telephone triag egraphic1

TELEPHONE TRIAGEHans L. Duvefelt, M.D., ABFM

tri-age (French) sorting, sifting

“The sorting of and allocation of treatment to patients and esp. battle and disaster victims according to a system of priorities designed to maximize the number of survivors.”

Merriam Webster’s Collegiate Dictionary

Outcomes of triage call

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• Activate Emergency Response



• Urgent Office Visit




• Non-urgent / Routine Office Visit





• Advice from nurse/provider/other party





• Advice from nurse/provider/other party• Activate Existing Plan (“Dr X told me to call next

time this happened, so she could try me on Supercillin.”)

Common Triage Decisions

Chest Pain

Acute Allergic Reaction

Seizure

Respiratory Distress

Major Trauma

Emergency

Common Triage Decisions

Sore Throat

Earache

Bronchitis

UTI / Blood In Urine

Sprains, Strains

Most rashes

Urgent

Common Triage DecisionsCommon Triage Decisions

Physicals

Chronic Problems

Routine

Non-Medical Staff Triage?

Non-Medical Staff Triage? Sure!


• When to activate Emergency Response System



• When to interrupt nurse / provider (the Time Factor…)




• When to offer a call back




• When to offer a call back

• When to make a Routine Appointment (and when not to…)

Activate Emergency Response

Activate Emergency Response

Stated Concern About…

Heart Attack

Stroke

Serious Allergic Reaction

Respiratory Distress

Major Trauma

If the patient declares an emergency, it may not be wise to talk him/her out of it.

Involve the Nurse?

Interrupt or Not?

Involve the Nurse?

If you’re not sure whether it is an emergency.

Interrupt or Not?

The Time Factor!

The Time Factor

The Time Factor I

“I have a terrible headache.”

“When did it start?”

“When I was in Vietnam.”

“What made you decide to call today?”

“I got tired of it.”

“Let’s make you an appointment!”

The Time Factor II

“I have a terrible headache.”


“Yesterday, and I can’t get rid of it.”

(There are no acute slots.)

“I’m going to have the nurse call you back as soon as she is free.”

The Time Factor III

“ I have a terrible headache.”


“20 minutes ago, and it’s getting worse every minute.”

“I’m going to let you talk to a nurse right away!”

Five Fundamentals of Triage


• Expect the worst



• Common things are common




• Consider the time factor





• Is the cause known or suspected?





• Is the cause known or suspected?

• Location Matters

Common Things Are Common

“Has anyone else been sick with anything like this?”

Common Things Are Common

“Has anyone else been sick with anything like this?”

“Have you had anything like this before?”

Most patients with indigestion, headache, backache, the flu or hemorrhoids have just that.

It is more likely that the patient has a slightly unusual presentation of a common ailment than something exotic.

IS THIS AN EMERGENCY?(The Time Factor…with some Cause…)

Johnny has an awful cough…



…after just running around with those glass beads in his mouth!

IS THIS AN EMERGENCY?(The Time Factor)



EMERGENCY




…it started yesterday and his inhaler isn’t stopping it!

EMERGENCY





URGENTEMERGENCY





…that lasts a week every time he goes to the zoo!

URGENTEMERGENCY





…that lasts a week every time he goes to the zoo!

URGENTEMERGENCY ROUTINE


I have a rash…

…I just got stung by a bee and I’m breaking out in hives!


I have a rash…



I have a rash…

EMERGENCY


…I must have come in contact with poison ivy over the weekend!


I have a rash…

EMERGENCY




I have a rash…

URGENTEMERGENCY



…my elbows are thick and scaly like psoriasis!


I have a rash…

URGENTEMERGENCY



…my elbows are thick and scaly like psoriasis!


I have a rash…


IS THIS AN EMERGENCY?(The Cause Factor)

Johnny got hit in the head…

IS THIS AN EMERGENCY?

…by a wrecking ball that knocked him to the ground!

(The Cause Factor)




(The Cause Factor)


EMERGENCY



…by a baseball!

(The Cause Factor)


EMERGENCY



…by a baseball!

(The Cause Factor)


URGENTEMERGENCY



…by a baseball! …by a Nerf ball!

(The Cause Factor)


URGENTEMERGENCY



…by a baseball! …by a Nerf ball!

(The Cause Factor)



(The Cause Factor)

Mary’s belly hurts…


…her period is way late and she’s wicked pale and lightheaded!

(The Cause Factor)




(The Cause Factor)



EMERGENCY


…she’s got cramping and diarrhea. The rest of us have just gotten over the stomach flu!

(The Cause Factor)



EMERGENCY



(The Cause Factor)



URGENTEMERGENCY



…every morning before the school bus!

(The Cause Factor)



URGENTEMERGENCY



…every morning before the school bus!

(The Cause Factor)




(The Location Factor – stay away from the high rent districts!)

I suddenly got this excruciating pain in my…


…abdomen

…head

…chest




…abdomen

…head

…chest




EMERGENCY

…abdomen

…head

…chest

…big toe

…ankle

…knee




EMERGENCY

…abdomen

…head

…chest

…big toe

…ankle

…knee




URGENTEMERGENCY

…abdomen

…head

…chest

…big toe

…ankle

…knee

…tooth




URGENTEMERGENCY

…abdomen

…head

…chest

…big toe

…ankle

…knee

…tooth





COMMON SYMPTOMS AND WHAT WE DO FOR THEM

FEVER

Is there a dangerous temperature?

FEVER


Not really! Fever is a symptom. We look for the cause. Sometimes we don’t find it…

FEVER


Not really! Fever is a symptom. We look for the cause. Sometimes we don’t find it…

In infants under one year we MUST find the cause, because they may have atypical presentations of meningitis and other serious infections.

POISONING

POISONING

We can’t keep track of all of them, se we advise our callers to contact

POISON CONTROL

1-800-442-6305

1-800-222-1222

INGESTEDOBJECTS

INGESTEDOBJECTS

Usually, once swallowed, objects make it all the way through to the other end..

INGESTEDOBJECTS

Usually, once swallowed, objects make it all the way through to the other end.

Sometimes we x-ray the abdomen to make sure they make it through the stomach and into the small intestine.

DIARRHEA ANDVOMITING

DIARRHEA ANDVOMITINGWe try to QUANTIFY to decide on severity “How many times have you had diarrhea? Every time!” (…is not good enough!)


Generally no cure.

DIARRHEA ANDVOMITING

We try to QUANTIFY to decide on severity “How many times have you had diarrhea? Every time!” (…is not good enough!)

Generally no cure.

Don’t make it worse - advise the BRAT diet:BananaRiceApplesauceToast

NO MILK


Generally no cure.

Don’t make it worse - advise the BRAT diet:BananaRiceApplesauceToast

Caution: Bloody or black diarrhea is an emergency, although Pepto Bismol makes stool black.

NO MILK

PAIN ANDSWELLING

PAIN ANDSWELLINGIs the cause known or suspected?


Ankle pain after falling off a roof?



Is somebody liable?



Is somebody liable?

If it happened on the job, it MUST be processed as a Worker’s Comp case.



Is somebody liable?

If it happened on the job, it MUST be processed as a Worker’s Comp case.

Motor vehicle accidents with personal injuries must be investigated by the police.

WORK INJURIESWORK INJURIES

WORK INJURIES

Must be processed as such.

WORK INJURIES


Employer chooses provider for the first 10 days.

WORK INJURIES



First visit will be billed as a New Patient Visit, takes longer and involves enough paperwork to document future court case.

WORK INJURIES



First visit will be billed as a New Patient Visit, takes longer and involves enough paperwork to document future court case.

M-1 form must be completed first and last visit, and every 30 days in between.

MOTOR VEHICLEACCIDENTS


Motor Vehicle Accidents with personal injuries must be reported to the police at the time of the accident.



Often many x-rays are needed, which can strain our staff resources. CT scans are often needed.



Often many x-rays are needed, which can strain our staff resources. CT scans are often needed.

MVA’s are often referred to the ER.

BACK PAIN

BACK PAIN

Is the cause known? (Yes)

BACK PAIN

Is the cause known? (Yes)

Unless there is neurological deficit (urine, bowels, leg weakness), mechanical back pain is generally not an emergency.

Most mechanical back pain gets better lying down.

Generally no acute x-rays needed.

BACK PAIN

Is the cause known? (No)

BACK PAIN

Is the cause known? (No)

Uncommon causes include:

Kidney stoneGallbladder AttackBlood clot in lungCollapsed lungRuptured aneurysmPancreatitisUTI

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