Nurse Triage: Essentials for Expert Practice

Basic "How to" Perform Telephone Triage or Nurse Triage. Controversies and Suggested Solutions. Addresses Risk Management, Nursing Process, Communication and Documentation Risk Avoidance, Pattern Recognition and Patient Context Assessment tools, Rules of Thumb or Heuristics, Documentation Form, Universal Guideline, Standards, Job Description & Qualifications, Performance Review, Nurse Triage Process Work Flow. Legal malpractice case studies, Exemplars of Structure and Process. Historical and Foundational nurse triage content.

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Telephone Triage:
Essentials for Expert
Clinical Practice
Sheila Wheeler, RN, MS
TeleTriage Systems
www.teletriage.com
Seminar/Workshop
! Your expertise and questions are welcome
! Collaborative atmosphere
! Case Studies from your experience
! My Goal: “Real World” solutions
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Expectations for Training
! Standardized practice
! Risk Management, Legal issues
! Assessment
! Communications, Documentation
! Guidelines
! Competency: QA Audit 2

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Agenda
! Legal & Professional Issues
! Right Structure
! System Components
! Right Process
! Nursing process
! Assessment, Communications, Documentation
! Informed Consent, Continuity
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New Field
! Telephone Triage is defined as:
! Getting patients to the right level of care at the right time with right provider.
! “Making decisions under conditions of uncertainty and urgency” (Patel)
!  “The safe, effective and appropriate disposition of symptoms via phone by trained, experienced
clinicians using decision support guidelines.”
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Research on Safety
! Safety of Telephone Triage Decisionmakers
! Nurses have most complete plan (guidelines, EMR, Training, Standards)
! Physicians and Clerical: Have little or no plan
! Clerical: Were not shown to perform telephone triage.
! Wheeler, 2015, Telephone Triage: Safety of Clinical & Non-Clinical Decision Makers

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Research on Safety
! Nurses:
! are as safe and proficient as physicians
! use pattern recognition and context
! estimate the urgency of symptoms
! may be safest, best match to task
! Wheeler, 2015, Telephone Triage: Safety of Clinical & Non-Clinical Decision Makers
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Research: CDSS
! Guidelines (CDSS)
!  have not been systematically studied and validated (Marklund, Randell)
! Some experts feel algorithms may be overly deterministic (diagnosis-focused)
! Nurses fail to use guidelines as required (Greatbatch, Holmstrom)
! Wheeler, 2015, Telephone Triage: Safety of Clinical & Non-Clinical Decision Makers
Research: CDSS
“Designing computer systems that work well
with incomplete or imprecise information is
challenging. Particularly in medicine, where
the consequences of defective decision-
making may be catastrophic.”
Lowe, MD, NY Times
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Research Health IT
! MD EMR Survey: poor usability, time-
consuming data entry, alert fatigue, poor
work flows, widespread dissatisfaction.
! ….Unanticipated consequences of health IT -- whopping errors, maddening work flow
changes
! Wachter, Why Health Care Tech Is Still So Bad?, NYT, March 21, 2015
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“Quality = Love”
! “Systems awareness and design are
important for clinicians, but they are not
enough.
! Ultimately it is the ethical dimensions of individuals that are essential to a system’s
success.”
! Donabedian
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Telephone Triage is
Gangly Adolescent
! Which Subspecialty Guides Unruly Teen?
! IT: Technology outpacing Professional Standards
! Physician Practice: Bad match of strategy for “Real World” telepractice
! Nursing Standards: Structure, Process for Quality, Safe Outcomes
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Adolescent Field
with Professional Identity Crisis
! Who Are We? Telephone Triage Task is NOT:
! Medical Message-taking
! Medical Diagnosis
! Practicing medicine via phone
! “Gatekeeping”
! Crisis Hotline
! Health Information Hotline
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Adolescent Field
with Professional Identity Crisis
Who Are We?
What is our Role in the Brave New World of Telehealth?
Are we really part of the “Medical Fold”?
Do We Belong?
Professional Insecurity,
Professional Identity Crisis
! Medical Fold: A “Body of Knowledge”
requires Agreed-Upon Triage Terminology
! nomenclature (Classifications: 5-Tier)
! definitions (Define emergent, urgent, etc)
! teaching (evidence-based)
! methodology (Nursing Process)
! audit (QA based on standards)
! Manchester Triage Group, 2015
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Professional Insecurity,
Professional Identity Crisis
! ‘‘Professionals suffer from reluctance or
inability to establish valid normative
standards for outcomes’’
! Donabedian
! Standards require, at minimum, common terminology and language
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Adolescent Field
with Professional Identity Crisis
! Who Am I?
1. Knowledge Worker
2. Clinical Informaticist
3. Clinical Triagist
4. Other:
! Impromptu case manager
! Negotiator
! Resource expert, Health Educator, Counselor
! Coordinator par excellence
New Professional Identity:
Knowledge Worker
! Who Am I?
! Knowledge Worker: “workers whose main capital is knowledge, typically lawyers,
physicians, pharmacists and other clinicians
whose job it is to “think for a living”.
! Key Skill: Metacognition “thinking about thinking”, knowing when & how to use certain
strategies for solving a problem”
WIKIPEDIA
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Knowledge Worker:
Metacognition
“Knowing when & how to use certain
strategies for solving a problem”
1. Knowledge: Recall information
2. Comprehension: Understand meaning
3. Application: Use concept in new situation
4. Analysis: Distinguish between facts & inferences
5. Synthesis: Pattern recognition & matching
6. Evaluation: Make judgments
New Professional Identity:
Knowledge Worker
! Metacognition: knowing when & how to
use certain strategies for solving a problem”
1. Nursing Process
2. Assessment, Communication Tools (4)
3. Rules of Thumb
4. Red flags
5. Crisis Intervention
6. Estimating Symptom Urgency 19
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Knowledge Worker:
Metacognition
! Need to decide what is signal (significant)
and what is noise (“red herrings”).
! “In medicine, thinking is our most important procedure….Computers are good
at crunching numbers, people are good at
matching patterns.”
! Dhaliwal, MD, Expert Diagnostician at UCSF, NYTimes 2011.

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New Professional Identity:
Clinical Informaticist
! Clinical Informaticist
! “Use of Health Information Technology to improve health care via any combination of
higher quality or efficiency and new
opportunities.”
! WIKIPEDIA
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New Title:
Clinical Triagist
! Clinical Triagist is a clinician who:
! estimates symptom acuity to determine whether symptoms are: life threatening, emergent,
urgent, acute, or non-acute
! uses clinical knowledge & clinical informatics to triage symptoms and to make safe, timely
dispositions
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Challenge of Telephone Triage
! Challenge: Communication with,
Assessment of Invisible Patients in order to
make safe, timely disposition of their
symptoms
! Requirements to Elicit, Appreciate & Communicate Significant (Noteworthy,
Important) Information

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Challenge of Telephone Triage
! How:
! Adequate Preliminary Assessment
! Pattern Recognition, Contextual info
! Forming mental images of patient
! Intepreting patient responses
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Challenge of Telephone Triage
! Telephone Triage of Invisible Patient =
! High Risk
! High Stakes
! Risk Management is enhanced by
! A System (Structure)
! A Systematic Approach (Process)
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Chapter 2: Risk Management
! Safe., Timely Triage of Invisible Patient
! If you fail to plan, plan to fail. (IOM)
! Delay in Care: “Care Delayed is Care Denied”
! Root causes of Error (Joint Commission):
! Assessment
! Communication
! Continuity
! Informed Consent
! Human Error

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Risk Management
! Pitfalls in Triaging Invisible Patients
! Reasonable, prudent nurse = Standard
! Implied Relationship
! Misrepresentation
! Duty to Terrify
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Risk Management
! Structure Reduces Error in Triage
! Reasonable, prudent Employer develops a Complete, High Quality System
! Standards: Practice & Call Center
! Training: Formal, Preceptor, Ongoing
! Documentation and/or Audiotaping
! Guidelines: Valid and reliable
! Qualified Staff in adequate numbers
Chapter 3: Rules of Thumb
! Structure for Triage of Invisible Patients
! Cardinal Rules
! Symptom-specific Rules
! Age-based Rules
! Trauma-based Rules
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Structure:
Cardinal Rules of Thumb
! When triaging invisible patients, as is
reasonably possible, thou shalt:
! Err on the side of caution; bring patient in earlier rather than later
! Speak directly with patient
! Be curious and investigative
! Trust, but verify, correct & update Pt Back Story
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Chapter 4: Process
! Problem Solving Strategies for Invisible
Patients
! Identify & verify emergent symptoms
! Identify potentially urgent symptoms
! Estimate symptom urgency
! Rule out urgent symptoms
! Interpret patient responses
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Nursing Process Modified
! How to best make good Clinical Decisions
about Invisible Patients?
! Step 1: Assessment
! Step 2: Working Diagnosis
! Step 3: Plan/Disposition
! Step 4: Self-Evaluation Instruction
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Failure to Assess Adequately
! Assessment Failures are a key Root Cause
of Error (JCAHO)
! Leads to selecting guideline prematurely
! Jumping to conclusions
! Wrong train syndrome (Wrong guideline)
! SOLUTION: Assess First; use Guideline as the finishing touch
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Process: Assessment
! Step One: Preliminary Assessment
! Assessment is foundation of telephone triage
! First step of clinical process
! May establish urgency
! Helps identify correct guideline
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Process: Assessment
! Methods to Assess Invisible Patient
Symptoms
! SAVED (Global Assessment)
! Red Flags: Hi risk Symptoms & Populations
! SCHOLAR: Symptom History
! RAMP: Patient History/ Back Story = Context
! ADL, A DEMERIT: Non-Verbal Patient
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The Global Assessment
or Red Flags
! SAVED
! Severe, Strange or Suspicious Symptoms
! Age: Very old, very young, childbearing women
! Veracity (Communications Barrier)
! Emotional Distress
! Debilitation
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Global Assessment: SAVED
Severe, Strange, Suspicious Symptoms
! Severe
! Strange: Novel (New, atypical, unusual presentation) “Worst, sudden, unexpected,
recurrent”
! Suspicious (assoc with malpractice) Head, chest, respiratory, abdomen, “flu”,
dizziness
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Global Assessment: SAVED
“The Woman’s Heart Attack”
“Mixed bag: feeling vaguely unwell, fluttery sensation at sternum rising into throat, mild
chest pressure, chills, sudden nausea, vomiting,
diarrhea.”
The Missing Nugget of Common Sense (ROT)
“If a symptom is unlike any you have experienced before, make the call, get a reality
check”.
Lear, MW, New York Times, Sept 28, 2014
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Assess Globally: SAVED
! AGE
! All children,
! especially newborns
! under 3 months
! under 6 years
!  All elderly, especially frail elderly
!  Men over 35, women over 45
!  All women of childbearing age
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Assess Globally: SAVED
! VERACITY (Patient ability to adequately
describe symptoms)
! Second-party calls
!  Lo w literacy
!  Language barrier (if no medical interpreter available who is not family member)
! Incoherent, slurred speech
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Global Assessment: SAVED
! EMOTIONAL DISTRESS
! Frequent phone calls in brief period of time is a “Red Flag” indicator of anxiety
! Hysteria or denial; inappropriate affect in caregiver
! Emotional distress or recent stress
!  Lack of affect/flat affect
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Global Assessment: SAVED
! DEBILITATION
! Chronic Disease
! Immunocompromised
! Frail Elderly
! > 75 Yr or > 65 Yr with Functional Impairments
! Afflicted with physical or mental disabilities
! DISTANCE
! Time to treatment
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Chief Complaint History
SCHOLAR
! Symptoms & associated symptoms
! Characteristics
! History of complaint in past
! Onset of symptoms
! Location of symptoms
! Aggravating factors
! Relieving factors 43

Patient History
“Trust but Verify”
RAMP “The Back Story” “Contextual”
! Recent: Injury, Ingestion or Illness & ANY infection, Implant or Invasive surgery or
procedure, International travel
! Allergies
! Medications
! Pregnancy/breastfeeding 44

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Activities of Daily Living
(ADL)
! Non-verbal/Poor Historians: Children/
Elderly/Developmentally Disabled
! Intake
! Output
! Sleeping
! Activity level
! Mood
! Color
! Skin
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A DEMERIT
A DEMERIT: Non-verbal/Poor Historian
Extreme changes in appearance and behavior:
! Difficult to awaken or to keep awake
! Expression: decreased
! Movement: little or no spontaneous movement
! Eye contact/focus: decreased
! Recognition of caregiver: decreased
! Interactivity: decreased
! Talking: decreased 46
Case Study
15-year-old female. Her sister is calling for
appointment for the patient who has been
“vomiting hourly since midnight”. Patient is
“too sick to come to the phone”.
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Case Study
! 50-year-old healthy male with nosebleed.
First episode. Denies history of
hypertension, bleeding disorder, blood
thinners. Able to get bleeding to stop within
10 minutes. Denies dizziness, weakness.
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Case Study
! 30-year-old male carpenter with severe flu -
like symptoms, chills, fever, diarrhea,
vomiting, weakness, pallor. C/o severe arm
pain that made moving and sleep very
difficult. Not drinking fluids. History of
chronic eczema on arms. Multiple calls.
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Duty to Invisible Patient
! Clinician Duty:
! Elicit Significant Information
! Be Inquisitive, Curious, Exploratory, Probing
! Build a Mental Image of the patient’s symptom pattern
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HMO Z Audit
! Evidence from Audits
! Inadequate Time Allotted to each step:
! Assessment
! Impression (Working Diagnosis)
! Disposition & Advice
! Self Evaluation Instructions
! No sense of a completed task
! No recognizable, consistent nursing process
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Audit Goals
! Proportion of Time spent per step:
! Assessment 80%
! Impression (Working Diagnosis) 3%
! Disposition, Advice 7 %
! Self Evaluation Instructions 10 %
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Chapter 5:
Clinical Decisionmaking Process
! Thinking about thinking involves knowing
when and how to use particular strategies
for problem solving.
! Guidelines are one strategy
! Knowing when and how to use guidelines for to triage invisible patient
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Chapter 5:
Clinical Decisionmaking Process
! When and How to select the guideline
Choose:
! symptom that seems most serious
! symptom patient is most concerned about
! symptom most likely to lead to appointment
! Or Select the Generic Guideline
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Clinical Decisionmaking Process
Guideline (Plan)
! Step 2 Working Diagnosis, “Impression”
! Step 3 Disposition, Advice
! Step 4 Self Evaluation Instructions
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Clinical Decisionmaking Process
! Step 2: Working Diagnosis (Impression)
! Educated guess; estimate of symptom urgency
! Forms the basis for subsequent Disposition
! Examples:
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Clinical Decisionmaking Process
! Step 3: Disposition & Advice (Informed
Consent)
! When, Where, by Whom and Why Patient will be seen/not be seen
! Home Treatment/ First Aid
! Example:
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Clinical Decisionmaking Process
! Step 4: Self-Evaluation Instructions
! What to expect
! Failure to improve Instructions
! Example:
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Reminder: ! The assessment process is your best security blanket. Use
one or more of these tools:
1. SAVED
2. SCHOLAR
3. RAMP
4. ADL, DEMERIT
! Investigation precedes guideline
! Guidelines are only as good as the information elicited prior to consulting them
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Best Approach
! Be investigative
! Explain silences
! Trust but Verify: Confirm, correct, update patient’s “Back Story”
! Do not explain away, or offer explanations for symptoms (and do not allow patients to
do so)
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Remember:
Patients call for a Reason
! New Research “ER Visits at Record High, 96
Percent Needed Medical Care within 2 Hours” ! 
! 60 % arrived after normal business hours
! 30% of visits patients < Age 15 or > Age 65
! 30 % of all visits were for Injuries ! American College of Emergency Physicians, 11/14
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Our “Meat and Potatoes” ! Common Reason for ED Visit:
1. Stomach and abdominal pain (11.1 million)
2. Chest pain (7.1 million)
3. Fever (5.1 million)
4. Headache (4.3 million)
5. Cough (4.1 million)
6. Back symptoms (3.9 million)
7. Shortness of breath (3.7 million)
! http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf
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Chapter 6: Guideline
Philosophical Divide in Telephone Triage:
! Decision Support vs. Decision-making Tool
! Bottom Line: Expert Nurse Brain
! Guidelines Remind us of info/questions we have once known, but may have forgotten
“Out of Guideline” Experience
! Problem: “Out of Guideline” Experience.
! Solution: A “Fall Back”, when no guideline applies, develop a Contingency or General
Policy
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Generic Guideline Prerequisite
! Prerequisite: Proficient Assessment
! Based on the concept of educated guess, Urgency estimation, Pattern Recognition
! Based on:
!  ACEP descriptions
!  Five level Emergency Severity Index
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Generic Guideline as a
General Policy
! Functions as a General Policy (Standard) by
providing broad:
! defined acuity categories for life threatening, emergent, urgent, acute and non-acute
! disposition time frames corresponding to acuity levels
! broad descriptions of a range of emergent to non-acute symptom patterns
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Generic Guideline
! If telephone triage interaction is potentially
fraught with error, how can we reduce it?
! Assessment Require robust assessments
! Communication: Clear, consistent disposition directives
! Continuity Contiguous disposition time frames
! Human Error: user friendly
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Clarity of Disposition
! “Duty to Terrify” (Tennenhouse, 1993 )
! Duty to apprise patients of seriousness of symptoms
! Five Tier Telephone Triage
! LEVEL OF ACUITY, TIME FRAME, SETTING
! Defined Acuity Levels
! Contiguous, flexible Time Frames
! Fosters RN autonomy
! Limit Disposition options: Keep it Simple

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Simplicity
! That’s been one of my mantras - focus and
simplicity. Simple can be harder than
complex: you have to work hard to get your
thinking clean to make it simple. But it’s
worth it in the end because once you get
there, you can move mountains.
!  Steve Jobs
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Simplicity
! Example:
Case Study ! 23-year-old Pakistani student with previous history of
moderate back pain. Today, he experienced a sudden onset
severe back pain while standing in kitchen making
breakfast. The pain was so severe that he had to sit down
immediately. Pain described as excruciating, I can barely
move, “hard to bear, unbearable, agonizing, severe,
terrible, awful”. He cannot walk standing straight up.
Multiple phone calls from patient and his mom.
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Thinking about Thinking
! Is this a high-risk patient?
! Are these high-risk symptoms?
! What are the Red Flags?
! Assessment Tool
! Impression
! Guideline(s)
! Acuity level
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Afternoon
! Communication Strategies
! Documentation Tools And Strategies
! Avoidable Human Errors; Role Play
! Assessment By Proxy
! Crisis Calls, “War Stories”
! Role Play
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Clinical Teletriagist
! Schmitt’s Rule of Thumb:
! “Least paid person who can safely do the job”
! Qualifications
! 5-10 year’s clinical experience
! Life experience/Parenthood/Maturity
! Good judgement (Critical Thinking Skills)
! “Telecharisma” (Nordstrom's, ED, “Car Talk”)
! Bi-lingual!
! Excellent communications skills (Phone Preview)

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Chapter 7: Communication
! Duty to Elicit Info
! Patients are not required to provide all needed information.
! Duty to Communicate
! Significant information to patient and provider
! Decision Making
! Patients call for & deserve a disposition. Do not leave it up to the patient
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Communication Excellence
! Patient “buy-in”. Collaborate and Negotiate
! Be understanding (reduces lawsuit risk)
! Reassure but don’t Over-Reassure (explaining away symptoms)
! Expect Increased Calls when change occurs
! Be mindful of Hidden Agendas
! Confirm Informed Consent 76
Chapter 8: Documentation 101
! “My computer record had lengthy notes full
of repetitious boilerplate language and lab
data…I found only a few brief descriptions
of how I felt or looked.”
! Relman in Wachter, Digital Doctor, 2015
! “Ghost charting”
! Overuse or indiscriminate use of “Smart Phrases” 77

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Documentation 101
! “ While the computerized notes can be
improved through better IT design, it is up
to us to record a narrative that brings the
patient’s story to life.”
! Wachter, 2015
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Documentation 101
! Reduce Documentation Phobia by following
this advice”
!  “Write Drunk; edit sober” ! Earnest Hemingway
! ….at least when collecting the initial symptom history: Let patient tell their story at first and
document in their own words. Edit later
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Documentation 101
! Document patient statements in own words
! Be brief, concise, detailed and explicit
! Document by inclusion
! Documentation is evidence of care.
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Documentation 101
! Contextual Information
! Quantify and Qualify Symptoms by using measurable terms (8,9,10 Pain)
! Elicit Pertinent negatives to “Rule out” Urgency
! Use Time Frames (8, 16, 24, 48 hours) to establish urgency (Context)
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Chapter 9: Human Error
! Cognitive Errors
1. Premature termination: Jumping to conclusions
2. Confirmation bias: Selective search for evidence
3. Recency: emphasizing more recent information, while ignoring the back story
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Human Error: Cognitive
! Selective perception: Stereotyping patient or
symptoms
! Inertia – Incurious
! Wishful thinking or optimism bias. Over reassurance, “explaining away” symptoms
! Anchoring. Closed mindedness
! Source credibility bias: Bias against person or groups 83

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Remedies for Cognitive Error
! Talk Directly to the Patient
! Perform Adequate Assessments
! Allow enough Time
! Remain open to new information
! Be Mindful of Red Herrings
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Remedies for Cognitive Error
! Avoid Leading Questions
! Avoid Medical Jargon
! Avoid Stereotyping
! Do not rely on Non-Diagnostic Diagnosis:
! Patient’s own diagnosis of problem
! Previous diagnosis or erroneous diagnosis
! “Seen in ED or clinic”
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Decision Fatigue Research
! Decision fatigue: “deteriorating quality of
decisions made by an individual, after a
long session of decision making”.
! The brain eventually looks for shortcuts – reckless decisions or do nothing. Not unlike
preparing for wedding, a ritual akin to the
decision-fatigue equivalent of Hell Week.
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Decision Fatigue
! Example: Researcher wanted custom suit
made, involving multiple choices style,
fabric, type of lining and style of buttons,
lapels, cuffs, etc.
! “After the third pile of fabric swatches, I wanted to kill myself,” “I couldn’t tell the
choices apart anymore. My only response to the
tailor became ‘What do you recommend?’ I just
couldn’t take it.” 87

Decision Fatigue Research
! Exhaustion of the gift registration ritual:
! Plain white china or something with a pattern?
! Which brand of knives?
! How many towels?
! What color and kind of sheets?
! Precisely how many threads per square inch?
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Decision Fatigue in Telephone Triage
! Decisions in Telephone Triage:
! Which Symptom? 1- 20+ choices
! Which Guideline? Range: 42 – 350+ choices
! Which Question(s) in Guideline? 1- 20+
! Which Disposition? 5 – 10+
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Guidelines:
Right Numbers & Titles ! Table of Contents: Alphabetical and Site Based (42 choices)
1. Burn:1 Thermal; Chemical; Electrical 2 Radiation (Sunburn)
2. Chest Pain: Pressure/Pain; with or without Trauma
3. Ear Problem:1 Pain w Trauma; FB; Hearing Loss; Ringing; Earlobe Trauma; 2 Pain w/o Trauma; Discharge; Congestion; Earlobe Swelling
4. Eye Problem: 1 Pain w Trauma; Burn; FB; Vision Changes; Blood In 2 Pain w/o Trauma; Photophobia; Blood In; Discharge; Swelling; Vision
Changes
5. Face/Jaw: Pain w or w/o Trauma; Swelling; Weakness
6. Fever: High; Moderate; Mild
7. Head Problem: 1 Pain; Laceration; Level of Consciousness Change w Trauma 2 Pain; Level of Consciousness Change w/o Trauma
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Guidelines:
Too Many & Confusing Titles ! Table of Contents: Alphabetical 340+ Choices
1. Altitude Sickness
2. Anaphylaxis
3. Animal Bite
4. Animal or Human Bite Infection on
5. Antibiotic Follow-Up Call
6. Anus or Rectal Symptoms
7. Anxiety and Panic Attack
8. Arm Injury
9. Back Injury
10. Bed Bug Bite
11. Bee or Yellow Jacket Sting
12. Bluish Skin of Body Part (Cyanosis)
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Chapter 10: Assessment by Proxy
! Invisible Patient (or Parent) can self-assess:
! Blanching rash
! Level of consciousness
! Pitting edema
! Point tenderness
!  “Medical App-ready” Assessment
! Pulse, Respirations,Temperature, Blood Pressure, Medical Skyping
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Pain Assessment
Standards & Strategies
! Standards
! Severe pain is an Emergency (ACEP Policy)
! Pain: fifth vital sign, & assessed in all patients (Joint Commission)
! Strategies
!  SCHOLAR to assess pain quality, location, etc
! ADL to elicit effect of pain on Patient normal daily Activities
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Severe Pain Definitions
! 8-10 on scale of 10.
! Sudden onset is considered to be more serious than gradual onset.
! Localized pain is considered to be more serious than generalized pain
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Severe Pain Definitions
! Described as “excruciating”, “worst”,
“unexpected”, “unusual”, “sudden”,
“recurrent.”
! Pain that is unrelieved by correct dose of prescribed pain medication
! Pain that awakens patient from sleep or keeps patient awake
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Chapter 11:
Crisis Call from Invisible Patient
! EMTALA: Access to emergency care is a
fundamental right
! Rules of Thumb:
! Time is muscle; Time is tissue.
! Minding the Gap; Alert the ED
! Emotional Callers, Second Party Caller
! Remain with the caller if possible
! Three-way conference call
96
Medical and Psychological Crises
! Medical crises: 911
! Poison Control:
! Ingestions
!  Exposures
! Sexual Assault
! Psychological crises:
!  Suicide, Homicide
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Crisis Call Continuity
! Avoid patient abandonment by performing
warm transfers and remain on the line to
facilitate because not all call centers are
staffed with clinicians:
! 911 & Sexual Assault: No
! Suicide Prevention: No
! Poison Center: Yes
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Suicidal Callers
! Confront the Taboo
! Buy time while establishing trust
! Be Authentic and Resourceful
! See Suicide Guideline in Appendix
! In-service with Suicide Prevention
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100
Research: Metacognition
Critical Thinking Requires Time
! Inadequate Time = Inadequate Data
! “Under time pressure, people use less information to make decisions, which are often
suboptimal.” Vimla Patel
! Does time pressure worsen decision fatigue?
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Research: Metacognition Which of these enhance or impede Critical Thinking?
! Age
! Habitual Evaluation
! Lack of Self-Confidence
! Anxiety
! Awareness of Risks
! Stress
! Emotional intelligence
! Effective reading/writing/learning skill
! Unhealthy Lifestyle
(Alfaro-LeFevre, 2004)

35. 35

Research: Sitting = Smoking
Analysis of results of 18 studies (800,000
participants). Compared to least time sitting,
those with most time sitting had:
! increased diabetes (112%)
! cardiovascular events (147%)
!  death from cardiovascular causes (90%)
!  death from all causes (49%) ! Diabetologia, November 2012
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Movement is Therapeutic
! Examples:
! Walking meetings
! Shorter Shifts
! Rotate work between TT (desk-based) and clinic
! Wireless Headsets: Untethered increases movement
! No Instant message; walk to the persons’ desk
! Sit-Stand Desks
103
Sit-Stand Desks
104

36. 36

Healthy Practices
! Eating more fruits, vegetables may cut stroke
risk worldwide American Heart Association
News, 05/09/2014
! Dietary fiber intake and mortality among survivors of myocardial infarction: prospective
cohort study BMJ, 05/09/2014   
! Diet beverages and the risk of obesity, diabetes, and cardiovascular disease: a review of the
evidence Nutrition Reviews, 05/07/2013  
105
“The Secret of Quality is Love”
! Love of the patient, love of your profession.
! If you have love, you can work backwards
to monitor and improve the system. The secret of quality is love”.
Donabedian in Wachter, Why Health Care Tech Is Still So Bad?, NYT, March 21, 2015

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APPENDICES
! Stress Reduction Care For The Caregiver
! Telephone Triage –specific policies
! Patient Brochure
! Risk Management Articles
! Safety in Decisionmaking Article