Telephone triage nurses have a challenging job. Nurses are trained to assess from the second they lay eyes on a patient. A significant part of a head to toe assessment is the initial presentation - what the patient looks like at first glance. Are they awake? What is their skin tone? Do they appear in distress?

Nurses, especially experienced ones, often operate off "gut feelings " - the nagging feeling that something isn't right. This presents a challenge when assessing over the phone. When a patient calls and speaks to a triage nurse, the nurse first asks what the main complaint is. From there, he or she asks questions about the complaint while listening to cues from the patient that may point to other health issues. For example, if a patient calls in with a complaint of fatigue, and the nurse might pick up on shortness of breath or a cough which could be indicative of a breathing or cardiac issue. This assessment finding leads the nurse towards a more specific line of questioning.

So how do telephone triage nurses ensure all clinically pertinent information is addressed? Many organizations have triage protocols in place to ensure no significant assessment piece is missed. The protocols are developed and refined by clinical staff (i.e., physicians, nurses, nurse administrators, etc.) and are reviewed regularly to ensure the protocols are appropriate and follow current evidence-based practices.

Responsible reporting is also a critical factor in ensuring the best telehealth is provided to patients. Any safety issues or adverse patient outcomes should be reviewed and remediated, and used as an opportunity for quality improvement. Since nurses are patient advocates, reporting safety and patient care concerns is critical.

Ongoing staff education for nurses should also take place. Ideally, case studies should be presented, and nurses should practice assessing and advising appropriately. Didactic and hands-on teaching should be components of staff nurse education.

Telephone triage nurses are crucial in the healthcare field- they help offload physicians and help patients avoid unnecessary office or ER visits. Keeping them clinically competent and up-to-date on various facets of the ever-changing world of healthcare is essential for positive patient care outcomes.

Amanda Bucceri Androus RN, BSN
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