AMBULATORY NURSING TRIAGE DEVELOPMENT - mc.vanderbilt.edu · triage Recordsaudits • Integrate...

• <50%ofcancerrelatedcallsareresolvedatinitialpointofcontact

• >30%ofpatientsymptomsdonothaveaprotocolinplace

• Bothfactsabovesupporttheneedfor:- Additionalprotocols(i.e.,edema,congestion,mentalstatuschanges)

- Annualrevisionofexistingprotocolstobroadennursingscope

• Continuationofquarterlynursetriageaudits

• Integrateclinicandtriagenursesintomeetingstodefineroles/expectationsandresolveissues

Access Redesign Methodology

Protocol Development Process

Telephone Nurse Triage Model

• Thisprocessconsistedofateamofnursesandprovidersfrommanyareasofexpertiseutilizingevidence-basedpracticeguidelines.

• InconsistentapplicationofprocessesandstandardsfortriagingpatientphonecallsintheVanderbilt MedicalGroup(VMG)ambulatoryenvironment• Lackofestablishedguidelinesforaddressingpatientphonecalls• Variableandinconsistentlevelsofcare-advicebasedonnursingexperience,notonevidence-based practiceguidelines• Inconsistentandinformalprocesstomanagepatientcalls,whichresultedin:• Delayofpatientcare

• Symptommanagementbasedonurgency• Medicationmanagement• Numerousquestions/concerns

• Callmanagementsystemthatwasnotmeasurable;inabilitytotrack/identifynurse-relatedphonecalls

VMGconsistsofapproximately125ambulatoryclinicsthroughoutthecommunityandsurroundingareas,whichgenerateover1millionpointsofcontactannually.• Progress:todate,theclinicsthathavehad

PerformanceImprovementOffice(PIO)involvementequalonly23%oftheannualvisitvolume.

• RemainingEfforts:77%ofclinicvolumeremainsasworktobecompleted;inwhichthereisnoabilitytoself-selecttospeakwithalicensednurseordistinguishbetweencalltypes.

THE SCOPE:

THE PROBLEM: THE METHODOLOGY:

Evidence-Based Telephone Nurse Triage Protocols:

FINDINGS & RESULTS:

CONTRIBUTORS:StephanieHyde,RN,ADNHelenaBruner,RN,BSN,OCNPatriciaMyers,RN,BSNDebbieBrandle,RN,ADN,OCN

SusanCosenza,RN,BSNDauphneMcGavic,RN,MSNCherylBates,BS,CentralAppointmentSchedulerAmySpence,CentralAppointmentScheduler

Access Model Triage Model

• BEFORE:Fromaninformalsystemwithnumerouslevelsofundefinedrolesandfunctionality

• AFTER:Toastandardizedsystemwithwelldefinedrolesandfunctions

• Atpointofcontact,patientsaregivenatimelyplanofcareandappropriatedisposition.

Work Thus Far

• Protocolsinclude:1. Bleeding2. Constipation3. Diarrhea4. Dysphagia5. Fatigue/Malaise6. Fever7. Nausea&Vomiting8. Pain9. Mucositis/Xerostomia10.Rash/SkinIrritation11.Drains

Access Center Nurse TriageTransition to Current State

Total Call Volume for Vanderbilt Cancer & Breast Access Centers

23,22722,375

23,85222,380

2328224509

21205

2454023510

22422 2259821863

2389822901

0%

5%

10%

15%

20%

25%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

22,000

24,000

26,000

Total Access Center Calls Abandoned %

Breakdown of Nurse Triage & Scheduling/Ancillary Call Volume for Vanderbilt Cancer & Breast Access Centers

14842 1455616290 15102 15912 16053

1383415834 15578 14884 15166 14050

15740 14832

8385 78197562

72787370 8456

7371

8706 7932 7538 74327813

81588069

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

0

5,000

10,000

15,000

20,000

25,000Scheduler & Ancillary Calls Nurse Triage Calls Abandonment Rate

Telephone Nurse Triage Audit ResultsPatient Call Status

Emergent2.3%

Urgent20.4%

Non-Urgent & Home Care

77.3%

Triage RN CompletesPatient Encounter

25.1%

Further Action Required by

Clinic RN44.8%

Further Action Required by NP/PA

22.1%

Further Action Required by MD

8.0%

Telephone Nurse Triage Audit ResultsPatient Encounters - Level of Completion

Telephone Nurse Triage Audit ResultsCall Type

PriorAuthorizations

2.9%Ancillary

Groups 4.0%

Prescription Requests 3.0%

Orders 6.1%

Appt/Test Scheduling19%

Call Back 18.1%

Results11.3%

MedicalRecords

Issues 4.2%

Medication Question6.0%

Symptom/Sick 16.0%

Telephone Nurse Triage Audit ResultsProtocols Used

Bleeding2.9%

Constipation4.1%

Diarrhea4.6%

Dysphagia0.9%Fatigue/Malaise

3.7%

Fever5.2%

Mucositis2.2%

Nausea/Vomiting8.0%Rash

1.2%Drain0.6%

Pain32%

Other (Specify in comments)

36%

AMBULATORY NURSING TRIAGE DEVELOPMENTESTABLISHING CONSISTENT EVIDENCE-BASED STANDARDS OF NURSING CARE

AUTHORS:NancyMuldowney,MLAS,BSN,RN;JenniferMitchell,MSN,ANP-BC,GNP-BC

Vanderbilt-Ingram Cancer Center

Transition

The Vanderbilt-Ingram Cancer Center (VICC)isaleadingmulti-siteoncologycenterwithover6cancersub-

specialtiesandmorethan90providers.NotonlyistheonlyNationalCancerInstitute-designatedComprehensive

CancerCenterinTennessee,itisalsoamemberoftheNationalComprehensiveCancerNetwork,anon-profit

allianceof21leadingcentersworkingtogethertoimprovequalityandeffectivenessofcancercare.

Access Center Clinical Calls

Common EBP Nursing Assessment & Questions

Patient Has Options at Point of Contact

Plan of Care Clarification

Questions & Follow Up

Protocols &

Directives

Rx Renewals

& Med Mgmt

CAS PSR

Back Lines

AA & OA

Clinic Primary Outbound & Multiple Call Backs,

Patient Delays

•HandOff•Message

•HandOff•Message

•HandOff•Message

•HandOff•Message

VICC6%

Urology2% Breast

Center1%

Women'sCenter

3%

WilliamsonPrimary

Care4%Otolaryngology

5%

GeneralSurgery

2%

All Other77%

Nurse Triage

Nurse TriageCentralizedClinicalEffectiveEvidence-Based Protocols

DedicatedStaffPatient-CentricMeasurable

• FourKeycomponentsareincludedinthecentralizationofaccess.TheNurseTriagecomponentaddressesqualityofcarebaseduponnationalstandardsandguidelines.

Before After