Questioning Our Assumptions in Telephone Triage: False Expectations, Common Errors and Evidence-Based Policies

Abstract

Opinion piece regarding false assumptions in telephone triage practice.

Full text

Questioning Our Assumptions:
Expectations, Error and Evidence-Based Policies
Although telephone triage is a uniquely high-tech eld, it is still
evolving professionally. And because it lacks full professional
development, it is reasonable to question our current assumptions.
For example, is it our task to perform a dierential diagnosis? Does
Information technology inherently make the work safer? Historically,
developers have given short shrift to the nursing process and its
clinical application to the task of telephone triage. Do medically
developed algorithms take the place of critical thinking and clinical
training in telephone triage?
Finally, has technology made our professional lives easier? Is our work
less stressful or safer? New research nds that user-unfriendly
software creates more work for some physicians, who now work 11-
hour days (Gawande, 2018). Can telephone triage nurses be far
behind? Some software may exacerbate decision fatigue – a
predictable human condition that degrades decision-making after 6
hours (Linder, 2019).
Safe assumptions about the eld of telephone triage are that

It is a form of clinical care

it is designed to facilitate safe, timely (early or on time) access

it is a form of pre-arrival care (takes place prior to arrival on
site )

it requires clinical decision-making under conditions of
uncertainty and urgency
Expectations
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


 !"
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 #

“Triage is not an endpoint but a beginning. Systems with a basic
premise of attempting to make a tentative medical diagnosis at triage

are doomed to fail. Diagnosis-based triage scales could actually be
dangerous because triage, by denition, has limited time, history, and
objective data. The only appropriate focus of triage is to identify key
signs/symptoms so as to place patients in an appropriate level for their
generic acuity or risk.” (Manchester Triage Group in Zimmerman,
2001)
'(
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
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./ 
  0-
Error: Unintended consequences of IT
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(


“We've learned that automation does not eliminate errors. Rather, it
changes the nature of the errors that are made, and it makes possible
new kinds of errors. The bottom line is this: Systems that integrate the
best of human abilities and technology are the safest for all
concerned: 788 +95
:
Evidence-based Policy?
$A
88
( '*
/9
7 5
8.:
4 
 

  

1#
*;&%&/
 +#
 
 */
0.
 
  
  -
 9!(:
 (*0 ;&%B/
'C901): 
!

Systems Error1>'9
750#.:*3;&%B/
.35.
)
9D:


 E&F 
*
/

 
39 
 # 
:*3;&%B/8 

9 :
Human Error: Decision Fatigue1?
(
<#
1G
1>' "

*H;&%B/8
*#?/
( 

Pre-Hospital Calls and Sepsis #
#EI
C#E&A&F
*/
Evidence Based Medicine149 
*0)5/
C C
9
Little or no research on Early Sepsis Recognition in telephone triage
exists.85% of sepsis
cases arrive with sepsis,I&F
60)5


EVIDENCE-BASED POLICIES

Based on the above research, it seems reasonable and prudent to
promote a Culture of Safety in telephone triage grounded in EBM
polices.

Formally recognize and legitimize Telephone Triage as Pre-
hospital care -- the rst contact and initial phase of the Continuum
of Care,

Enable patients with self-identied urgent symptoms to jump the
line

Implement Sepsis Early Recognition Guideline especially for
children and elderly
Integrate the Nursing Process more formally into training
materials and guidelines
Institute 4-6 Hour shifts in all High Call Volume clinical call
centers or 8-hour dedicated positions.
ASSUMPTIONS AND KNOWING WHAT WE KNOW
'

( 
'(.-“there are known knowns -- things we know
we know…..there are known unknowns; things we know we do not
know….there are also unknown unknowns—the ones we don't know we
don't know”. *Wikipedia)
REFERENCES
)=H*;&%$/7
150+?JE$<A%
+ ;&%G.;BJ%&;%A$2150+8%;&I;I
0 *;&%B/.7!
(8=+75
@1*;&%?/4.'>
J222C2;&%?2%%2%;2
@C.*;&%A/.0J6+,+
8=-5KEA%+E?A%
7*;&%?/C+8
https://www.healthcatalyst.com/success_stories/inpatient-sepsis-care-
mission-health
H4*%BB?/'HK=IB;'1

J222C22%BB?2&E2!
IB;2E&GIEA2
H=*;&%B/.".1>'
J222;&%B2&I2%A22

,K+*;&%&/
J Telemed Telecare;&%&L%GJE?E?
3.*;&%B/750#.>
'=BJ222;&%B2&G2&?222
 MNM3NM
4-*;&%$/'..J.
5"71
48O*;&%B/''J00#+Structure,
Process and Outcomes for 5-Level Telephone Triage.370''
8+ */
48ON5H*;&%B/''-5J-
''01 7670.
8370''8+ */
P+@*;&&%/' I
68=0K;$E
;AG;IA