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June 2014
What are the Nurses Doing on the Phone?Nurse Telephone Triage in General PracticeA Suggested Method for Reducing Variation
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Practice Nurses take a lot of Calls
• The callers are often symptomatic looking for advice, or an urgent appointment.
• What training do the nurses have for this skill?
• What visibility is there on the advice they provide?
• What consistency is there in the advice given?
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A Bit of Background
• Partner at Island Bay Medical Centre in Wellington:
• 11000 patients;
• 6 GP partners, 3 associates, 1 registrar;
• 7 nurses – mix of full and part time;
• 1-2 nurses available for phone calls.
• Usually very busy. Some acute GP slots available, usually get filled.
• Tension between providing a safe service and not being too overworked.
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• 24/7 nurse based telephone triage.
• 100+ nurses.
• 1500 calls a day – 80% symptomatic.
• CECC software with 400+ Guidelines.
• We lower disposition rates, i.e. on balance lower acuity of response, sometime increase it.
Healthline
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The Nature of Triage
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A Tool That May Help
• Reduce the variation.
• Use NZ modified reviewed guidelines.
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What is Symptom Checker?
• It’s an iOS app originally developed for Medibank customers in Australia.
• Has been modified for New Zealand.
• Uses the same guidelines that Healthline nurses use, but with less detail. Not
all 400 guidelines.
• Guidelines are international, from USA with modifications for Australia and NZ.
Regular review.
• We would like to have it available on other platforms, no funding right now, but
may well be part of new telehealth service that we are working toward.
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Island Bay Pilot
• As far as we know, we haven’t had any adverse outcomes from existing telephone service the nurses provide.
• Asked the team if they were interested in trialling the symptom checker for some, but not all, calls.
• Setup a keyword in Medtech.
• New billing code to monitor use via query builder.
• Stressed that these are guidelines, clinical decision is still the nurses, don’t let guideline override clinical judgement.
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How it Works
• Nurse checks that it is not immediately life threatening.
• Usual initial questioning to check identity.
• Gains a snapshot of the callers problem.
• Makes a decision if this would be appropriate for using symptom checker:• Single issue;• Not a lot of comorbidity or psychosocial issues;• Key difference with Healthline is that the nurses may well know the patient, has
access to full notes and the patients GP.
• Opens symptom check to appropriate place and works through the questions.
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Four Possible Outcomes
• Call 111.
• ‘Call Healthline or Your Doctor Now’ = make an appointment from them to be seen acutely same day.
• ‘Call your doctor within 24 hours (Office Hours) or Healthline’ – offer non urgent appointment.
• Self care – Home Care Advice is part of the app.
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Nosebleed
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Nosebleed continued
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Nosebleed continued
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Nosebleed continued
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The Results• Have been using it for 2 months.• Has been used 136 times.
• Wide age range. 0-10 years x 6810-20 years x 1520-50 years x 3250+ years x 21
• None have needed 111.
• 68 had had appointments made same day , 12 double booked – rest able to fit in.
• 22 had had non-acute appointments made.• 46 have had home care.
• No comparator with previous management.
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Symptoms Triaged
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Nurse Response
“A good support for call”
“Helps decide whether they need to come in or not”
“Backup for grumpy doctors”
“Backs up your decision” “not making stuff up off the top of your head”
“really like it… it’s good, could be really useful at afterhours too”
“Consistency”“can we keep them?”…“I think so”… “Cool…good”
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Questions? Thank You
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