Skilled Telephone Triage Programs Streamline Symptom Management

When Kristin Cawley, RN, bgins her day at Memorial Sloan-Kettering Cancer Center (MKSCC) in New York City, she has two essential tools at her fingertips: a set of telephone triage protocols and a standard documentation form. In the next 10 hours, she will see patients and confer with their physicians. But like the 400 other RNs in ambulatory care at MSKCC, she will also talk to dozens of patients on the phone. Most of those calls will concern symptoms and will draw on Cawley's specially honed skills in telephone triage.

A thousand miles to the south, Irene Rosenberg, RN, prepares for her day at Lake County Oncology and Hematology in central Florida, where she heads a team of nine nurses who divide their time between several clinics in the county. At least one of those nurses will take telephone triage duty that day and, like Cawley, practices in a highly specialized area of oncology nursing.

"We consider this a very high-level skill," said Elizabeth Rodriguez, RN, nurse leader in MSKCC's ambulatory care department. "It's one of the biggest learning curves for nurses coming here from other places."

Telephone triage represents a totally different way of interacting with patients. It is a specialty, and oncology telephone triage is a subspecialty within it, said Virginia Martin, RN, clinical director of ambulatory care at Fox Chase Cancer Center in Philadelphia, which has a staff of seven dedicated triage nurses.

Cawley, Rosenberg, Rodriguez, and Martin are part of a growing trend in oncology nursing. In a 2004 survey of ambulatory care nurses conducted by the Oncology Nursing Society (ONS), about 54% of respondents said that telephone triage was part of every nurse's assignment, and 27% said their departments had designated telephone triage nurses. The American Academy of Ambulatory Care Nurses (AAACN) reports in its publication on telehealth practice standards that telehealth nursing—an umbrella term that includes telephone triage—is one of the fastest growing opportunities for nurses. Certification is available through the AAACN, which also publishes other resources in this field (see sidebar).

Patients have been calling nurses, and vice versa, for decades. But formal telephone triage programs in oncology began in the 1980s when cancer treatment moved from inpatient to outpatient settings. Unstructured at first, triage has evolved into what is now called telephone management. According to the ONS, the process includes written protocols or guidelines, complete and concise documentation, and procedures within the busy practice setting.

Some institutions have also established formal e-mail programs for patients' questions on routine matters such as scheduling or prescription refills. Symptoms are not managed by e-mail, and phone calls still outnumber e-mails. But researchers are looking at the potential of e-mail in special situations where telephone communication may be difficult.

How It Works

Telephone triage programs can take several forms. At MSKCC, each nurse works with one physician and spends equal time in the clinic and the office; in both settings, the nurse is involved in telephone triage. Lake County nurses also combine face-to-face patient care with triage duty, which rotates to a different nurse each day.

Other oncology centers, like Fox Chase, have dedicated triage nurses. At Kaiser Permanente Fair Oaks Medical Center in Fairfax, Virginia, the oncology department uses a variation on this model: Kara Dunn, RN, a dedicated triage nurse, takes most calls but receives backup as needed from a health-care team nurse.

Regardless of the system used, the basic triage process is similar. The first step, which takes place at the office or clinic, involves educating patients about when to call.

"This is extremely important and has to be constantly reinforced," Rosenberg said.

Nurses in practices that allow e-mail instruct patients to report symptoms or side effects by phone rather than e-mail. The incoming e-mails at Kaiser, for instance, are monitored, and those containing questions about urgent symptoms are referred to a nurse, who then telephones the patient.

At most institutions, calls from patients go first to reception staff, who either take a message or forward the call to a triage nurse. Training reception staff to distinguish between urgent calls, which must go directly to a clinician, and nonurgent calls is an important part of the process, Rodriguez said. At Fox Chase, reception staff members also use an online documentation form to obtain basic patient information.

Nurses in a variety of practice settings report that most questions they receive by phone concern symptoms and side effects of treatment. But patients also call to clarify treatment goals and home care instructions, obtain lab and test results, request prescription refills and referrals, and ask for help with insurance issues.

When triage nurses return calls regarding symptoms, they perform a systematic assessment using a standardized protocol for each symptom. These guidelines consist of detailed questions about specific symptoms: How long has the vomiting lasted? How often does it occur? What is its appearance? The nurse then assesses the level of urgency, again using standard guidelines, and decides on the next step. This may involve changes in home care, for example, or urging the patient to come in to the office.

Maureen Espensen, RN, helped create and now teaches the AAACN's core course on telehealth nursing practice, which includes telephone triage (see sidebar). The importance of protocols and guidelines cannot be overemphasized, she said, because they ensure both a logical sequence to the assessment and adherence to a standard of care for all patients.

But even with the use of protocols, telephone nursing relies heavily on expert communication skills. Symptom assessment is rarely cut and dried, and evaluating patients without being able to see them presents the fundamental challenge of telephone management.

"Your ears have to become your eyes," Dunn said.

Susan Newton, RN, who coauthored the ONS handbook on telephone triage, also rates good communications skills as a primary requirement in this subspecialty.

"A triage nurse has to make sure she's listening and asking the right questions, but at the same time not leading the patient," said Newton, an oncology advanced practice nurse in Dayton, Ohio.

Espensen agrees that the nurse directs the assessment, but the patient must participate actively.

"Because the nurse can't see or touch the patient, the patient must help with the assessment," she said. "Is the area around the catheter port red? Does it feel warm?"

Once the triage nurse has appraised the symptoms and formulated a plan for managing them, the next step is verifying that the patient understands both. According to Newton, two essential questions—often overlooked—should conclude a telephone conversation about symptoms: "Can you repeat what we have just discussed?" and "Is there anything that would keep you from doing what we just talked about?"

The last step is documenting the call. Many institutions use special forms, either hard copy or electronic, to record the reason for the call, the assessment performed, the outcome, and the planned follow-up. The form becomes part of the patient's record, and physicians and other nurses are alerted to the reason for the call and its outcome.

Web-based systems can streamline the entire triage process. At institutions with electronic medical records, triage nurses conveniently call up patient records, including physician notes on a patient's last visit and other details of treatment that can inform the telephone assessment.

Just as telephone management settles into established forms and standards, electronic communication has emerged, presenting a whole new set of issues. Informal e-mails between patients and physicians or nurses are no longer unusual in many practices, but formalized systems have only recently been developed. At M.D. Anderson Cancer Center, for instance, a new web-based process allows patients to ask non-symptom-related questions and receive educational materials, said Colleen Jernigan, RN, clinical administrative director.

Nurses and physicians at the Kaiser oncology office in Virginia have been answering secure member e-mails since August 2006 as part of a larger initiative called Kaiser Permanente HealthConnect. The program provides members with online access to their medical records, lab results, and other health information. A prime advantage of e-mail is its potential to reduce telephone interruptions and "telephone tag" for nonurgent questions, Marshall said.

Privacy is a major issue in e-mail programs. The special websites help ensure e-mail security, as messages are not sent from or received on the patient's home e-mail but only on the secure website. Software that encrypts messages passing outside the institution's firewall provides another solution, which MSKCC has adopted.

Resistance among providers may account for the slower adoption of e-mail programs. In response to a survey of surgeons and nurses who care for head and neck cancer patients, the surgeons expressed misgivings about privacy, liability, reimbursement, lack of effective two-way communication, inappropriate topics, and "abuse of unlimited access to a health-care provider." Nurses voiced additional concern about patents' access to e-mail and ability to use it. The head and neck cancer patients, on the other hand, in a separate survey supported the use of e-mail for their questions to clinicians, said Sarah Kagan, PhD, RN, at the University of Pennsylvania School of Nursing, who led both surveys.

As telephone and e-mail programs expand, liability and other legal issues become more critical. Implementing a risk management plan and using standard protocols and guidelines can reduce risk, said Maureen Power, RN, who conducts AAACN seminars on risk management in telephone triage. Ensuring that only RNs perform triage will also help avoid liability, and some experts in oncology recommend that only experienced oncology nurses undertake triage.

"If you're brand-new to oncology, you wouldn't be in triage," Newton said. "It's hard to overestimate the importance of this job."

Disclosures:

The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.