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In pediatrics, the telephone rules-during hours, after hours, all hours. It’s not news to you that babies and children get sick frequently, and subtle symptoms can mean something serious-or nothing at all. Your expert attention is required to tell what’s wrong, especially in a preverbal patient. You must be accessible to patients and parents at all times, and the telephone is the most direct route.
That is why, if you do not already have one, you should consider your need for a telephone triage nurse-a specially trained nurse who uses protocols to handle patient calls. On average, a pediatrician receives 20 calls a day about sick patients-and another 20 from parents who want an appointment for a sick child that day. A telephone triage nurse should handle about 10 calls an hour, not including appointment calls: just right for a small group practice.
What does a telephone nurse do?
When a parent calls your office with a question about a sick child, the first person reached ought to be, as noted, the receptionist. If the parent requests an appointment, the receptionist gives it-no telephone nurse, no triage. If the parent isn't sure whether the child needs to come in, or has a question for the nurse, the receptionist either transfers the call, puts the caller into the nurse's voice mail, or takes a message. Any true emergency calls can go right to 911 or to you directly.
The telephone triage nurse must be available immediately. If the parent must leave a message, at least make sure the nurse callback takes place within half an hour. An astute receptionist can convey the urgency the caller feels to the telephone nurse or to you. Then, the nurse decides if the patient needs an appointment, by consulting with you.
Your nurses are, of course, highly skilled at their clinical and administrative tasks, but telephone triage requires a certain aptitude as well as training.
Why do parents call?
In most instances, you don't need prepared protocols for your work; telephone nurses do. Triage protocols must balance carefully whether patients need emergency care, an office visit, or home management only.
A telephone triage nurse must rely on printed protocols (an example is Pediatric Telephone Protocols by Barton D. Schmitt, MD, available from the American Academy of Pediatrics). It's easier to use a book such as Schmitt's volume than to devise your own protocols. But you'll definitely want to review such prepared protocols carefully and customize them for your own practice so that you and your colleagues are comfortable with them. The most frequent change pediatricians make to these protocols is, based on the nature of the emergency, whether a certain problem should go to the office or the emergency room. (Don't customize by physician in your practice, however-that would make life impossible for the triage nurse.)
At first, the telephone triage nurse should deal only with the top 20 or so symptoms. According to Schmitt, 25 symptoms account for 90 percent of your calls.
The most common symptoms that parents call about are listed in the accompanying table. Some frequent symptoms are actually "safe symptoms," says Schmitt: for example, yellow nasal discharge or green stools. Your nurse should have a list of safe symptoms, too, so the caller can be reassured immediately.
Your telephone triage nurse needs to be familiar with these protocols from the beginning. She (he) also must be able to use multiple protocols at times. If the complaint is a cough, for example, go to the cough protocol but, if the child also has asthma, you may need to apply the protocol for that illness, too.