Telehealth- high risk, high stakes- October 2011

Legal issues with Teletriage

Source

The following presentation is a summary of the teletriage conference presented by Sheila Wheeler, RN, MS. For more information please visit www.teletriage.com

Written permission to share this presentation with CNL was obtained by Lorman

What teletriaging is NOT: We are not “gatekeepers”- in no way are

we to interfere with a patient speaking with their MD or obtaining care for their child.

Providing Symptom Diagnosis- leave that to the MD’s. It is beyond the scope of nursing practice.

Nurses practicing medicine by telephone -We follow algorithms that were approved by our medical director. We do work under the supervision of MD’s at all times.

What we are NOT, continued Message-takers for the MD’s -We are

intelligent, knowledgeable, highly trained RN’s working within the subspecialty of teletriaging.

“health information”- our job is “triaging” not giving “non essential health information” or “appointment makers”

Telemarketing- We are not selling anything to our patients. The clients call us for a very specialized service.

The rights of teletriage… Getting patients to the right level of

care, at the right facility, at the right time with the right provider

Legal issues Negligence-failure to provide due care to the

patient. In Teletriage it is defined as failure to communicate significant information in a timely manner to the physician or patient

Duty of Due Care -duty that the nurse owes the patient- competent care. Must do what a reasonable, prudent nurse would do in a similar situation

Implied Relationship –between the nurse and the patient. Relationship begins the moment the nurse answers phone.

Client Abandonment -anytime the professional unilaterally terminates the relationship without adequate replacement

Nurses responsibility

It is not incumbent on the patient to provide all pertinent information. It is the nurses responsibility to ask all the appropriate questions and make an informed decision based on her assessment

Area’s of potential risk Practicing outside the scope of nursing -happens

when nurses start making diagnoses. Nurses can form a nursing impression or working diagnosis. We triage, NOT diagnose.

Delay or denial of care- If the disposition is See in ED Now, the patient can NOT wait 4 hrs- They must go NOW

“duty to terrify” - term developed by a physician-attorney. The nurse must apprise callers of the seriousness of the symptoms they are describing in order to motivate them to seek the appropriate level of care in a timely manner.

If the disposition is 911 or ED be sure to ask/state: I need you to call 911 now- will you

do that? This could be a life threatening

emergency- will you go to the ED in the next hour?

Most lawsuits are brought about d/t delay of care.

Management Pitfalls Lack of adequate number of staff - call

volume is usually heavier on Monday, Fridays, after 3 day holidays and during cold/flu

Lack of Qualified Staff – average of 5-10 years of nursing experience, good judgment and critical thinking skills. Telephone charisma-good teaching skills, integrity, resourcefulness

Lack of Adequate training Lack of Protocols/Documentation Lack of Standards

Triage Nurse Pitfalls Inadequate “talk time” - nurse did not take the time

to elicit enough information to make an informed decision

Insufficient Data Collection -nurse did not ask enough questions to make an informed decision/adequate assessment

Weak Critical Thinking Skills -sloppiness. Must be vigilant on the phone. Health history, medications, allergies, chronic diseases ALL factor into your decision

Insufficient Documentation – if it’s not written, it wasn’t said!

Protocol Misuse -be sure to review the “see other guideline” section and read the description/definition of each protocol.

Avoiding misuse of protocols Perform a thorough assessment

before choosing a protocol Remain open to new information

Using Critical Thinking skills Critical thinking requires time.

Inadequate time= inadequate data The elderly and pediatric clients often

present with Ill structured, novel or atypical symptoms.

Rationale: their immune systems are not fully developed (pediatric) or are starting to break down (elderly). These patients often present in atypical ways

Nurse negligence claims: Failure to use a systematic approach

or process. Always follow the Nursing Process

Failure to use (or improper use of) protocols/guidelines

Failure to make safe disposition-within a timely manner

Failure to communicate significant information in a timely manner to patient or physician

Nurse negligence claims

Failure to document Delay in returning call Delay in care

Reducing risk

Practice Standard of Care Systematic assessment- includes the

Nursing Process and critical thinking skills In Teletriage: Assessment, impression or

working dx, plan, self evaluationAssessment Tools:

SAVED, SCHOLAR, PAMPER, ADL, DEMERITProtocol UseDocumentation

SAVED = YOUR RED FLAGS

S-Severe Symptoms ( can be pain, diarrhea, vomiting, rashes, ANY severe symptom)

A- Age V- Veracity E- Emotional Distress or Stress D- Debilitation or Distance

SAVED- The “S”

Symptom-Based: ANY severe symptoms (pain, bleeding, diarrhea, rash etc…)

Strange Symptoms: “Atypical” ie “worst”, “new”, “sudden”, “unexpected”, “recurrent”

Suspicious Symptoms: the BIG SIX- head, chest, respiratory, abdomen, flu and dizziness)

SAVED- The “A” – Age Based High Risk populations are: Very Young Very Old Child bearing age Men over 35 Women over 45

SAVED- The “V”- Veracity: getting the facts right. Second Party Third Party Pre-Verbal Confusion Aphasia Language Barrier

SAVED- The “E”- Emotion Based Emotional Distress or Stress Frequent phone calls in a brief period

of time High anxiety vs Denial Lack of Affect

SAVED- The “D”- Debilitation/Distance Debilitation: chronic

Illness/homelessness Mental illness Children: Frequent minor illnesses: URIs,

Oms Frail Elderly Distance: More than 2-3 hours from

hospital raises urgency for some problems

Traffic gridlocks

The most frequently misdiagnosed conditions that lead to malpractice are Ectopic Pregnancies, MI, Appendicitis

Reducing risk Document, Document, Document! Be

brief but concise and complete Document those pertinent negatives Use the patients own words with quote

marks Only use approved terms/abbreviations Use overlapping time frames- when

symptoms started, what time treatment started, when you told the patient to seek treatment (ETA!)

Reducing Risk, cont.

Asking what medications the patient takes on an daily basis can clue you into what chronic diseases they have.

Assure your client is stable before entering protocol. Always perform your preliminary assessment first!

SCHOLAR: Obtaining a thorough History S- Symptoms and Associated Symptoms C- Characteristics H- History of symptoms in the past O- Onset L- Location (diffuse or localized) A- Aggravating Factors (what makes it

worse) R- Relieving Factors (what makes it

better)

PAMPER- Patient History

P- Pregnant or LNMP A- Allergies M- Medications P- Previous Medical History E- Emotional Distress or Stress R- Recent Injury, Illness or Ingestion

Silent/Atypical/Novel Symptom Presentation

ADL: This is practically all you have to go on with infants and the frail elderly. Compare “now” with what is “normal” for patient.

ASK: intake (liquid and food); Output (urine, BM, emesis, diaphoresis); sleeping (too much, too little); Activities: disinterested in usual activities; Mood (marked changes); Color (pale, red, blue, grey, ashen); skin (turgor) lips/tongue/tears.

A DEMERIT- Assessing Infants A-Any extreme change of behavior:

irritable/inconsolable; crying/clingy OR extremely quiet and disengaged.

D- Difficult to awaken or keep awake E: Expression: decreased M-Movement: little or no spontaneous movement E- Eye Contact: decreased focus/caregiver

recognition R- Refusal to eat/nurse/bottlefeed I- Interactivity: decreased T- Talking/babble: decreased

Rules of Thumb (ROT)

A method or procedure based on experience and common sense. Not necessarily scientifically accurate.

Rules of Thumb Kids get sicker quicker Once an ectopic, always an ectopic

(until ruled out by a medical provider)

Any pain btw the nose and navel is chest pain until proven differently

All snakes are poisonous until proven differently

ROT: the 8 Extreme’s of an MI

Extremes in: Emotion Weather -very hot or very cold Exertion- Age (over 75 is higher risk) Eating (too much) Epigastric distress Essential hypertension Early am

Use the Nursing Process

Assessment Working Diagnosis Plan (per protocol) Evaluation

TIMELY ACCESS to CARE

Be sure to direct the patient to the nearest/safest and most prudent facility. Directing a patient with moderate to severe asthma symptoms to an ED > 1 hr away may result in severe complications!

Nursing Judgment/Intuition No Protocol can provide all the

answers. Teletriage Nurses rely heavily on their nursing experience, judgment and intuition. You must engage ALL of your senses to assure your patients are safe and all reach the appropriate level of care. Never assume that all vomiting is the stomach flu, all coughs are just colds or all bumps on the head are benign!