Pediatric Telephone Triage

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Pediatric Telephone Triage

• Tips, Trips, and Falls
• Paul D. Berkner,D.O., FAAP

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Telephone Triage

• When Protocols are not used, most health care
  providers show serious deficiencies
• The level of medical knowledge or length of
  experience in performing primary care is not
  correlated with level of performance
• Mid-level health workers such as NPs are as good
  as, if not better than, physicians
• There is enormous variation in physicians
  behavior on the telephone.
• Protocols are safe, practical and can be used by
  most health care providers
• Public Health Reports July-August 1980, Vol.95,
  No. 4 pages 327-328

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Telephone Triage

• Residency Training in Telephone triage still is
  very limited
• Less than half of all pediatric residency
  training programs offer formal training in
  telephone care. (AAP SOTC 2006)
• Nursing Phone Triage has become the standard of
  care in most Pediatric offices.

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Telephone Triage

• More than two thirds of the offices used
  answering services to take their calls.
  Ninety-three percent of the practices required
  the patient to decide whether the problem was
  emergent enough to require immediate notification
  of the on-call physician. Physician reviewers
  reported that 50 (range, 22-77) of the calls
  not forwarded to the on-call physician
  represented an emergency needing immediate
  contact with the physician.
• After-hours telephone triage affects patient
  safety. Hildebrandt DE, Westfall JM, Smith PCJ
  Fam Pract. 2003 Mar52(3)222-7.

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Tips

• Goals
• Ensure safety of patient
• Establish a plan that the patient/parents are
  comfortable.
• Empower the patient/parent to follow up the next
  day

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Tips

• Things you do not want to do
• Lecture the patient about calling protocols
• Get angry with patient
• Always remember this may be your 10 th phone call
  of the night but only the patients first.

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Tips

• Have a liver person answer the phone
• Establish that there is no life threatening
  emergency
• Use Protocols / Algorythms
• Pediatric Telephone Protocols-Dr. Barton Schmitt

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Tips

• Identify yourself and your role.
• ie This is Dr. Berkner and I am covering for Dr.
  Peters
• Listen to whole complaint.
• Be specific with advice.
• ie Give your child 1/2 tsp of Tylenol every 4
  hours.

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Tips

• Ask the patient to repeat your instructions back
  to you.
• Ask the patient if they are comfortable with the
  plan.
• Are you comfortable with the plan or do you feel
  your child needs to be seen tonight
• If the answer is yes. HAVE THE CHILD SEEN
• Encourage them call back if the situation changes
  or they have any concerns.
• Document the conversation immediately.
  Legibly

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Trips
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Trips

• Grandmother of 1year old calls during a busy
  office day and tells your receptionist that her
  granddaughter has just gotten into her purse and
  opened her bottle of medications. She has a
  number of different pills in there.

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Trips

• Your immediate concerns are?
• Your instructions to the grandmother are?

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Trips

• It is 2 am and you get a call from the father of
  a 6 yo male with abdominal pain of 4 hours
  duration. It has been acute and periumbilical.

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Trips

• Differential diagnosis
• Appendicitis
• Constipation

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Trips

• Questions for father
• Appetite
• Stool pattern
• Fever
• Nausea/Diarrhea

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Trips

• 14 yo healthy female who was walking home from
  school and slipped on the ice falling backwards.
  Patient has a persisting headache and is
  nauseous.
• What are your recommendations to her mother?

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Trips

• You get a call about a 16 yo basketball player
  who injured his ankle tonight during a basketball
  game.

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Trips

• Your recommendation to his father?
• What if the father insists that his son be seen
  in the ER.

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Falls
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Falls

• Mom calls you with concerns about her 10 day old
  infant who is fussy.
• Full term delivery
• G3P3 mother no c/o except viral illness 2 weeks
  prior to delivery
• Breast fed infant
• Seen at 1 week weight back to BW no jaundice noted

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Falls

• Questions to ask
• Behavior
• Fussy and mom noted 20 second staring and
  twitching episode this evening
• Fever
• 100.5
• Skin color
• Pale
• Appetite
• Decrease Breast feeding

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Falls

• Red flags
• Third child
• Fussy
• Twitching episode
• Temp
• Decreased feeding

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Falls

• You receive the following note which one of your
  triage nurses has just taken.
• 2 y.o. saw Dr. Smith 2 days. Diagnosed with the
  flu.Still has a fever up and down. Drinking
  Coke- keeping it down. Weak-listless.Moans when
  touch her. No diarrhea-vomits if try solids.
  RX-give clear liquids-today-call am.

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Falls

• Concerns
• Red Flags
• Actions

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Falls