Telephone Triage in Healthcare Practices

The telephone is one of the most important communication tools in healthcare practices. Telephone calls must be prioritized and routed appropriately so patients receive the proper medical attention. Telephone triage, like triage in person, is a critical step in ensuring that patients see the appropriate provider at the appropriate level of care.

Healthcare practices should have written policies and protocols that specifically address handling telephone calls, triaging patients, scheduling appointments, refilling prescriptions, and addressing patient questions and problems. These procedures should specify that documentation is required for telephone-based encounters.¹

Front-office staff should have clear guidelines for telephone triage and notification of a physician or designated clinical staff member when an emergent or urgent situation arises. Evidence of training in telephone triage should be maintained for any healthcare employee that handles calls of an urgent nature.

Although telephone triage is limited because it can’t replace an onsite visit and a physician’s examination and professional judgment, it can help improve access to the level of care needed, the efficiency of the practice, and the patient’s satisfaction. However, telephone triage also may present risks to healthcare practices. Some risks may involve healthcare employees not following practice triage protocols or required scripts as well as offering guidance outside of their scope of expertise. Other risks include the failure of healthcare employees performing telephone triage to:

• Speak directly with the patient
• Accurately assess the level of urgency of the caller’s situation
• Properly document the call in the patient’s health record

Since triage systems involve screening patient symptoms and providing subsequent clinical advice, registered nurses with the appropriate background, training, and clinical experience should perform telephone triage in healthcare practices. These nurses should use written clinical protocols in performing telephone triage, and these protocols should be updated on a consistent basis with new medical information.

The type of provider who should conduct telephone triage depends on state laws related to scope of practice.² Some states allow licensed practical nurses who have been appropriately trained to engage in telephone triage, while other states require registered nurses for this role. Additionally, some state laws allow more duties in the scope of practice for medical assistants, so the established practice protocols in the healthcare practice should comply with state law and be specific to this expanded role if applicable.

Regardless of who provides telephone triage services, the practice should have written protocols and policies that specify the extent to which these employees may provide healthcare advice based on their scope of expertise.

Any medical advice given to a patient on the phone is legally deemed as medical practice; therefore, the supervising physician is responsible for all medical advice given from the practice — no matter which healthcare employee provides it. Therefore, physicians should annually review and approve the practice’s written protocols and phone scripts and educate their staff members.

Telephone Triage Services

Some practices engage a telephone triage service because it can ensure that the nurses conducting the triage are functioning within the appropriate nursing scope of practice. Additionally, software-based and written telephone advice protocols are available commercially as well as from professional associations. These telephone protocols assist clinical employees in healthcare practices with the data collection, triage, decision-making, disposition selection, and advice-giving processes.

In many states, the Nurse Practice Act requires that nurses use standardized protocols if they are providing telephone triage and giving advice. It is prudent to always check applicable state laws.

Some of the commercial telephone triage services have evolved from using unstructured protocols (written guidelines that rely heavily on previous training and judgment) to using structured protocols (clinical algorithms that are essentially created by physicians and involve yes-no decisions).

If telephone advice protocols are used, physicians and clinical personnel should review and adapt them to meet the needs of the practice. They can provide a standardized approach to telephone triage, reduce telephone errors and legal liability, and improve efficiency. Additionally, clinical personnel who give telephone advice must receive training on the protocols and conduct themselves within their scope of practice, and they should have documented competence in telephone assessment.

If physicians employ a telephone triage service as an extension of their practice, they may perform due diligence by doing the following:

• Scrutinize the service as carefully as if it were in their own office
• Review nurses’ scripts and protocols to determine whether they comply with acceptable standards and the physician’s own medical philosophy
• Periodically pose as a caller and contact the service to monitor its efficiency and accuracy³

However physicians choose to conduct telephone triage in their practices, they should ensure that telephone triage policies and procedures are based on current standards of practice and on state laws. Physicians should also ensure that their staff members are fully complying with those procedures.

Risk Strategies When Using a Telephone Triage Service

Following are some risk strategies when using a telephone triage service:

• Document all telephone communications on a standard phone encounter form (to go into the patient’s health record) or on a template in the practice’s electronic health record system.
• In addition to using written protocols for clinical decision-making, be sure the healthcare employee conducting telephone triage also uses critical thinking and empathy.
• Document any decision in a patient’s health record that deviates from the practice’s written protocols.
• Ensure the patient understands advice given (employ the teach-back method in which the healthcare provider asks the patient to repeat back the advice given using his or her own words) and document it.
• Review protocols and algorithms annually to ensure compliance with current standards of care.

Conclusion

Telephone triage does not replace medical care, but it’s a vital part of a healthcare practice because it involves screening of patient symptoms and providing clinical advice. Delineating responsibilities for telephone triage in job descriptions will ensure the appropriate healthcare employee is providing it and working within his or her scope of practice. Documenting these patient calls as well as creating and reviewing written telephone triage protocols and guidelines are critical to minimizing the risk potential that telephone triage may pose in any healthcare practice.

Endnotes

¹ ECRI Institute. (2013, September 1). Communication and Patient Safety. Ambulatory Care Risk, Quality, & Safety Guidance — Guidance. Retrieved from www.ecri.org/

² ECRI. (2017, January 18). Ask ECRI: Who can triage walk-in patients and telephone calls? Ambulatory Care Risk Management. Retrieved from www.ecri.org/

³ American College of Physicians—American Society of Internal Medicine. (2000). Telephone triage. Retrieved from www.acponline.org/acp_policy/policies/telephone_triage_diagnostic_techniques_procedures_ 2000.pdf

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