Telephone Triage in Women’s Health Care: Logistical and Legal Considerations
Patricia C. McMullen
Nayna D. C. Philipsen
The telephone, initially used merely as an appointment-scheduling device, has become an integral part of provider-patient interactions throughout the world. Now, much of primary health care is handled over the telephone, and some practices, especially managed care, find it almost indispensable. Some calls are handled by a provider (advance practice registered nurses or physicians), some by other licensed personnel (registered nurses or licensed practical/vocational nurses), and some are delegated to unlicensed assistive personnel (UAP) such as office staff. The process of managing health complaints over a telephone line, known as telephone triage, can be a double-edged sword, sharing many of the general benefits and risks of other forms of e-health or telecare. It can increase access to care and quality of care, reduce exposure to contagious illness in waiting rooms, enhance the medical response to disasters or epidemic “surges” in demand, meet needs for care over distance, and promote continuity of care and patient compliance. Telephone triage can determine a need for extensive or immediate care or provide detailed health care advice and treat simple problems, all while containing cost, which is particularly important in the current cost-conscious managed care environment. On the other hand, providers who use telephone triage are disadvantaged because they must rely on the verbal information provided by the patient or other caller rather than being able to use visual cues and a variety of physical assessment skills. Providers who are tempted to “overdelegate” may face increased liability risk for lack of adequately trained personnel and related unclear documentation, delay of care, inappropriate assessment of acuity, and failure to diagnose.
Because of its relative newness, providers face practical and legal questions unique to telephonic care. What is the purpose and scope of their telephone triage? Who should make or receive the calls? What is the appropriate documentation? How should they safeguard protected health information (PHI)? How can they protect against the creation of new legal duties and liabilities? All of these are important questions to answer in establishing guidelines or protocols for calls. Telephone triage can increase the quality, efficiency, patient satisfaction, and safety of care, and even decrease liability, if it is informed and carefully planned.
Without proper protocols and training, telephone triage can result in improper diagnosis and management (Kempe et al., 2006). An early study by Rupp, Ramsey, and Foley (1994) highlighted the importance of an adequate telephone triage plan in women’s health settings. These investigators had a college student pose as a 16-year-old girl and
call adolescent clinics nationwide complaining of acute onset “belly pain.” The telephone triage responses of 35 clinics were evaluated. Telephone triage was performed by nurses, receptionists, and a teenage peer advisor. An amazingly high 37% of the 35 clinics gave inadequate telephone advice by failing to rule out a possible ectopic pregnancy. Another dramatic study by Janssen and colleagues (2006) demonstrated that careful telephone triage can be a very valuable tool for evaluating labor in women with an uncomplicated obstetric history who are at term and advising them when to come to the hospital. In this study, a telephone triage nurse managed 731 women, whereas another group of 728 women received a nurse home visit. Outcomes, including rate of cesarean delivery, use of narcotic or epidural analgesia, and augmentation of labor, were comparable between the two groups.
call adolescent clinics nationwide complaining of acute onset “belly pain.” The telephone triage responses of 35 clinics were evaluated. Telephone triage was performed by nurses, receptionists, and a teenage peer advisor. An amazingly high 37% of the 35 clinics gave inadequate telephone advice by failing to rule out a possible ectopic pregnancy. Another dramatic study by Janssen and colleagues (2006) demonstrated that careful telephone triage can be a very valuable tool for evaluating labor in women with an uncomplicated obstetric history who are at term and advising them when to come to the hospital. In this study, a telephone triage nurse managed 731 women, whereas another group of 728 women received a nurse home visit. Outcomes, including rate of cesarean delivery, use of narcotic or epidural analgesia, and augmentation of labor, were comparable between the two groups.
This chapter provides a brief overview of the history of telephone triage and important legal and regulatory factors to consider for providers who want to establish a telephone triage system that will enable them to provide this service to female patients with confidence. This includes drafting guidelines or protocols appropriate for whoever will handle the calls and assuring compliance with laws, such as the state Professional Practice Acts, and the obligation to safeguard confidentiality as federally mandated by the Health Insurance Portability and Accountability Act (HIPAA) and the American Recovery and Reinvestment Act (ARRA). A sample triage form for triage personnel and providers is also included Figure 1-1.
» THE ORIGIN AND EVOLUTION OF TRIAGE
The word “triage” is of French origin and means to sort, classify, or choose. Triage was first used in medicine to set priorities for mass casualties experienced during World War I. However, it was not until the 1960s that triage techniques became widely used to set priorities for the care of patients presenting to civilian emergency rooms for treatment (McMullen et al., 2014).
Today, telephone triage is used in virtually every clinical setting, and it is generally accepted that it can be safe, convenient, and economical (Knox & Smith, 2007; McNeil, 2007). For example, Marklund and coinvestigators (2007) assessed 362 calls in a telephone nurse triage system in terms of the appropriateness of referrals to the correct level of care as well as the patients’ compliance with the advice that was given and cost. These investigators found that the nurses provided appropriate advice 97.6% of the time and that the telephone triage system was cost-effective. Research by Giesen et al. (2007) also considered the safety of telephone triage advice given by nurses. Triage nurses were presented with 352 triage scenarios. The nurses assigned the adequate level of urgency 69% of the time and underestimated the level of urgency in 19% of the contacts. Not surprisingly, there was a significant relationship between the nurse’s training on the use of telephone triage guidelines and the correct estimation of urgency. Adequate education of those providing the telephone triage is a critical factor.
 Figure 1-1 Sample telephone triage form. |
Smulian and colleagues (2000) reviewed 276 after-hours telephone calls from women received by 12 residents and 9 private physicians. Calls were classified as women’s health or primary care and according to whether the women were pregnant, not pregnant, or in the postpartum period. One hundred ninety-two (69.6%) of the calls were from pregnant women, 20 (7.2%) were related to postpartum concerns, and 45 (24.1%) were associated with a primary care complaint. Common reasons for calling included nausea and vomiting, vaginal bleeding, leg edema, backache, pelvic pain, headache, and questions regarding oral contraceptives or hormone replacement. Symptoms of urinary tract infection, viral illness, and diarrhea also were regularly reported. Three triage dispositions were available: evaluate now, office follow-up, and home care. Of the callers who were pregnant, between 35.1% and 41.9% were told by the residents or private physicians to seek immediate evaluation. Between 10% and 11% of women in the postpartum period were triaged to immediate evaluation. There were no significant differences in disposition based on whether the provider was a resident or a private physician. Callers also were asked what they would have done if they had been unable to contact the physician by telephone. Slightly more than one third of the 139 women who were triaged to the office stated they would have presented to the emergency room had they been unable to reach a provider, representing a significant cost saving. A 2014 study of 132,509 nurse-triaged calls by Navratil-Strawn, Ozminkoqaki, and Hartley for Optum NurseLine found that most of the callers complied with the advice that they received, with an average cost savings of over $300 each.
These studies and others demonstrate that telephone triage, when properly implemented, can be an effective tool in women’s health to increase access to quality care and to minimize costs. The question that remains is how to take advantage of these benefits while minimizing practical and legal risks.
» BASIC CONSIDERATIONS IN ESTABLISHING A TELEPHONE TRIAGE SYSTEM
Important legal issues need to be addressed before starting a telephone triage system. Any facility desiring to initiate such a system must find suitable answers to questions regarding its scope and format, personnel, documentation, and necessary information pertinent to its program to improve care and efficiency as well as to assure legal compliance.
Are “Protocols” or “Guidelines” the Appropriate Format?
Every provider must make some basic decisions about implementation of telephone triage. Key is the answer to this question: Is a protocol or is a guideline the most appropriate format for our purpose? This includes determining the expertise of the person who will make or receive calls. A general rule is that the less formal preparation (education and licensure) the person handling triage calls has, the stricter the protocols and training must be. This is especially critical for any calls delegated to UAP. Evidence established in this chapter supports why many telephone triage authorities emphasize the use of
appropriately licensed personnel. They also emphasize strict adherence to state nursing and medical practice acts.
appropriately licensed personnel. They also emphasize strict adherence to state nursing and medical practice acts.
The legal community often makes a distinction between a protocol and a guideline. Protocols are rules or procedures one must follow when performing a clinical function or service authorized by a policy. Generally, the legal community views them as mandatory. That is, if protocols exist, people assume that the health care team will be instituting care according to the protocol. Thus, if the protocol states that the provider will return all patient calls within 24 hours to determine the patient’s status, failure to make the call is a violation of the protocol and is evidence that the provider did not comply with reasonable standards of care. For this reason, if the office or clinic elects to have protocols, they need to be realistic. If there is one UAP fielding 300 triage calls per day, it may not be practical to mandate that all telephone calls receive a follow-up call from the provider.
Protocols also need to be reviewed at least once a year and revised as necessary. Unfortunately, in many instances, they are updated shortly before The Joint Commission visit or a managed care audit. Health care standards are ever-changing. If an office protocol still advocates “leaching” and “bleeding” for an infection, it is time to do an update!
The dating and signing of all protocols by the providers and administrative personnel involved in their development helps to establish that all relevant parties concurred with the protocols and gives legal counsel an idea of when the protocol was put into effect. Outdated protocols should be kept on file in the event a question arises later regarding the protocol that was in place during a certain period of time. The timeframe for this should mirror the timeframe for retention of medical records.
There are positive aspects to having the more rigid protocols as opposed to flexible guidelines. The use of protocols means that everyone handling the telephones will give consistent information. This helps avoid conflicting advice, which can lead to patient confusion or patients playing one provider against another. Protocols also help inexperienced providers get an indication of important history information and devise appropriate management strategies. Protocols are critical in situations where a provider is delegating the call to another person, especially to UAP, to help defend against charges that the delegatee is practicing medicine without a license. They also can serve as a foundation for later testimony in a lawsuit concerning what patient information was elicited and what advice was given.
Guidelines are more permissive and require the use of critical thinking and professional judgment. They establish what information is important to collect and suggest appropriate management strategies. This allows more independent decision making on the part of the provider, so it is appropriate when a qualified provider or licensed personnel is on the call with the patient.
Guidelines also give the provider more legal leeway because strict adherence to a guideline is not deemed to be legally necessary as is true with a protocol. If a lawsuit is filed concerning telephone advice and the current literature supports the correctness of the information given, it is more likely that the provider will be found to have met reasonable standards of care regardless of whether the information was consistent with
guidelines. A 2014 study by Ernesäter, Engström, Winbald, and Holmström found that the open-ended questions and “back channel responses” more typical of guidelines provided fuller descriptions of patient issues for licensed professionals and were associated with a lower risk of malpractice claims than other calls.
guidelines. A 2014 study by Ernesäter, Engström, Winbald, and Holmström found that the open-ended questions and “back channel responses” more typical of guidelines provided fuller descriptions of patient issues for licensed professionals and were associated with a lower risk of malpractice claims than other calls.
What’s the First Step in Drafting Protocols or Guidelines?
After deciding whether their system will be based on protocols or guidelines, providers should begin recording the number and types of calls received each day. This allows the health care team to either employ existing protocols or draft new protocols or guidelines that deal with the various types of calls received. These guidelines or protocols should be (1) symptom-based, (2) offer relevant subjective and objective data associated with the problem, (3) give possible differential provider diagnoses, and (4) outline appropriate disposition or management strategies. Each problem should be limited to approximately one typed page.
In this book, all of the pertinent elements of a sound protocol are addressed. Each symptom-based complaint is listed in alphabetical order, and protocols generally are one page in length. Both referral and home treatment strategies are suggested.
Who Should Handle the Calls?
Deciding who will handle the calls involves several issues. If the provider, whether a physician, nurse practitioner, or other independent licensed professional, is delegating the calls to someone else, state law may set limits on who that delegatee can be. The Professional Practice Acts, such as the Nurse Practice Act and the Medical Practice Act, are state laws that define the practice of that profession and to whom a licensed provider may delegate. Do the triage tasks require the use of skills gained in professional medical or nursing education or defined as within the scope of practice of a licensed profession? The general rule for delegation is that a provider can delegate only something that is within the scope of practice of his or her own licensure and expertise and only to those who are both adequately trained and legally allowed to do the delegated task. Some things, including diagnosis, treatment, or patient education, cannot be delegated to a UAP under most state laws. In some states, a nurse may only delegate to a certified assistant. A provider who delegates to a UAP remains legally liable for the acts of that delegatee. A provider who delegates to a registered nurse has less liability because state laws make registered nurses independently responsible for their practice (Rutenberg, 2016). In a 2014 position paper, the National Council of State Boards of Nursing affirmatively concluded that telehealth, including telephone triage, is the practice of nursing. Following the mentioned general rule for delegation and checking the Practice Act regulations in your state provide peace of mind in delegation and demonstrate “reasonable” delegation by a provider under law.
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