be mindful to not delay a patient seeking care by being argumentative, badgering or coercing the patient to comply.
Involve Others
If you have a high level of concern, consider involving the patient’s primary care provider (PCP). Family members may also be important advocates (if the patient agrees with involving them in the decision).
Document The Call
Note your recommendation, the patient’s non-compliance, understanding of the consequences and intent for care, if disclosed. Document any special efforts made (e.g., involving their PCP).
Debrief with Your Lead or Charge Nurse
Concern for the patient’s safety or that a collaborative partnership was not established in a call can be worrisome to a triager. If needed, debrief and review with a lead or charge nurse to see what opportunities there may be for improvement or learning. A follow-up call to the patient can be helpful.
Closing Points
Triagers aim to provide a quality assessment and efficient direction to the appropriate level of care using active listening, clear communication, and critical thinking.
Being prepared for a caller’s “no” will aid the triager in guiding the caller to the optimal level and timing of care.
Preparing for “no” can help improve communication and the patient’s understanding of the rationale behind a disposition.
Clearly document when a patient has declined to follow your instructions.
Author
Cheryl Patterson, RNC-TNP, BSN
Nurse Editor, Adult Clinical Content
Schmitt-Thompson Clinical Content, LLC
Co-Authors
Gary Marks, DO
Medical Editor, Clinical Informaticist, Adult Clinical Content
Schmitt-Thompson Clinical Content, LLC
David Thompson, MD
Senior Medical Editor
Schmitt-Thompson Clinical Content, LLC
References
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Thompson DA. Coronavirus (COVID-19) - Diagnosed or Suspected. Adult After Hours Telephone Triage Guideline. 2020. Schmitt-Thompson Clinical Content.
Valanis B, Gullion C, Moscato S, et. Al., Predicting Patient Follow-Through on Telephone Nursing Advice, Clinical Nursing Research. 2007 August; Vol 16 (3): 251 – 269.
Williams Arthur Robin, Olfson Mark, Galanter Marc. Assessing and Improving Clinical Insight Among Patients “in Denial,” JAMA Psychiatry. 2015 April; 72(4): 303–304.