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Foundational Tips for Telephone Triage Nurses

Telephone nurse triage is a system that requires the work of dedicated nurses who can think on their feet in order to quickly and accurately direct callers to take the appropriate actions in any given situation. While that may sound daunting, it can become significantly easier to accomplish with basic knowledge of what to do during any caller interaction so that nurses can effectively triage patients every time they pick up the phone. Nurses should also always use standard triage protocols, such as the gold standard Schmitt-Thompson protocols, when triaging patients. These ensure appropriate patient care advice and allow nurses to document the call information.

With that being said, this article covers 5 tips that act as a foundation to help triage nurses with common issues that apply to all triage calls. Read on to learn how to avoid some of the most common of these and, instead, ensure positive triage outcomes.

1. Listen to the Entire History Before Triaging

It is easy to jump straight into triaging the first symptom mentioned by the patient. To avoid this, listen carefully to the caller’s history and symptoms and explore all possibilities. For example, abdominal pain in an older female may signal a urinary tract infection, while, alternatively,  a nurse may need to consider pregnancy in a younger female. Asking for a brief history and exploring the caller’s concerns in more detail will prevent overlooking any serious symptoms and triaging the patient to the wrong disposition.

 2. Properly Use the Nurse Triage Protocols

Triage protocols are carefully and thoroughly designed, but they can still be misused. Nurses can occasionally omit using a protocol, use the wrong one, or use one improperly during triage. For example, with new nurses, we often see fever protocols being overused. When things like that occur, no matter how insignificant they might seem, they put the patients at risk and potentially lead to dreadful outcomes. Watch this great video on ensuring patient safety during a 911 call. 

 3. Avoid Stereotyping

As a triage nurse, it’s important to be objective no matter the circumstances. It can be easy to mistake a caller’s gender or age by just listening to the voice on the phone. To avoid stereotyping the caller, take care to always confirm the age, gender, and medical history before triaging a patient.

 4. Hear the Caller’s Concern

While the triage nurse is the trained professional, the more anxious of callers have to be taken seriously as well and get an extra-thorough assessment. This both ensures that there is nothing especially serious going on that the caller forgot to mention.  It also reassures the caller that you are both taking them seriously and that they will be okay.

 5. Use Your Own Professional Judgment to Assess the Situation

It is important to listen to the caller to understand their concerns and get a good patient history. However, callers sometimes come up with their own diagnoses. As a triage nurse, accepting these as fact can often end poorly. For example, a parent may call and say her child has chickenpox. It is the nurses’ role to understand that the caller is concerned about chickenpox. However, the nurse cannot assume that the parents are correct. Instead, the nurse must still do a full assessment of the child’s airway, breathing, and circulation on top of assessing the rash and any other symptoms the patient may have in order to make the correct triage decision.

Because our nurses cannot see or touch the patients, they must adapt and hone their other skills so that they can still send their patients to the right disposition. The tips above, provide the basis for accomplishing that. By keeping them and using them in conjunction with previous training, triage nurses will be well on their way to ensuring that they provide the best possible patient care during every call.

If you’ve found that your organization needs help taking patient phone calls, then contact us today! The skilled members of our team will discuss your needs and set up a personalized plan that will work best for both your organization and your patients.

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