Today, as patient care moves from inpatient to ambulatory care, care delivery methods are changing. Telehealth nursing is a growing field in which nurses meet patient needs and deliver high-quality care efficiently and effectively. Telehealth nursing is practiced in medical practice settings, call centers, home health agencies, and other outpatient settings; it's not uncommon for patients to even call their inpatient nurses after discharge.
Telephone triage is a process of assessing patients without seeing or touching them, then prioritizing their needs and referring them to appropriate care. Despite the barriers, quick, accurate recognition of a life-threatening emergency and a prompt response are critical. Although all potentially lethal emergencies are too numerous to list here, I'll review a process to help you promptly identify red flags that need an immediate response.
Systematic approach to the primary survey
Commercially developed decision-support tools are available to help you determine the urgency of problems, but they should supplement, rather than overrule, your critical thinking skills and clinical judgment. Above all, rely on the nursing process, which includes:
- thorough assessment, including what you can hear, what the caller can measure, and what the patient can observe
- diagnosis of urgency
- collaborative planning
- attention to continuity of care
- a plan to evaluate the effectiveness of the intervention.
Usually, telephone calls about obviously life-threatening problems such as frank hemorrhage or loss of consciousness are made to 911. The calls you get may concern less obvious emergencies, but they may be equally life-threatening. To promptly recognize them, do a primary survey early in the interview to identify actual and anticipate potential problems related to airway, breathing, and circulation (ABCs) and neurologic status/deficit. And be on guard for stumbling blocks that can prevent recognition of life-threatening emergencies. (See Pitfalls to avoid.)
Airway. Partial airway obstruction is usually audible, so always ask to speak to the patient or have him brought to the phone so you can assess him. This is true even for infants, patients with limited verbal ability, and those who otherwise can't give a meaningful history, such as small children or patients with dementia.
Wheezing, stridor, croupy cough, and a muffled voice are obvious signs of airway compromise, but hearing no sound at all may indicate a severely obstructed airway. You also need to consider a potential airway obstruction such as in the case of an anaphylactic reaction, which may be associated with a bee sting or rash. Also at high risk may be patients who've sustained blunt or penetrating trauma to the throat or neck.
Breathing. Abnormal breathing can raise a red flag about a dire emergency. Speak to the patient, listen to him breathe, and count his respirations. If he's gasping short phrases or can't clearly complete a sentence, his breathing is probably severely compromised. Pay attention to his respiratory pattern and listen for more subtle clues such as moaning, grunting, or other abnormal sounds. Ask too about inaudible cues such as retractions, nasal flaring, and the color of his skin, mucosa, and nail beds.
Circulation. Stay alert for many circulatory problems that could signal potentially life-threatening conditions. During assessment of circulatory emergencies, think about the pathophysiology that might be associated with the patient's chief complaint.
- Chest pain, especially with shortness of breath, nausea, or diaphoresis, must be considered life-threatening until proven otherwise. Delay in treatment due to denial is a significant cause of death in myocardial infarction. Life-threatening pulmonary events such as pulmonary embolus might have similar signs and symptoms. Promptly refer a patient with blunt or penetrating chest trauma.
- Bleeding can pose significant challenges. Using the right words to lead the patient through assessment regarding the type and amount of bleeding is an important skill for a telehealth nurse and can be critical to identifying significant hemorrhage. (For advice on the various types of bleeding, see Assessing and responding to blood loss.)
- Shock. Careful assessment for signs and symptoms of shock such as orthostasis, diaphoresis, tachycardia, thirst, altered level of consciousness (LOC), and other signs and symptoms is important. Hemorrhage is a common cause of hypovolemic shock. Severe dehydration secondary to vomiting, diarrhea, and decreased fluid intake can lead to shock as well, and can be especially dangerous in infants, older adults, and patients with preexisting health conditions. Consider cardiogenic and neurogenic shock when the suspected illness or mechanism of injury supports those possibilities. Suspect septic shock in someone with a history of fever or infection who's profoundly weak, very ill, or vomiting.
- Vascular events. In someone who's sustained blunt extremity trauma, checking capillary refill, skin color, and temperature distal to the injury is necessary to assess circulation. Pain in the calf muscle or medial thigh, especially with edema, may signal deep vein thrombosis. Consider acute peripheral arterial occlusion if the patient's extremity suddenly becomes pale, cold, and painful, with or without a history of trauma.
Severe, sudden-onset pain could signal a vascular event such as a dissecting aortic or cerebral aneurysm and should be addressed emergently. (Pain severity doesn't always accurately indicate the seriousness: Dissecting abdominal aortic aneurysm often causes vague back pain.) Testicular pain and swelling could indicate torsion. Sudden sustained or transient vision loss may signal a thromboembolic event. Other more obscure emergencies should be considered, such as temporal arteritis, especially in a woman over age 55.
- Syncope. The cause of syncope or near syncope is frequently cardiogenic, so assess the rate and rhythm of the patient's pulse.
Neurologic deficit. Slurred speech, blurred vision, ataxia, confusion, unilateral weakness, or loss of function may signal a neurologic problem. Even subtle neurologic deficits can herald life-threatening problems. A good rule is to have any change in LOC, even a slight one, evaluated immediately. Also consider complaints such as “He's just not himself today” as altered LOC until proven otherwise. This is especially true in nonverbal patients such as the very young and the very old and those with baseline neurologic deficits such as developmental disabilities.
Assess for neurologic signs such as nuchal rigidity and respond promptly. Take any complaint of numbness, tingling, or weakness seriously, especially if it's a new onset or worsening of a preexisting condition. Recognizing serious mechanisms of injury is essential. For example, a patient with neck pain following a fall or a flexion/extension injury of the cervical spine, with or without obvious associated neurologic deficit, should be promptly immobilized and transported.
Many substances can trigger lethal events, so maintain a high level of suspicion when signs and symptoms are difficult to explain. Factors such as carbon monoxide exposure or toxic ingestion, including intentional or unintentional drug overdose, can lead to altered LOC and death.
Other life-threatening conditions. The following list, though not all-inclusive, provides additional sources of a potentially life-threatening emergency.
- Depression. Anyone who expresses suicidal thoughts must be referred for immediate evaluation. Generally, keeping the patient on the line until a responsible adult is present is best, even if he reassures you that he doesn't have a plan or a means to carry one out.
- Possible sepsis. Any immunosuppressed patient must be referred promptly when you suspect infection. Fever guidelines for patients receiving chemotherapy or immunosuppressive therapy (such as transplant recipients or those on high-dose steroids), those with AIDS, and asplenic patients, must be more conservative than for the general population. Patients at extremes of age are also at risk. Any fever over 100.4° F (38°C) rectally in an infant under age 3 months must be referred for immediate evaluation. Even a low-grade fever in a frail older adult might herald sepsis as well. Other patients with chronic illness or who are otherwise debilitated or marginally compromised should be handled cautiously if you suspect infection.
- Rash. Most rashes aren't life-threatening, but failure to recognize certain life-threatening problems, such as petechiae associated with meningococcemia, could have devastating effects. Err on the side of caution—consider prompt referral for anyone with a generalized febrile rash.
- Obstetric emergencies. When the patient is pregnant, you must consider her health and that of her fetus. Refer her for prompt evaluation if you suspect preterm labor, bleeding, or premature rupture of membranes; if she reports severe abdominal pain or absent or decreased fetal movement; or if she has signs and symptoms of preeclampsia (blurred vision, swelling, headache, epigastric pain, or vomiting).
- Orthopedic emergencies. If a patient sustained blunt extremity trauma, the involved extremity must be assessed distal to the injury for sensation, color, motion, and temperature. Refer a patient with a suspected septic joint (pain, warmth, redness, and swelling) for prompt evaluation.
- Ocular emergencies. Any acute decrease or loss of vision or severe eye pain, with or without redness or visual changes, must be evaluated immediately.
Documenting with caution
You need to document all telephone encounters, but it might be prudent to limit your documentation of an emergent call to basic demographics (such as the caller's name and location) and findings to support the emergent disposition. Although you must try to document thoroughly, helping the patient get immediate evaluation for a potentially life-threatening emergency is vital, and delaying care to document is contraindicated.
Pitfalls to avoid
Patient self-diagnosis. A patient may explain her problem according to health conditions she knows about and unintentionally withhold key information. A prime example would be someone calling about a toothache who's actually having a myocardial infarction. Always investigate beyond the patient's self-diagnosis to determine the cause of her signs and symptoms.
Failure to think “Worst possible.” You may have been taught, “If you hear hoofbeats, look for horses, not zebras,” but failing to look for zebras during telephone triage can be dangerous. Consider every call life-threatening until proven otherwise.
Patient reports that don't jibe. Equally important to skillfully collecting information is how you process it. If elements of the problem are inconsistent with the overall situation, delve deeper. For example, if a family member attributes an older adult's mood shift and refusal to eat as “being cantankerous,” find out if this is a new problem. It may signal an altered level of consciousness and a potentially life-threatening condition.
Assessing and responding to blood loss
Lacerations. Determine the character and amount of bleeding and promptly distinguish venous from arterial blood so appropriate first-aid measures can be initiated. Although spurting blood is a classic sign of arterial bleeding, small nicks in arteries can cause less obvious pulsation. Blood color can help distinguish venous from arterial blood, but the caller may not be able to tell the difference. For any profuse bleeding, promptly institute appropriate first-aid measures and tell the patient to call 911.
Epistaxis. Estimating the amount of blood loss with a nosebleed may be difficult for the patient. To be safe, refer a patient who's been bleeding for 20 to 30 minutes for immediate evaluation, especially if signs of shock are evident.
Hemoptysis and hematemesis. Although these problems commonly represent blood-streaked sinus drainage, carefully assess them. A patient who's coughing or vomiting frank blood should be transported immediately—he may have bleeding esophageal varices or erosion of pulmonary vessels, which can't be managed at home.
Rectal bleeding. Get details on whether the patient has bright red blood on the toilet paper, blood streaks in his stool, drops of blood coloring the water in the toilet pink, or a commode full of bright red blood. Melena may indicate upper gastrointestinal (GI) bleeding. Taking iron supplements or an upset stomach remedy also can cause black stools, so don't make any assumptions—he may not have bleeding or he may be taking these drugs to treat anemia or gastritis associated with GI bleeding.
Vaginal bleeding. Find out how many pads are saturated per hour, keeping in mind that this parameter varies with the many types of feminine hygiene products used. Saturating one pad or tampon an hour is the general rule for immediate referral—remember to err on the side of caution. Tampon use is widespread, so stress the importance of not inserting anything into the vagina until the source of bleeding is identified.
Internal hemorrhage. Many factors can cause internal bleeding, such as blunt abdominal trauma or a ruptured ectopic pregnancy. Maintain a high index of suspicion for these and other problems; carefully assessing for signs and symptoms of hemorrhagic shock is a priority.