Take 5: Developing an Electronic Telephone Triage Document in the Adult Ambulatory Care Setting
Oncology nurses are on the frontline of telephone triage. Optimizing telephone interactions with patients is key to improving ambulatory nursing practice, as it allows nurses to efficiently provide symptom management; patient education; emotional support; and high-quality, complete documentation for comprehensive and consistent patient care.
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Oncology Nursing Society 36th Annual Congress
Poster 202 / abstract 1025642-Developing an Electronic Telephone Triage Document in the Adult Ambulatory Care Setting
Catherine Wickersham, RN, BSN, OCN; Young-Shin Park, RN, MSN, CNOR; Maryellen O’Sullivan, RN, MSN
Department of Ambulatory Nursing, Memorial Sloan-Kettering Cancer Center
Oncology nurses are on the frontline of telephone triage. Optimizing telephone interactions with patients is key to improving ambulatory nursing practice, as it allows nurses to efficiently provide symptom management; patient education; emotional support; and high-quality, complete documentation for comprehensive and consistent patient care.
Ambulatory nurses at Memorial Sloan-Kettering Cancer Center (MSKCC) field approximately 200,000 calls per year, so it is critical that a searchable, structured framework for patient information be in place. Prior to the current study, nurses at MSKCC used an electronic signature note that included areas for documentation of only 15 symptoms and did not allow for querying of data.
• Following an evidence-based review, members of the ambulatory nursing practice council at MSKCC modified the institution’s current text-based telephone triage manual and developed an electronic structured nursing telephone communication note.
• The electronic telephone triage document, ClinDoc, is a 60-symptom tool developed by an MSKCC team of nurse informaticists, staff nurses, and clinical system analysts, using input on patient symptom information from several of the institution’s departments. It includes an explicit breakdown of each symptom so patients are triaged appropriately. It also documents reasons for the patient’s call (symptom management, patient education, reassessment, referral, lab/test result, treatment care, home care, and “other”) and the intervention that is recommended by the licensed practitioner.
• The document guides nurses to triage by symptom severity, quality, onset, duration, associated symptoms, and precipitating / alleviating factors. Nurses also can pull patients’ laboratory values directly into the document and can enter orders, allergies, falls, and infection-control precautions.
A 2-week pilot test of the new documentation form was conducted in 3 services: Neurology, Thoracic Surgery, and Lymphoma. Subsequently, the form was modified based on nurses’ feedback and a phased implementation by all ambulatory services, including regional sites, was initiated. The pilot test was started in May 2010 and implementation at the regional sites was completed in December 2010.
• The top five symptoms identified in the 2-week pilot test were “other,” pain, constipation, cough, and edema.
• In the first quarter of 2011 (January through late March), there were 54,530 calls.
• Analysis of presurvey and postsurvey results indicate that response to the electronic documentation system has been very positive, and ClinDoc was viewed as clear, concise, and easier to read compared with the previous documentation tool used at MSKCC.
The benefit of the electronic documentation system is its ability to standardize a large call volume, decreasing documentation errors and improving the availability of patient information. The data not only allow nurses to review practice issues in specific patient populations, but they also inform future nursing research and guide education of both nurses and patients.
• Next steps include elimination of “other” as a reason for call and as a symptom choice, since this was linked to a free-text area so the information added is not searchable or quantifiable. For this reason, and because nurses were sometimes using the “other” section to document a symptom already included in the 60-item list, cases of missed symptom capture occurred. Education of nurses to ensure proper use of the electronic documentation tool is ongoing.
