Telephone Triage Nurses and Telemedicine Providers: Key Strategies for Teamwork in Office Practice

Oct 14

Telemedicine (TM) video visits were off to a slow start in most offices and clinics. Then along came the COVID-19 pandemic and TM care took off. To prevent the spread of the virus, primary care providers (PCP) transitioned from in-person visits to providing as much definitive care as possible by video visits. Being able to bill at in-person rates was an added motivator. PCPs quickly adapted, overcoming any concerns about learning video visit technology. Reports that a significant percentage of contagious patients with this new virus are asymptomatic increased their interest. Families who were afraid of catching COVID-19 in a medical setting welcomed a video visit option. Convenience was an added incentive. This report reviews how to optimize teamwork between telephone triage nurses and the PCPs who provide video visits during office hours.

Repurpose Telephone Triage Protocols to Support Telemedicine (Video) Visits

Nurse triage continues to be a vital part of how office practices manage their patient populations. Nurses can use the triage questions and care advice as written but modify the dispositions to include a TM option. Most of the current dispositions simply need to add the phrase “or schedule a video visit” to the existing “in person visit” wording. See Table 1.

There are two main exceptions:

1. Triage questions that fall under the 911 or Go to ED Now dispositions. These indicators recognize serious conditions where delay in diagnosis and treatment could lead to adverse outcomes.

2. Patients who are nurse-triaged to the Home Care dispositions. They usually don’t need PCP involvement.

Use Nurse Triage to Front-End PCP Telemedicine (Video) Visits

Office triage nurses can continue to independently manage most calls about well children (such as eating, sleep, behavior, vaccines and new baby questions). During office hours, these may account for 30% of pediatric calls.

For calls about sick children, each practice will need to decide if nurses continue to triage all of them or just some of them. If the practice wants nurses to triage all sick child calls, up to 50% will be triaged to the Home Care disposition (mildly ill and don’t need to be seen). Nurses can then schedule the patients who need to be seen to the PCP for an in-person or video visit.

Some practices prefer to let the parent decide. After knowing the reason for the call, the front desk staff can ask: “Do you want an appointment with your doctor or do you want to talk with our advice nurse?” If they want to be seen, an in-person appointment can be scheduled. If a parent prefers a video visit, it can also be scheduled, but only after a triage nurse or PCP confirms the main symptom is appropriate for telemedicine. For TM visits, the protocol-recommended timeframe (such as See Today) for in-person visits should be adhered to for risk management. If a TM visit is available earlier, that is a win.

Help Triage Nurses Select Appropriate Sick Patients for a Video Visit

Some PCPs have attempted to provide telemedicine visits on almost all sick patients who would normally be triaged to an office visit. Most of the time, it is successful with a video physical exam and without any lab tests. When not, the patient is sent to the office soon after the call. The office visit can then be a brief encounter, such as to perform a rapid strep test or COVID-19 test, This solution is called a “split visit” or “2-step visit”. We learned of this innovative approach from colleagues who practice pediatrics in the Denver community.

Most PCPs want nurses to more carefully select patients for telemedicine visits. Here are some tips. Establish exclusion criteria for telemedicine visits. This is easier than trying to establish inclusion criteria. Which symptoms would be difficult to manage by TM provides an easier consensus than inclusion criteria. It’s also a shorter, clearer list for triage nurses to understand, implement and even memorize.

Some offices where a physician and nurse have worked as a team for many years may not even need such a list. Nurse judgment and experience from working closely with a specific PCP might allow the triage nurse to select appropriate patients for telemedicine visits. When in doubt, office nurses can ask for guidance in real time.

Telemedicine Exclusion List for Office Triage Nurses: Symptoms and Conditions Not to Refer for a Video Visit

The Telemedicine Exclusion List in Table 2 is a work in progress. It will need to be customized by most primary care practices. Office providers and triage nurses may find it a helpful resource that they can build upon. Some software platforms with protocols in electronic format support customizing specific triage questions that are not appropriate for telemedicine. Nurse judgment and awareness of PCP preferences will also play an important role in deciding who is appropriate to refer for telemedicine. In our experience, most suspected COVID-19 calls and symptoms are being managed by telemedicine visits.

Another decision is where to start. Table 3 lists the nurse triage protocols that are the most amenable to telemedicine care. They are protocol symptoms with high call volumes. They also have a high likelihood that a video visit can provide definitive diagnosis and treatment.

STCC Guidance for Video Visits within Office Hours Protocols

STCC editorial teams are adding video telemedicine visits as an option to appropriate dispositions (see Table 1 for details). We are also tagging individual triage questions as either eligible (Yes) or not eligible (No) for a video telemedicine visit. These two improvements for nurse telehealth triage decision support will be part of the 2021 Office Hours annual content update.

We are initially performing telemedicine tagging of 50 pediatric and 50 adult triage protocols. We have selected these protocols based on high call volume and whether the symptom (reason for call) is a unique triage challenge. This will result in some differences in the topics selected for the pediatric and adult protocol sets.

STCC initial tagging for video visits will have safety as the highest priority. This can be looked upon as basic tagging. We recognize that telemedicine practice varies across the country. We expect individual practices to approve additional patients and symptoms for video visits based upon their experience. In the meantime, Tables 2 and 3 may help offices start a video visit program or improve their existing call selection process.

Join the New Normal

TM video visits are part of the new normal in pediatric offices. Most PCPs have learned how to provide them. Families appreciate their convenience and safety from COVID-19 contact. Most parents also want the service provided by their PCP, not an unknown health care provider from a direct-to-consumer TM company. More importantly, the PCP can seamlessly convert a video visit into an office visit when needed.

During office hours, office triage nurses can schedule TM visits in real-time. On weekends and holidays, call center nurses can schedule patients triaged to the Video Visit within 24 Hours disposition with on-call PCPs who are willing to provide this service during the day. These are the patients who otherwise might need referral to an ED or UCC over the weekend. In summary, this is what we have learned from managing calls about suspected COVID-19 infections: There is no “going back”.

Table 1: Office Hours Calls: New Dispositions that Include a Video Visit Option

The following dispositions with Video Visit added can replace the existing office hours dispositions within Pediatric Telephone Protocols and Adult Telephone Protocols books (American Academy of Pediatrics Publisher). The same can be done for the expanded number of office hours protocols in software.

Call EMS 911 Now – no change
Go to ED Now – no change
Go to ED/UCC (or to Office with PCP Approval) Now – no change
Go to Office or Video Visit Now
Call Transferred to PCP or Video Visit Now
Callback or Video Visit by PCP within 1 Hour
See in Office or Video Visit Today
See in Office or Video Visit Today or Tomorrow
Callback or Video Visit by PCP Today
See in Office or Video Visit Within 3 Days
See in Office or Video Visit Within 2 Weeks
Home Care- no change

Table 2. Telemedicine Exclusion List for Office Triage Nurses

Emergent Dispositions (911 or Go to ED Now) need to be excluded from video visits. See Table 1.
Specific Protocols may be excluded. Examples: Earaches, Confusion, and Poisoning.
Physical Finding not visible by video visit is required for diagnosis. Examples: severe ear pain that needs an eardrum exam; throat lesions that are difficult to visualize, vision loss that needs a retinal exam.
Genital Image is required for diagnosis. Reason: sensitive image to transmit.
Lab Test is required for diagnosis. Example: suspected urinary tract infection (UTI) that needs a urinalysis and urine culture (exception: bubble bath urethritis); suspected Strep pharyngitis that requires a rapid Strep test; chronic symptoms that require any lab work.
Imaging is required for diagnosis. Example: injured lower extremity and child can’t bear weight.
Procedure is required for treatment. Example: gaping wound that needs suturing or an animal bite wound that needs vigorous irrigation.

Note: Telemedicine providers can also elect to order outpatient lab tests (such as a CBC) or imaging (such as ankle films) to complete their evaluation.

Table 3. Recommended Nurse Protocols for Video Visits

Dermatology protocols: Rashes, skin lesions, bites and stings are where most PCPs start (includes 30 topics in the AAP pediatric book). Tip: request caller send an image in advance.
Allergy protocols: Allergic rhinitis and conjunctivitis are easy to manage.
Cough and Cold protocols: A virtual visit can rule out signs of respiratory distress. Once that is done, most coughs and colds can be managed successfully, including sinus symptoms.
Diarrhea and Vomiting protocols: A virtual visit can rule out signs of dehydration, such as a prolonged capillary refill. Prescriptions for ondansetron have reduced the need for intravenous rehydration.
Follow-up visit protocols: Examples are follow-up calls for patients with bronchiolitis or taking antibiotics for an infection.

Authors

Barton Schmitt, MD, FAAP

Medical Editor, Pediatric Content

Schmitt-Thompson Clinical Content, LLC

Past Medical Director 1988-2019, Pediatric Call Center, Children’s Hospital Colorado

Daniel Nicklas, MD

Contributor, Pediatric Content