Timely Tips for Telephone Triage Nurses

While use of computerized guidelines is the standard of care in telephone triage, nurses can sometimes rely too heavily on these decision support tools and miss essential elements of a patient's problem. In her article in the September/October 2009 issue of AAACN ViewPoint, Carol Rutenberg notes that these tools should be used as blueprints, and that the nursing process should be used as in other types of nursing. She offers tips to adjust the nursing process for telephone triage nurses.

During assessment, the nurse can glean key information not only from the caller's words, but also from listening to the patient's breathing and speech, Rutenberg says. Callers can also provide objective measurements such as temperature, blood pressure, and weight as well as describe lacerations and amount of bleeding. Rutenberg writes, "A good rule of thumb is that anything nurses can do with their eyes, hands, or nose, callers can do…with adequate direction from the nurse."

During each call, the telephone triage nurse must identify a problem as emergent, urgent, or routine, develop a plan of care that the patient is likely to follow, and implement that plan. This continuity of care is an essential part of the telephone triage nurse's role.

Finally, to evaluate the interaction, the nurse must have a plan to determine if the patient got better. If not, the nurse must reassess him or her, revise the plan of care, implement the new plan, and reevaluate. Rutenberg says doing a thorough assessment, anticipating the worst possible scenario, and erring on the side of caution are key to successful telephone triage.

("Telephone Triage: Timely Tips"; Carol Rutenberg, RNC-BC, MNSc; AAACN ViewPoint; September/October 2009; www.aaacn.org)