Customer Interview – Sawtooth Mountain Clinic

This is the second in a series of articles introducing you to some of our customers. We all learn and grow from sharing in the experiences of others, we hope you find this interview helpful. The conversation is with Kate Surbaugh, RN, Clinical Nurse Manager for Sawtooth Mountain Clinic.

Here’s an overview of the topics we discussed:

Sawtooth Mountain Clinic Description

ClearTriage: Thanks for joining me this morning. Could you tell our readers a little bit about Sawtooth Mountain Clinic?

Kate: Sure. We’re a Federally-Qualified Community Health Center located in northern Minnesota, just forty miles south of the Canadian border on the shores of Lake Superior. We share a location with a small hospital and nursing home; otherwise the next closest medical care of any kind is almost 2 hours south of us.

We have six physicians and a nurse practitioner in our clinic. One of the great things about being the primary healthcare provider for this community is that we really get to see families grow and change and go through the whole life cycle. There are families where we have taken care of mom when she’s pregnant, kids have been born, kids grow up, they get married, they stay here, we see their kids… So, it’s a very rich community that we are really integrated with.

ClearTriage: That sounds like a very rewarding way to be able to provide care, and a great community to be part of.

Kate: Absolutely. We also serve the needs of the tourist population that comes in during the summer months. This weekend is Fisherman’s Picnic, which is one of the biggest weekends of the year. It’s a very popular time for tourists to come and it’s also a homecoming weekend for folks who grew up in the county and live elsewhere now. It’s a very, very busy time for us.

ClearTriage: Well thank you for taking the time to talk with us! What is your role there at Sawtooth?

Kate: We all wear different hats here because we are a small organization. I am the Clinical Nurse Manager which means I’m an RN and I supervise our other nurses. I manage fourteen nurses doing a variety of things from being on the floor and rooming patients to scheduling referrals, outreach and of course triage. We are staffed by nurses here, both LPNs and RNs. We don’t have any CMAs or other sort of med techs or nursing assistants because we wear so many other hats and need people who are qualified to take on those other roles.

The Sawtooth Triage Team

ClearTriage: How many of those fourteen nurses are involved in telephone triage?

Kate: There are four RNs who are trained to work on the triage desk including myself.

ClearTriage: So you have specific desk where you sit when you are filling the triage role?

Kate: Exactly.

ClearTriage: Do the triage calls require one person fulltime or are they just part of one person’s time?

Kate: It really is an 8-hour daily job for one person. And then there is another nurse who sits next to the triage nurse – we call that person a float nurse. They can help with overflow calls if it’s very busy. The float nurse will sometimes also talk to and triage walk-ins; we get a lot of walk-ins in the summer. The float nurse is also available to do prescription refills and help the floor nurses if they get busy. So triage is probably a little bit more than a full-time job.

ClearTriage: How does the float nurse help triage walk-ins?

Kate: They come in and they talk to the front desk first, but the triage nurse and the float nurse sit in the next room. So if the front desk needs a nurse to help triage a walk-in, they’ll just walk through the door and ask for help.

ClearTriage: That makes sense. How do you view the role of telephone triage? What is telephone triage providing to your organization and to your patients?

Kate: We see telephone triage as a really critical part of our role as the primary care provider for our community. We get a wide variety of phone calls. The vast majority of them are from our established patients. The triage nurse does a lot of the short-term scheduling. I know a lot of other places might have a front desk staff that’s a little bit more empowered to make some appointments, based on what the schedule looks like, but we really do try to talk to any patient who might have an acute issue just because we think that’s important to the continuity of care.

Peds Calls in a Full-Age Range Clinic

ClearTriage: So you serve a full age range of patients. Do your calls tend to be balanced between peds and adult calls or do you get more calls on the adult side?

Kate: That’s a good question. Because this is a vacation and retirement community, our population skews older. The county is about one hundred miles from end to end and the population is about five thousand people. I don’t know the demographic breakdown but there aren’t a huge number of young families relative to the whole population. So we do get more adult calls than peds calls. But we’re the one stop for everybody; so if anybody has a question, we are the place that they call.

ClearTriage: Do you get enough peds calls that it keeps everyone pretty fresh on those issues? I’ve heard some nurses talk about the peds calls being harder just because they don’t deal with them as often.

Kate: I think we do. I will say that the nurses who didn’t work with peds as much in previous jobs really do appreciate that part of ClearTriage. It’s a great double-check to make sure they are on the right track and are asking the right questions. We always have that heightened level of alertness when we take a peds call. Our emergency room is a level 4 trauma center so almost any serious peds case will get sent two hours down to Duluth. We need to be ready to make that call in a timely fashion.

Selecting Triage Nurses

ClearTriage: You said you have fourteen nurses with four able to take triage calls. How do you wind up selecting the nurses who are rotating through that triage role?

Kate: We had one nurse who was our triage nurse for fifteen years or so and she recently retired. She worked 4 or 5 days a week at that triage desk with another nurse as her backup for that one day a week or if she went on vacation. That other nurse is now our head triage nurse and has trained the two RNs who we brought in as floor nurses and chose to further train at the triage desk based on their skills and competencies as well as having the right sort of personality for the job and their interest in it.

ClearTriage: When you say their skills and personalities, what kind of things led you to select them – what do you think is important for a good triage nurse?

Kate: That’s a good question. I think that a certain level of unflappability is important, being able to stay calm under pressure. If you have someone who is upset on the phone, you need to be able to calm them down and make sure they understand the information you’re giving them. Also really clear communication skills. Obviously you’re speaking on the phone to the patients so you need clear verbal communication skills, but the written communication skills are extremely important as well because you need to document all of this for the provider and whoever else needs to be informed.

Critical thinking skills I think are the other big component. Especially in a clinic like ours where we’re not just deciding whether you should go see a doctor or not. We need to make that appointment, we need to know which doctor would be appropriate to see, what’s the schedule looking like at the clinic, what time of day should we put them in… If they’re a female with abdominal pain we need enough time to get them assessed before the clinic closes. There are a lot of different things to keep in mind when making those decisions.

Training Triage Nurses

ClearTriage: How did you go about training the new people you brought into the triage role?

Kate: We felt that it was important that they get a sense of the way the clinic works first by working on the floor and so that’s how they came in. Even though we knew that triage could be a role for them in the future, we wanted to make sure that they had an overall background first. The length of that depended on a number of different factors. But getting in at least three to six months on the floor and seeing all the different ways the clinic works and how it connects to all of our other services: when people need to be referred down to Duluth, what our social service situation is and is not in the county and all of those other kinds of things.

ClearTriage: They’re doing so much more than referrals just into your clinic; they really need to understand the options in your community.

Kate: Yes, absolutely. You have to have a sense of the county, because it looks very different than if you come from Minneapolis where there are all of these different resources for patients. You might not know coming in here, for example, that we don’t have hospice care in the same way that you would in an urban area. And the day-to-day flow of the clinic is important to understand when you’re trying to schedule on a busy day; deciding who needs to be seen today or tomorrow, with which doctor at what time. I think being on the floor gives the nurses a really good sense of that before they even sit at the triage desk.

ClearTriage: Sure. And once you do move them into the triage role, how do you train them?

Kate: We have a manual with the workflows and things that folks need to read. But really it starts with shadowing, listening in on calls with the current triage nurse with the headset muted. Then as they get comfortable they move in to taking calls with supervision from another nurse who’s listening in. And then finally and only when they are ready in the view of the head triage nurse who has been either training them or coming in and evaluating them periodically, they will start taking calls on their own. And the way that we have things set up with the float nurse, they always have another more experienced nurse on hand to help with questions.

Using ClearTriage

ClearTriage: How do you use ClearTriage in your triage process?

Kate: The float nurse and triage nurse both have double monitors so they can have ClearTriage up on one screen while they have our EMR up on the other screen. All of our triage nurses document in the EMR as they are on the call, I’m assuming that happens in most places. We always use ClearTriage as our starting point for the sake of consistency and for the sake of doing our quality assurance – making sure that we are triaging things appropriately, that our ED dispositions are appropriate and so on and so forth.

ClearTriage: What EMR are you using with ClearTriage?

Kate: GE Centricity.

ClearTriage: Are they working well together for you?

Kate: Yes, it’s very simple. We use the copy button, then we do control-v to paste it into the text portion of the phone note. It’s great because that helps everybody’s documentation to be standardized. I don’t open one phone note and see that it’s paragraphs long and know that so and so wrote it, then open another phone note and it only has one sentence. This way I can see that everybody is going through the same steps. ClearTriage kind of forces them in a good way to go through those steps and document in a similar fashion, which is great as I’m the one that does the quality assurance checking.

Why ClearTriage?

ClearTriage: Why did you select ClearTriage?

Kate: It was actually the retired head triage nurse who chose it, partly for training purposes. She had been here for so many years that she had all of these protocols basically in her head. And when we sat down to plan for her retirement, we said this isn’t going to work.

We knew we needed to hire a new person as well as move up the other two triage nurses. We knew we needed protocols in place and we couldn’t just download her brains. So she reviewed our options and felt that ClearTriage was the winner. And once we all looked at it we were really happy, especially the new head triage nurse. You know, he’s been a nurse for many years and he’s not super computer-savvy, he was happy with how simple and smooth it was use. So it got the thumbs up from everybody and it’s been in place since then which is almost a year now.

Advice for Others

ClearTriage: I have one last question for you – do you have any guidance that you would share with an organization that is working to improve its telephone triage?

Kate: I feel like it has been really important and beneficial for us to set up systems, especially now that our triage is shared among three people rather than being with one nurse as it was for so many years. It’s been sort of a new year for us and I feel like having the new protocols in place has been really important. But we try to keep it simple at the same time because you just can’t go looking too many different places when you’re trying to get information. And so aside from ClearTriage which has a big repository of information, we really just have the manual I mentioned with our clinic workflows and a cheat sheet with things like medication refill questions. With these three tools they should have everything they need right there at their fingertips.

ClearTriage: That sounds great – thank you so much for your time today!

Kate: You’re welcome.

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