PhoneRN TRAINING 2013

Protocol StructureThe structure of a protocol provides direction

and supports-but does not control-the nurse’s clinical decision process. The intent of triage is not to diagnose, but to identify health problems that need medical evaluation. The triage process and use of a protocol facilitates an appropriate plan of care using options ranging from emergent to home care.

Acuity Levels within the ProtocolsProtocols are structured to flow from the

most emergent symptom to the least urgent, i.e. 911 symptoms to home care. The assessment questions are ordered so that emergent/urgent symptoms are ruled out as you progress through the protocol and triage process.

OverviewEach protocol has an overview or Disease

Definition. This provides a description of the particular protocol and a summary of key clinical points. The overview may also contain elaboration of the assessment parameters, as well as other clinical content for the nurse to consider when choosing the correct protocol. Some also contain information that is useful for the nurse to educate the caller regarding their symptoms

BE SURE TO ALWAYS LOOK AT THE DEFINITION BEFORE CONTINUING WITH

YOUR TRIAGE

Triage Assessment QuestionsAssessment questions provide structure to

the assessment process and prompt, thorough assessment of the presenting problem. The questions are sequenced in order to distinguish the acuity level of the presenting problem, and eliminate guesswork on the part of the nurse. They also provide order and flow to the triage assessment process.

FIND THE “INITIAL QUESTIONS” SECTION OF EACH PROTOCOL IN TRIAGE LOGIC

DispositionsA list of recommended action is organized within

specific disposition levels of the triage protocol. There are reasons to choose each disposition listed in the protocol. These help to accurately identify and determine the acuity of the problem and the appropriate intervention based on the nursing assessment, i.e. see provider within 24 hours or home care. It is important that the reason for a disposition chosen be included in the nursing assessment.

Care AdviceCare advice to be given will be dependant on the

disposition chosen. When you click on the correct disposition statement, the appropriate care advice can be accessed from the disposition screen. Care advice in some protocols can be individualized based that patient’s symptoms, age and acuity of symptoms. Care advice may differ depending on the age or assessment information of that pt. For example the care advice for vomiting is different for a breast fed infant vs. a bottle fed infant or for a child over 12mos of age vs. an infant under 12mos of age. Only the information pertinent to that specific child needs to be given and documented. Care advice instructions give the caller/parent a plan to follow in lieu of or until a provider is seen.

Continue with your assessment..Choose protocols, determine disposition and give caller the

information provided. “Based on the information you have given me regarding your child’s/your symptoms we would recommend that…etc” Tell the caller the recommended disposition and give them the care advice that pertains to them and the severity of their symptoms as per the Protocols chosen.

 At the end of the call, wrap up the call by saying, “Have I answered all of your questions?” or “Did you understand everything I told you? If your symptoms worsens, please call back or seek medical attention.”

This evaluates the nurse’s instruction and attempts to ensure that the parent does not need to call back for further instruction in the care advice that was already provided.

Examples of 911 calls are 1. Severe breathing problems Cessation of breathing Weak, slow breathing (almost ready to stop) Choking and unable to breath or turning blue  2. Difficulty breathing as part of reaction to medications, bee

sting, foods (possible anaphylaxis).  3. Severe bleeding: Blood is pumping or spurting from the wound Blood is pouring out and can not be stopped with direct

pressure  4. Major neck injury (advise not to move child until EMS

arrives).  5. Major open wound of chest or abdomen.  6. Seizure or convulsion in progress (has not stopped)  7. Coma or unconsciousness.  8. Shock suspected

Emergency Calls and 911/Cont. 9. Croup with severe stridor  10. Confusion now  11. Severe weakness (not moving or can’t walk)  12. Severe burns  13. Choking -severe  14. Cyanosis widespread  15. New onset severe drooling, can’t swallow  16. Severe dehydration  17. Near drowning  18 Electrical shock or lightening strike  19. Suicidal attempt, severe or homicidal  20. Hypothermia <95 F due to cold exposure or Hyperthermia >106 F from heat

exposure  21. Meningococcal sepsis suspected (purpura/petecchiae with fever)  22. Severe trauma 23. Calls that, using your nursing judgment, may require immediate CPR (cardiopulmonary resuscitation).  These calls will be documented using the 911 symptoms guideline in triage

logic.

Urgent Calls Difficulty breathing (e.g. choking,

stopped breathing, weak breathing, stridor, cyanosis or other signs of respiratory distress)

Possible anaphylaxis (difficulty breathing or swallowing following medicine, bee sting, food or other possible allergen)

Neurological symptom (e.g. seizure, loss of consciousness, syncope, hard to awaken, confusion, altered mental status, stiff neck)

Poisoning, ingestion, drug overdose Foreign body-airway (choking) or

swallowed Trauma Electric shock Near drowning  Heat exhaustion or stroke Hypothermia (body temperature <95 F)

Psychosocial emergencies: sexual assault, domestic violence, child abuse, and suicidal ideation.

Asthma, wheezing or croup (with no mention of difficulty breathing)

Foreign body- ear, nose, vagina Bleeding (including blood in vomit

or stool) (Exception – bleeding stopped)

Burns (other than sunburn) Bites (e.g. animal, snake, spider,

marine animal, bee, yellow jacket) Fever >105 F (not caller’s

statement of “high fever”) Infants <3 months Severe pain (especially abdomen,

head or chest) Possible dehydration Purple rash (purple spots or dots)

Non Urgent CallsAll others (cold, cough, etc.)- These are calls

in which a reasonable delay in call response is unlikely to result in a negative outcome.

Building TrustBe aware of your voice quality. How you

say it is just as important as what you say.Adjust the volume of your voice to the

callerAsk their name. It helps personalize the callMatch your pace to the callers natural rate

of speedBe aware of word choicesAvoid the use of jargon and complex

medical terminologyEnunciate and speak confidently

Say this, Not thatNegative Statements

Alternative Positive Statements

1. May I help you?/Can I help you?

2. May I ask your name?3. Can I ask you a

question?4. I am not sure about

that.

1. How may I help you?/ I can help you.

2. My name is Carol, and you name is?

3. I would like to ask you a few questions that will help in…

4. I do not have an answer for you. I will call you pediatrician and he/she will call you right back.

Effective CommunicationBe AttentiveBe Accepting- covey to the caller this is a safe

place to say whatever needs to be saidShow EmpathyShow RespectBe Genuine-honest, warm and

straightforward

The Process- it’s the Nursing Process! Identify the Problem: Gather information: your assessment. Ask

open ended questions. Paraphrase (and repeat back to caller).

Open your protocols to guide you to a disposition. Resist the urge to diagnosis- it is beyond our scope of nursing!

Explore solutions: plan of action Home Care and Teaching: most frequent

disposition used.

Handling Parents of Newborns Parents of newborns are often anxious and exhausted, and

sometimes require additional support and education.

Accepted call length times may be extended to allow for additional teaching/listening/support.

ALL calls for babies under the age of 3 months must be triaged, even if the parent is only calling for information. The exception would be if they are calling to page the MD for bilirubin or other lab/test results but always ask if the child is stable.

Always page the MD if the parent requests it, or if you feel any concern over the baby’s condition and/or the parent’s ability to cope with the situation.

Call Length Goals Intro/Presenting Problem 30 sec. Gathering demos 30 sec. Nursing assessment 1-2 min. Triage using guidelines 1-2 min. Disposition choice/Referral if needed 30 sec. Discussing Care Advice with parents 1 min. Confirming Parent understanding 30

sec. Confirming Plan of Action 30 sec. Documenting MD page/medication dosages/ other additional homecare 1 min. Closing Call 30 sec. ------------ Total: 7-9 min.

Medication AdviceKNOW YOUR MEDICATIONS!Doses/side affects/cautions,

contraindications. Do a COMPLETE Health assessment before giving out any medication dose (allergies/chronic health conditions/past medical history/surgical history/medication taken on a daily basis etc..)

Urgent Home Care with F/u Triage the patient using the appropriate protocol such as Asthma Attack, Croup

guideline. If appropriate, use the “urgent home treatment with follow-up” disposition. Advise the patient to use the appropriately prescribed rescue medication or home

treatment recommended by protocol. Call them back within 30-60 minutes. During the follow up call the nurse should document in the Additional notes section

if the pt’s symptoms have improved, worsened or stayed the same. Based on the follow up assessment the nurse should document what the new plan of action will be. For example; Call 911, Go to ED/UCC, PCP for referral, Call PCP or continue with homecare and call back if symptoms change or worsen.

Any additional care advice can be typed or the nurse may make reference to the protocol and disposition that the care advice was taken from. For example “care advice given as per Asthma Protocol (home care)”

If the patient has developed any new symptoms since the original call/triage was made a “New Note” must be opened, both previous(refer to first call) and present symptoms and treatment should be documented and appropriate protocols should be referenced.

Follow up Call for 911 911- Nurse will callback in 10 minutes to

assure caregiver reached EMS and offer assistance/comfort until EMS arrives

Post Orientation-What to expectWeekly note review with feedback and a

review data sheet listing strengths/area’s to improve and a plan for the upcoming week. Approximately 3 months

3 Months of Administrative QA following note review period

Support from your director, manager, supervisor, co-workers, charge nurse, and IS.