Telephone triage: It’s a better way to treat a cold
URI protocol draws raves from patients, providers
When patients of the Lahey Clinic in Burling-ton, MA, get the sniffles or throbbing sinus headaches, they pick up the phone. Within two hours, the nurse calls back with a generous dose of sympathy and an expert evaluation.
Using Lahey’s URI (upper respiratory infection) protocol, nurses determine whether the best treatment is antibiotics, an immediate appointment, or chicken soup and a warm bath. They call prescriptions into the pharmacy, and the physician signs off on the care plan.
"This project started because the staff kept saying there has to be a better way to handle URI calls.’ The physicians were gung-ho about it. The nurses love it because they can give the patients extra TLC, and the secretaries who answered the phones were all for it," says Kathleen Jose, Lahey’s chief nursing officer. Patients rate the service as excellent 89% of the time, she adds.
Any day of the year, 10% of patient calls involve URI symptoms: coughs, earaches, headaches or stuffy/runny nose. A three-month sample — November 1998 to January 1999 — from Lahey’s seven general internal medicine stations reports 1,018 URI complaints. The brunt of the load fell on the secretaries who transcribed the messages and on the doctors who had wads of messages by evening when they sat down to return calls. All told, each station sees about 100 patients a day.
When Jose and her associates invited people to participate in an improvement project, it was no trouble to assemble a team. Secretaries, physicians, and nurses jumped at the opportunity to provide prompt, appropriate care to their URI patients. One physician volunteered to champion the initiative.
Telephonic visits are less rushed than office visits. The nurses have time to teach, and patients have time to ask questions about everything from over the counter (OTC) medicines to folk remedies. "You know how nurses are," Jose says. "Any time they can get in a plug on compliance and the dangers of misuse of medications, they’ll do it. It has definitely resulted in safer use of antibiotics." Along with increased patient knowledge and satisfaction, the URI phone triage program has helped the nurses’ morale, Jose adds. They have more time for one of the things they do best: patient teaching.
The protocol includes checks and balances to separate home care cases from those that need clinical assessment. Nurses review symptoms and related health conditions and instruct patients about signs of worsening trouble, such as no improvement in three days. Jose adds, "Today’s patients are well-educated, so they have no problem with calling back if there’s no improvement."
Within 24 hours of each telephone encounter, the nurse mails an education packet. It reviews home care instructions, antibiotic use, and symptoms that warrant further medical attention. Packets are also available, free, at each general internal medicine nursing station. "Patients tell us that they love them," she says.
Improved resource utilization pleases patients and staff alike because "patients have so little time these days," says Jeanette Douglas, clinical manager of the department of general internal medicine at Lahey Clinic. "Women are just thrilled, for example, not to have to get day care for their kids when they have a condition that they’re just going to have to live with for a few days."
On the other hand, 11% of patients register dissatisfaction, primarily on access issues, Douglas notes. "Some people really want to see a doctor for the extra reassurance that their condition is not serious. Some who have a recurrence of symptoms think it wouldn’t have happened if they’d seen a physician in the first place." Patients who request an appointment are seen, regardless of the apparent lack of severity of symptoms.
Overall, though, 90% show improvement in their symptoms and most express appreciation at not having to make a trip to the clinic. Nurses maintain a response rate of one to two hours on URI calls. Lahey’s direct costs for treating URIs have diminished $156,110 per year. A sinusitis triage program predated, and was later rolled into, the URI protocol.
"No sweat" would describe the implementation of this project. Of course, it helped that Lahey routinely uses accelerated clinical improvement strategies. "When we started the URI program, the physicians were already excited about other accelerated improvements so it didn’t take us that long at all," Douglas notes.
The program was introduced in October 1996, and in May 1997, it rolled out to all seven general internal medicine nursing stations.
The first six weeks, the program concentrated on protocol development. Then physician champions from each of the general internal medicine offices attended a two-day training. Topics included statistical analysis, treatment procedures for complications, and issues surrounding antibiotics and OTC medications.
Usually, as clinicians look back on new initiatives like this one, they see some hitch that they wish they’d anticipated, but not here. "We would have started sooner if we had known it was going to be such a positive experience," observes Jose. "Maybe we could even have handled other changes at the same time. But at the time it was so new to us that we didn’t foresee how well it would go."
Douglas adds, "we know the accelerated change process now, and we can launch more than one change simultaneously." Douglas shares a maintenance tip, which keeps the URI phone triage in peak condition: Once a new process is running, keep an eye on the data, "so you can tweak it as needed." Call patients at random to gather suggestions for improvement. "Projects like these are living, breathing things," she notes. "We continuously watch for new antibiotics and OTC medications to evaluate."
Need More Information?
For more on iURI telephone triage, contact:
- Jeanette Douglas, Clinical Manager, Department of General Internal Medicine, Lahey Clinic, 41 Mall Road, Burlington, MA 01805. Telephone: (781) 744-5493. E-mail: [email protected].
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