Telephone Home Care Advice: Improve Your Skills

Jul 8

Telephone Home Care Advice: Improve Your Skills (PDF)

You just finished triage. Your patient does not need to be seen urgently. It’s home care advice time. It’s when you switch from asking triage questions to teaching. Here are some tips to help improve your nurse care advice skills:

Telephone Home Care Advice: 7 Parts

Let’s start by splitting home care advice into 7 parts. We’ll provide tips on how to discuss each part with your caller.

Primary Symptom. Name the non-urgent illness or injury.
Treatment. How to treat the main symptoms.
Medicines. How to reduce the unnecessary use of medicines.
Reassurance. How to reassure parents who have unnecessary fears.
Expected Course. How long symptoms will last.
Contagiousness. When the child can return to day care or school.
Safeguards. Reasons to call back.

Give the Non-urgent Illness a Name

Reassure the parent you know what their child has: ”From what you’ve told me, it sounds like your child’s symptoms are consistent with a mild viral cough.”
It’s a required first step in Care Advice (CA).
Conveying the “symptom is safe” is therapeutic.
Only then is the caller ready to listen to your home care instructions.

Nurses Can’t Make Diagnoses, but You Can Talk About Them

The state Nurse Practice Acts do not allow nurses to “diagnose”. Nurses can only assess and describe the acuity level for each symptom. So how can you reassure the caller their child is safe if you’ve triaged them to Home Care?

Protocol Diagnoses. Tell the caller the symptom diagnosis and status found under Home Care in the protocol. Examples: diarrhea without dehydration, minor wrist injury, eye allergy from pollen. The protocol you are using supports your symptom diagnosis.

Caller Diagnoses. Agree with the caller’s stated diagnosis if symptoms match the protocol’s criteria for that diagnosis. Examples: head lice, impetigo, menstrual cramps, thrush.

Provider Medical Diagnoses. For follow-up calls on patients already seen by a health care provider, elicit and use the medical diagnosis given by them. Examples: bronchiolitis, cellulitis, urinary tract infection. Your job is to rule out complications of that diagnosis by protocol triage.

Go to ED Diagnoses. Even if you know what the patient probably has, don’t share it with the caller. Reason: This is a medical diagnosis and requires a physical exam and perhaps some test results. Just tell them the protocol disposition and need for an urgent evaluation. Examples: appendicitis or pneumonia.

Treating the Main Symptom: First Elicit the Caller’s Approach

Find out how they are treating the symptom. Ask: “What have you tried so far?” Note: Some may have called you first.
If correct: give approval, such as “You’re doing a great job with this”.
If incomplete: add your advice.
If harmful: educate in a kind way. “Research has changed our approach to that”.
Example: OTC cough and cold medicines are not FDA approved before 6 years of age. Reason: side effects and lack of efficacy.
Goal: encourage caregivers to think for themselves.

Treating the Main Symptom: Give Your Specific Care Advice

Detailed CA is found in every protocol. Here are some brief examples:

Blocked nose: nasal saline rinses to remove dry sticky mucus. No medicine can do that.
Coughing fits: Honey if 1 year or older. Also helps sore throats.
Knee and ankle injuries: RICE.
Vomiting: ice chips or popsicles.

Medicines: Clarify Their Limited Value in Treating Common Illnesses

Try to understand the caller’s magical thinking about medicines. Examples:
Many think antibiotics will cure viral infections. Fact: They only kill bacteria. Most sinusitis is viral, a normal part of a cold.
Many think all symptoms are bad and need to be removed. Fact: most are beneficial, such as coughs that protect the airway and prevent pneumonia.
Many think OTC medicines will shorten the course of the disease. Fact: They do not.

Many think OTC medicines are superior to home remedies. Fact: Most have minimal efficacy. Example: studies have shown honey is more effective at reducing coughs than OTC cough syrups.

Reality: Medicines have a limited role in the treatment of common infections that all children get many times per year. Exception: analgesics for pain and antihistamines for allergies. The remedy for this demand is teaching.

Reassurance: Role in Care Advice

Reassurance can counter unnecessary or unrealistic fears.
Reassurance is indicated during many calls.
Parents worry more about certain children: their first born, infants, preverbal toddlers, children previously hospitalized or with a chronic condition.
Expect it and provide extra reassurance for these parents.

Symptoms Parents Worry Most About

Fever is #1. Many parents even consider fever an emergency. Reason: parents think it will keep going higher if they don’t treat it. Fact: untreated fevers from infections rarely go above 105 F. Fevers do not become harmful until they go above 108 F.
Vomiting is #2 Reason: parents afraid it won’t stop.
Coughing is #3 Reason: parents think it’s in the lungs.
Be prepared to reassure these callers.

Tips for Effective Reassurance

Listen carefully to identify the specific fear or worry.
Give strong targeted reassurance. Example: Fever turns on the body’s immune system. Fever from infections is always helpful.
Keep reassurance brief: just make one point. Example: coughing protects the lungs from pneumonia.
Universalize their fear or misconception: “Many parents worry about that”.
Universalize treating at home is safe. “Most children with …….don’t need to see a doctor.”

Expected Course: Recovery Time

Tip: When predicting how long the illness will last, give realistic cutoffs, not optimistic ones.
Don’t be tempted to make the parent happy.
Reason: parent will want child seen again if not recovering in the timeline you predicted.
Example: many viral coughs last 3 weeks. If you predict the cough will be gone by 2 weeks, the parent will call on day 15.

Contagiousness: Return to Day Care or School

Goal: prevent staying out too long.
CDC universal advice for respiratory infections: return when the fever is gone for 24 hours AND symptoms are improving.
Don’t have to wait until all symptoms are gone. Reason: day care is where they got the infection.
Upside: children in day care are building their immune systems.

Return Precautions: Call Back If

Call back instructions are your brief contingency plan in case evolving illnesses need re-triage. In our protocols, they usually include 3 warnings:

A serious new symptom occurs. Each protocol lists the 1 or 2 most common signs of a complication for that symptom. Examples: bloody stools for diarrhea or trouble breathing for cough.
Symptom lasts too long. Use the realistic cutoffs per protocol. Example: over 24 hours for isolated vomiting or 2 weeks for loose stools.
Your child becomes worse. A universal safety statement that encourages a recheck if the child becomes worse compared to when you triaged them today.

Telephone Home Care Advice: Reality Strikes

Does any telehealth nurse have the time to cover the 7 parts of home care advice with every caller?

Will the caller be able to take notes that fast?
If not, will the caller be able to remember all the important advice you carefully went over with them?
Of course not. This has been an exercise in advanced care advice with some tips you may use during future specific calls.
Call efficiency is equally important. See our December 2022 Newsletter on Winter Call Volume Surges for tips on efficiency.
An alternative: complete your caller education with Care Advice handouts, which align with protocol home care advice.

What Handouts are Available?

Pediatric Care Advice (PCA): 440 electronic handouts.
Adult Care Advice (ACA): 150 electronic handouts.
Included with all office-hours protocol and after-hours guideline sets.
Handouts are designed to match with specific protocols.
Available at end of your call.
Can text, email or send to a patient portal
Ask your software vendor for the easiest way to access the STCC handouts in their platform.

Sending Handouts: Benefits for Callers

Compensate for normal human forgetfulness.
Increase amount of information that can be transmitted.
Increase number of people who receive your instructions.
Improve accuracy of treatment plan that is implemented.
Improve caller compliance with your treatment plan.
Call back instructions improve patient safety and prevent medical liability.
Increase caller satisfaction with your care.

Sending Handouts: Benefits for Telehealth Nurses

Reduce call times. Save nurses from giving all CA live.
Greatest help with calls having long CA. Examples: Vomiting, Head Injury, COVID-19, Influenza and Head Lice calls.
Help you with Care Advice only calls.
Reduce unnecessary callbacks.
Help you catch up during call surges.

Care Advice Summary: What Every Parent Wants to Hear

“From what you’ve told me, your child has….”

A mild illness.
No complications.
Symptoms that are safe to treat at home.
“Here is exactly what to do.”
“If things change, always call us back.”

Patty Maynard