What is Telephone Triage?

The term triage is french in origin, and refers to the process of sorting. The original concepts of triage referred to mass casualty situations, such as during war times. Triage, by definition, is a dynamic process as the patient’s status can change rapidly.

With the evolvement of various triage systems, it is easy to forget that triage is still the central focus, and telephone triage is essentially like operating an ED triage area over the phone.
Telephone triage starts at the point of intake, or when the patient or caller makes the initial phone call. It is important that the first person they make contact with has good listening skills, is able to discern the main focus of the problem, and either route the call appropriately or take a complete message. If a message is taken incorrectly, valuable time could be wasted, as the telephone triage nurse might not be able to discern this is actually an emergency call. Accuracy is extremely important.

From that point, the concepts of triaging, sorting into priority, remains sound and unchanged and cannot be done by just anyone accurately. It requires someone who is medically trained and able to recognize what is an emergency and is capable of assessing over the telephone. If the telephone triage nurse is working from a queue, they must have the ability to sort out what is emergent, urgent and then non-urgent. This is where the basic concepts of  ABC’s comes into being. As in any triage situation, airways, breathing, and then circulation are the main priorities. Those calls should be taken first, and then more sorting of the remaining calls should follow. Non emergent calls such as rescheduling appointments or medication refills should be considered non urgent.
Once the calls are sorted and the nurse is in the process of the call, what is the next step? Again, true triage is sorting through the information being provided by the caller to determine the next step. In order to gain enough information, the telephone triage nurse should be able to select and follow the correct protocol or guideline with assessing the patient. In order to be a truly skilled and effective telephone triage nurse, the nurse must be able to think outside the box, examine the larger picture and then narrow it down to the correct protocol. Appropriately selecting and adhering to the correct protocol ensures the best patient outcomes, however the skill is in being able to select correctly.

Next, an effective telephone triage nurse is able to discern the appropriate disposition, or next step, and that again falls into the emergent (emergency room), urgent (urgent care or be seen in provider’s office ), or homecare (no follow-up needed unless symptoms worsen).

Many nurses, new to telephone triage, burden themselves with going above and beyond the next step, and with unnecessary details not pertinent to the current situation. This is not only non-efficient, but also can lead to burn out as it can be very overwhelming.

Telephone triage can be a very efficient process, and very beneficial in assisting callers if done in the correct manner.

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