Telephone Triage Protocols – Script or Checklist?

Part of my job is to demo ClearTriage to interested nurses, providers and administrators. I’ll often say something like, “as you know, the Schmitt-Thompson telephone triage protocols are meant to be used as a checklist, not as a script.” I’m surprised by how many people don’t understand what I mean by this. This concept is so critical to the efficient and successful use of these protocols that I want to explain more about this in our very first blog article. So here goes…

The Schmitt-Thompson protocols provide a series of triage questions arranged from highest to lowest acuity. The Clinical User’s Guide says to go through the questions until you reach the first positive question which will determine the level of care (the disposition) the patient needs. But going through the questions does not mean you need to verbally ask each question. That’s not the intent of the protocol authors. You have a brain! You are a nurse!

A triage call starts with listening and probing. You are picking up clues to determine what is going on, what the important symptom(s) are as well as their severity and duration. And you will learn quite a bit about the patient during this stage of the call, before you even select a protocol. Some of what you learn will mean that you don’t need to ask some of the questions.

For example, Jimmy’s mom calls and says that Jimmy has been vomiting, he’s stayed home from school, he’s on the couch watching cartoons and he won’t go back to bed. You hear him in the background, talking clearly and saying his tummy hurts. When you get to the vomiting protocol, you don’t need to ask if there are signs of shock, if Jimmy is difficult to awaken, if he’s confused when awake. But you do need to ask about things that you haven’t heard yet: does he have a stiff neck? Any chance of poisoning? Color of the vomit?

The Checklist Manifesto

Asking each question blindly in order makes you sound robotic to the caller rather than caring and reassuring. Use your judgment. Use your experience. But use the protocols questions as a checklist to make sure you didn’t miss anything serious. Dr. Atul Gawande wrote a great book about the value of protocols called The Checklist Manifesto. He gives multiple examples showing how checklists are not meant to supplant judgment but rather to make sure we don’t miss anything.

Take the classic example of the checklist used by pilots before the plane takes off. Pilots know the steps. They can recite them from memory if you ask. Nine out of ten times (or 99 out of 100 times) they’ll follow all of the steps perfectly without a checklist. But what about that 1 time? What if they miss one of the safety steps occasionally? With the redundancy in modern airplanes, chances are some automated system would catch the mistake before taking off. But what if the pilot doesn’t use a checklist, forgets a step, and the safety system for that equipment is broken? That’s what leads to an airplane crash.

So what if you as a triage nurse forget a question? It almost always won’t matter. But what if you forget to rule out appendicitis in the rare case where the patient with a stomachache has appendicitis? What if you forget to ask about petechiae in a child with a widespread rash and it turns out they have meningococcemia? That’s what a checklist is for.

Carol Rutenberg, RN-BC, C-TNP, MNSc is a nationally-known expert on telephone triage and is one of the strongest voices for the value of your knowledge and skills as a nurse. She even argues that you should do your triage completely and arrive at a disposition before consulting the protocol. But she still believes you need protocols. She says you should look at them after you arrive at your own disposition, using them as a checklist to make sure you didn’t miss anything.

That approach may not match with your workflow, it’s not the right triage process for everyone. But it highlights what you want to be using the protocols for. Dr. Gawande describes how humans doing repetitive knowledge-based tasks will periodically forget steps. Use the protocols as a checklist to make sure that doesn’t happen to you. That’s why they’re critical to the safety of your telephone triage.

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