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Figure 1.  Nurse Triage Phone Call Algorithm for Pediatric Otolaryngology Clinic
Nurse Triage Phone Call Algorithm for Pediatric Otolaryngology Clinic

APN indicates advanced practice nurse; EMR, electronic medical record; ENT, ear, nose, and throat; RN, registered nurse.

Figure 2.  Percentage of Nurse Triage Phone Calls Resolved in Less Than 2 Hours Over Time, 2014-2017
Percentage of Nurse Triage Phone Calls Resolved in Less Than 2 Hours Over Time, 2014-2017

The letters on the x-axis indicate the months. ENT indicates ear, nose, and throat.

Figure 3.  Percentage of Nurse Triage Phone Calls Following Optimal Process Over Time, 2014-2017
Percentage of Nurse Triage Phone Calls Following Optimal Process Over Time, 2014-2017

The letters on the x-axis indicate the months. APN indicates advanced practice nurse.

1.
Dawson  CJHM, Newton  S.  Telephone Triage for Otorhinolaryngology and Head and Neck Nurses. Pittsburgh, PA: Oncology Nursing Society; 2011.
2.
O’Connell  JM, Towles  W, Yin  M, Malakar  CL.  Patient decision making: use of and adherence to telephone-based nurse triage recommendations.  Med Decis Making. 2002;22(4):309-317.PubMedGoogle ScholarCrossref
3.
Vinson  MH, McCallum  R, Thornlow  DK, Champagne  MT.  Design, implementation, and evaluation of population-specific telehealth nursing services.  Nurs Econ. 2011;29(5):265-272.PubMedGoogle Scholar
4.
American Academy of Ambulatory Care Nursing.  Scope and Standards of Practice for Professional Telehealth Nursing. 5th ed. Pitman, NJ: American Academy of Ambulatory Care Nursing; 2011.
5.
Purc-Stephenson  RJ, Thrasher  C.  Nurses’ experiences with telephone triage and advice: a meta-ethnography.  J Adv Nurs. 2010;66(3):482-494.PubMedGoogle ScholarCrossref
6.
Moscato  SR, David  M, Valanis  B,  et al.  Tool development for measuring caller satisfaction and outcome with telephone advice nursing.  Clin Nurs Res. 2003;12(3):266-281.PubMedGoogle ScholarCrossref
7.
Wijers  N, Schoonhoven  L, Giesen  P,  et al.  The effectiveness of nurse practitioners working at a GP cooperative: a study protocol.  BMC Fam Pract. 2012;13:75.PubMedGoogle ScholarCrossref
8.
Varley  A, Warren  FC, Richards  SH,  et al.  The effect of nurses’ preparedness and nurse practitioner status on triage call management in primary care: a secondary analysis of cross-sectional data from the ESTEEM trial.  Int J Nurs Stud. 2016;58:12-20.PubMedGoogle ScholarCrossref
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Original Investigation
June 2018

Interventions to Improve Response Time to Nurse Triage Phone Calls in a Tertiary Care Pediatric Otolaryngology Practice

Author Affiliations
  • 1Department of Pediatric Otolaryngology, Nationwide Children’s Hospital, Columbus, Ohio
  • 2Quality Improvement Services, Nationwide Children’s Hospital, Columbus, Ohio
  • 3Wexner Medical Center, The Ohio State University, Columbus
JAMA Otolaryngol Head Neck Surg. 2018;144(6):507-512. doi:10.1001/jamaoto.2018.0308
Key Points

Question  How can the clinic nurse triage response time for caregivers and patients be improved in a high-volume tertiary care pediatric otolaryngology practice?

Findings  In this quality-improvement study, following the implementation of a collaborative team intervention, a 2-hour phone call response time for resolution of patient care concerns was achieved 76.7% of the time and sustained for 3 years.

Meaning  Utilization of advanced practice nurses, development of standardized education, and communication pathways have been successful in improving ambulatory patient care services.

Abstract

Importance  Delay in response for telephone triage calls that need clinician input for resolution can result in delay of care and unintended frustration for patients and families. It can be a challenge to manage calls in a high-volume pediatric otolaryngology practice.

Objective  To improve the percentage of nurse triage clinically relevant phone calls returned within 2 hours to parents or caregivers.

Design, Setting, and Participants  This was a quality-improvement study of a tertiary care pediatric otolaryngology practice with more than 32 000 clinic visits and more than 9000 surgical patients per year.

Interventions  In 2014, a collaborative team was created at our center to determine the optimal time for triage callback to families and to define an optimal process that would allow more rapid response time for calls that the triage nurses needed to escalate to the patient’s managing surgeon. Several plan-do-study-act cycles were performed to optimize the process. The utilization of advanced practice nurses as an intermediary step was crucial in allowing a more efficient flow of communication.

Main Outcomes and Measures  Percentage of triage phone calls returned within 2-hour time frame.

Results  Over 40 months, 4839 clinically relevant phone calls occurred, averaging 128 calls per month. The baseline mean was 101 calls per month, and the postintervention mean was 130 calls per month. Prior to this project, only 42% of calls were being addressed within 2 hours. After our interventions, the average time for caregiver callback within 2 hours decreased from 15.3 hours preintervention to 3.9 hours postintervention. In addition, caregivers received clinician callback within 2.0 hours 76.7% of the time postintervention compared with 42.0% with a baseline shift (difference probability between preintervention and postintervention, 0.21; 95% CI, 0.15-0.27). Outcomes were sustained for 3 years and continue to be monitored.

Conclusions and Relevance  The most effective intervention was using advanced practice nurses to efficiently resolve patient triage concerns that were outside the scope of practice of the registered nurse. By establishing clear pathways of communication and standardized education among our team, we successfully improved our processes, which resulted in more optimal care for our patients.

Introduction

Current trends in health care to increase efficiency and decrease costs are shifting more complex patient care services to ambulatory settings.1 Telephone triage can offer one solution to help patients become more proactive in their health care decision making and obtain information about their concerns in a convenient and cost-effective manner.2 Nurse telephone triage services are critical links within ambulatory settings that ensure patients and caregivers have the resources they need to navigate their health care with advice, support, and education when they have questions or concerns.3 Triage nurses are expected to use a systematic nursing process to assess, plan, implement, and evaluate the patient’s concerns to determine both the level of urgency and appropriate disposition of the call within their scope of practice.4 When patient concerns require input from the managing physician for resolution, the triage nurse must effectively communicate and escalate the patient's concerns to the appropriate clinician in a timely manner.1

In most academic medical settings, physicians are expected to navigate multiple responsibilities of clinical care, education, and research. Surgical subspecialties, such as pediatric otolaryngology, often entail a large clinical and surgical volume, adding additional time limitations. Pediatric otolaryngologists provide medical and surgical care for children with a wide variety of health care concerns, including specialized care for patients with medically complex issues. It is especially important to provide immediate care recommendations for patients with acute needs, such as patients with airway anomalies and those who have postoperative care concerns. Both patient satisfaction and clinical outcomes may be negatively affected when other physician responsibilities cause a delay in resolution of calls to a nurse triage line.

During the past 5 years, the rapid growth of our tertiary care pediatric otolaryngology department resulted in approximately 32 000 patient appointments and 9000 surgical procedures annually. More than 200 triage calls are received each week, with caregivers seeking answers to questions about appointment scheduling; administrative requests, such as school absence excuses and prior authorizations; refills on prescriptions; postoperative questions; test results; and other clinical concerns regarding their child’s care. There was no universally accepted, appropriate response time for triage calls across all outpatient clinics at our institution, and historically, a wide variation existed in our department on appropriate response time to calls that needed a clinician’s input. This variation and lack of standardization in the management of telephone triage calls resulted in the delay of response from clinicians that ranged from hours to several days at baseline. Approximately 60% of telephone triage calls that needed a clinician’s input for resolution took greater than 2 hours for response time. To maximize patient care outcomes and to establish efficient workflows across our team, we determined that an acceptable response time of 2 hours for caregiver callback was optimal to provide the best patient care experience.

The specific aim of this quality-improvement (QI) project was to increase the percentage of clinician responses within 2 hours from a baseline of 42.0% to 75.0% or greater for clinically related phone calls to the nurse triage line and to sustain this process over at least 1 year.

Methods

We conducted this QI project/intervention at a large, academic pediatric medical center that serves patients in Ohio and the surrounding Midwest region of the United States. Clinical clinicians in the department of otolaryngology include 10 surgeons, 1 fellow, 4 advanced practice nurses (APNs), 15 registered nurses (RNs), and 20 rotating residents during their pediatric otolaryngology training. Patients who receive care in this practice often require advanced care owing to their complex medical issues. This QI project sought not only to better serve patients with medically complex ear, nose, and throat (ENT) needs, but also to provide expert care advice for more routine procedures, such as an ear tube insertion or adenotonsillectomy. The Nationwide Children’s Hospital institutional review board reviewed this project, and it was considered exempt, given its QI focus.

Our current practice is that 2 RNs answer telephone triage calls Monday through Friday from 8 am to 4 pm. These RNs undergo specialized training during their new-hire orientation process to provide safe and effective telephone advice within their scope of practice. When a nurse does not staff the triage line during evenings and weekends, families are instructed to leave a nonurgent message for callback the next business day. For urgent messages, families are instructed to call the hospital operator and have the ENT resident on call paged. The resident can escalate unresolved questions to the ENT attending physician on call if needed.

The availability of telephone triage services provides families reassurance and advice for simple questions, such as managing postoperative pain, to more complex issues, such as airway concerns. Using standardized protocols, triage nurses can safely determine the level of urgency of the call and offer advice for appropriate next steps, such as self-care management at home, scheduling a follow-up appointment in the clinic, or referring the patient for more urgent evaluation at an urgent care or emergency department.3 If the triage RN determined that the next step was additional input for resolution of the call, a telephone encounter was created and routed to the patient’s managing ENT surgeon via their electronic medical record (EMR).

Initial interventions placed APNs as front-line clinicians who would manage patient concerns that were out of the scope of practice or knowledge base of the triage RN. Examples included calls such as radiology and laboratory results, refills for prescriptions, or additional treatment options for more complex patient care issues. Rollout of this new intervention to the surgeons, APNs, and RNs began during an inclusive department meeting, and then additional details were provided to the APNs and RNs by their section clinical leads. A series of emails directed by the project leader (K.R.J.) also further defined the on-call schedule for APN coverage for telephone calls. The RNs were instructed to continue to manage all telephone triage calls that were within their scope of practice. If they needed to escalate the concern to an APN, they created a telephone encounter in the patient’s EMR and routed it to the on-call APN. The APN would call the caregiver for resolution of the concern or delegate the intervention back to the RN with advice for management. If the daily on-call APN needed input from a physician, he or she could page or call the patient’s treating physician, or seek assistance from the daily on-call physician if more urgent input was needed.

Through several plan-do-study-act (PDSA) cycles, we identified additional interventions through feedback solicited from participants of the initiative. It was determined that questions related to hearing-impaired patients or those with tracheostomy tubes often need expertise from the APN who actively treats those patients. We determined that those calls would be routed to the specialized APN instead of the APN on call to provide consistency of care.

The APNs identified the need for more efficient communication from the RNs during their clinic hours. The on-call APN was expected to manage patient telephone calls while seeing patients for postoperative and follow-up appointments in the clinic, and response time was falling outside of the identified goal of 2-hour response time. A pager-based system was developed that sent text pages to alert the APN that a call was waiting for their attention. For calls that needed a simple answer, the triage nurses were encouraged to acquire “face-to-face” assistance from the APN or physician working in the clinic to expedite care.

In May 2014, surgeons, RNs, and APNs were educated on the new process (Figure 1). To ensure that the workload of the APNs did not significantly increase, we created a balancing measure, tracking the number and percentage of calls handled by each clinician. Although there was an increase in calls handled by the APNs (from 28% to 38%), the volume was felt to be manageable according to an anonymous survey of all APNs.

The percentage of total relevant calls resolved within 2 hours was analyzed on a weekly basis in the early stages of the project and ultimately monitored monthly. The consistent surveillance of our outcomes was critical to ensure that we had objective data validating maintenance of this new standard of care for our patients over time.

Results

Over 40 months, 4839 clinically relevant phone calls occurred, averaging 128 calls per month. The baseline mean was 101 calls per month, and the postintervention mean was 130 calls per month. Prior to this project, only 42% of calls were being addressed within 2 hours.

Process changes to the nurse triage line were initiated in June 2014. The average time for caregiver callback within 2 hours decreased from 15.3 hours preintervention to 3.9 hours postintervention. In addition, caregivers received clinician callback within 2 hours 76.7% of the time postintervention vs 42.0% of the time at the start of the project. The refined process steps led to clinician response time in less than 2 hours, above the 75.0% goal, as shown in Figure 2, which was a clinically meaningful improvement (difference probability between preintervention and postintervention, 0.21; 95% CI, 0.15-0.27). This response time has been sustained for more than 3 years. Our process measure results demonstrate that the new, optimal process was being followed approximately 90% of the time (Figure 3).

Discussion

This QI project standardized triage processes for managing telephone calls that required additional clinician input and led to a significant reduction in response time to caregiver concerns. The intervention strategy with the greatest effect was the use of APNs as intermediate clinicians for efficient resolution of calls that needed a clinician response by standardizing the mechanism of communication between the triage RNs and the physicians. This process change resulted in a marked decrease in response time from initiation of the project. From the first intervention to full implementation of the new process, there was a shift to a new baseline meeting the 2-hour goal of answering clinically related questions approximately 76% of the time, and this clinically meaningful change has been maintained for more than 3 years and continues to undergo surveillance.

Additional interventions that further defined our processes were important steps for achieving outcomes. The APNs who have more advanced ENT subspecialty knowledge (eg, sensorineural hearing loss or treating patients with more complex airway disorders with tracheostomy tube concerns) were identified as an important resource to address calls received for the specialized care of these children. Management of calls for these patients required additional expertise from the APN who was more familiar with their unique clinical history and individualized plan of care. In addition, these subspecialty APNs often had established pathways to rapidly contact the patient’s managing surgeon if needed, further expediting communication and more timely call resolution.

Establishing more efficient communication processes between the APNs and triage RNs was identified as a process improvement. The APNs were required to manage other clinical duties while proving triage call coverage and were not always able to readily log into the EMR to access patient information. Using text pages and face-to-face communication helped to streamline the process. Additional education was also provided to the triage RNs to help them feel empowered to continue to independently mange calls within their scope of practice. Didactic lectures were developed as part of bimonthly department meetings to provide the nurses further education on specific pediatric ENT concerns. The RNs also worked collaboratively with APNs and surgeons to further develop triage protocols that helped them to manage calls in a more autonomous manner. These physician-approved protocols provided guidelines with clear algorithms for identifying level of urgency and appropriate disposition of caregiver concerns and self-care advice for common triage calls, such as managing postoperative tonsillectomy pain or otorrhea in patients with pressure equalizing ear tubes.

During the past decade, there has been an increased focus on telehealth nursing and the opportunities that exist to enhance patient access to health care in a more effective and economical manner.5,6 Management of after-hours calls in adult general practice settings and the effectiveness of decision making and safety of nurse-led call centers has also been described.7 Our study was unique in its pediatric specific focus on identification of a clear process to answer calls within a 2-hour time frame during business hours with the deployment of APNs in our pediatric otolaryngology outpatient clinic setting. Our project reinforced the roles and responsibilities for triage duties that helped to maximize efficient management of telephone calls across all ENT team members and provided a simple algorithm of how to escalate calls to the appropriate clinician when needed.

Our results align with those of Vinson et al,3 who identified that nurses with expertise focused on the needs of a specific population of patients are better able to collaboratively manage their care with the patient’s physician. Furthermore, Varley et al8 contended that APNs with advanced triage knowledge are more likely to manage the call definitively and feel more comfortable recommending self-care advice vs scheduling a clinic follow-up appointment.

There was positive effect from this QI project for all the surgeons, APNs, RNs, and, most important, the patients. Surgeons immediately noticed a decrease in unresolved telephone calls from families that had called earlier in the day (or week) that required their involvement, allowing them to focus on other clinical and surgical duties. Triage nurses had increased opportunities for education to advance their clinical knowledge of ENT disorders and felt more empowered to autonomously manage telephone calls within their scope of practice. Instituting clearer pathways for communication ultimately led to increased RN satisfaction with triage duties because it decreased confusion about whom to contact when they had questions on how to resolve a patient concern. The patients often reported to the nurses that they appreciated the rapid turnaround in response time for their concerns, particularly for prescription refill requests. If the APN needed to collaborate with the managing surgeon to help determine the treatment plan, the family still received a call within 2 hours explaining that further clarification from the surgeon was needed, but they could expect a callback later that day.

As a balancing measure, we did see a minimal increase of calls routed to an independent clinician; however, this change was less than 1 additional call per day, which affected APN workload minimally. Calls routed to an independent clinician remained steady at the new baseline of 38%, even with the addition of 2 new surgeons and with continued increase in patient volume. Ongoing RN education and pairing new nurses with experienced nurses during their first 6 months of managing calls helped to keep triage processes consistent, even with the addition of 3 new RNs and 3 APNs since project implementation.

The success of our project was dependent on several factors. This study took place in a large tertiary care children’s hospital with a strong QI department and attending surgeons, APNs, and RNs who are highly motivated to provide excellence in family-centered patient care. Rapid improvement in outcome results were in part achieved with an experienced staff of RNs and APNs, with an average of 5 or years more of ENT nursing experience. Turnover rate of nursing staff is low, and senior leadership supports orientation processes that allow time to adequately train new staff. Weekly reporting and analysis of automated EMR data allowed timely feedback from the project lead to the nursing staff, using a variety of communication methods (face-to-face meetings, email) to efficiently troubleshoot issues as they occurred.

Limitations

Components of this project may be challenging to implement in smaller health care settings. While RNs in many triage centers answer calls in between other clinical duties or at the end of the day, we had 2 RNs dedicated solely to triage duties Monday through Friday to efficiently handle call volume and determine disposition of care to ensure that the APN had as much time as possible to respond to the call or consult with the physician if needed. The APNs were required to manage multiple duties of inpatient postoperative rounds, seeing clinic patients, teaching tracheostomy care to families and inpatient staff, and managing triage calls. Having multiple APNs allowed opportunities to help each other or reassign duties if call volume was higher than expected. However, no additional staff members were hired to implement these changes.

Conclusions

Utilization of telehealth services will only continue to grow as hospitals respond to concerns of rising health care costs. For this QI project, we used PDSA methodology to standardize the triage processes in our ambulatory otolaryngology clinic setting to ensure that caregivers received a callback that required a clinician response within 2 hours of the time of the initial call from a baseline of 42% to greater than 75%. Our interventions resulted in positive change that has been sustainable for more than 3 years, and the identification of clearer pathways of caregiver/patient-RN-APN-MD communication set the stage to for the successful implementation of other QI projects in our department.

Future steps to ensure continued success will include development of additional triage protocols that support RN decision making and the implementation of an EMR documentation flow sheet to streamline communication from the triage RN to the APN and allow more efficient gathering of data that describe the most pertinent clinical picture of the patient’s current health concern. We believe that prompt response to caregiver questions about their child’s care enhances patient-clinician trust, maximizes patient care outcomes, and provides a mechanism to transform the patient experience that meets or exceeds patient expectations.

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Article Information

Corresponding Author: Kris R. Jatana, MD, Department of Pediatric Otolaryngology, Nationwide Children’s Hospital, 555 S 18th St, Ste 2A, Columbus, OH 43205 (kris.jatana@nationwidechildrens.org).

Accepted for Publication: February 23, 2018.

Published Online: May 3, 2018. doi:10.1001/jamaoto.2018.0308

Author Contributions: Dr Jatana had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Payne, Justice, Elmaraghy, Ruda, Jatana.

Acquisition, analysis, or interpretation of data: Payne, Justice, Lemle, Elmaraghy, Jatana.

Drafting of the manuscript: Payne, Lemle, Elmaraghy, Jatana.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lemle.

Administrative, technical, or material support: Payne, Jatana.

Study supervision: Payne, Elmaraghy, Ruda, Jatana.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

Meeting Presentation: This study was presented at the Institute for Healthcare Improvement National Forum; December 12, 2017; Orlando, Florida.

Additional Contributions: We would like to thank the following members of the pediatric otolaryngology nurse triage team for their important contribution to the success of this project: Sarah Begue, APN; Kristyn Beyer, RN; Kelly Brothers, APN; Marie Burris, RN; Brittany Cerasi, RN; Jeffrey Criswell, APN; Kimberly Davis, APN; Kathryn Denny, RN; Lura Easton, RN; Haley Ellett, APN; Mollieanne Estrada, RN; Dia Gardner, RN; Andrea Gates, RN; Christina Jadlos, RN; Tracey Latham, RN; Sheryl Mann, RN; Andrea Mayer, RN; Marie Ndem, RN; Ashley Nesbitt, RN; Michelle Reardon, RN; Jennifer Rittenhouse, APN; Marianna Ryan, RN; Kelley Sherer, RN; Scott Stoverock, RN; and Donya Weeks, APN. None of the staff members were compensated beyond their regular salaries.

References
1.
Dawson  CJHM, Newton  S.  Telephone Triage for Otorhinolaryngology and Head and Neck Nurses. Pittsburgh, PA: Oncology Nursing Society; 2011.
2.
O’Connell  JM, Towles  W, Yin  M, Malakar  CL.  Patient decision making: use of and adherence to telephone-based nurse triage recommendations.  Med Decis Making. 2002;22(4):309-317.PubMedGoogle ScholarCrossref
3.
Vinson  MH, McCallum  R, Thornlow  DK, Champagne  MT.  Design, implementation, and evaluation of population-specific telehealth nursing services.  Nurs Econ. 2011;29(5):265-272.PubMedGoogle Scholar
4.
American Academy of Ambulatory Care Nursing.  Scope and Standards of Practice for Professional Telehealth Nursing. 5th ed. Pitman, NJ: American Academy of Ambulatory Care Nursing; 2011.
5.
Purc-Stephenson  RJ, Thrasher  C.  Nurses’ experiences with telephone triage and advice: a meta-ethnography.  J Adv Nurs. 2010;66(3):482-494.PubMedGoogle ScholarCrossref
6.
Moscato  SR, David  M, Valanis  B,  et al.  Tool development for measuring caller satisfaction and outcome with telephone advice nursing.  Clin Nurs Res. 2003;12(3):266-281.PubMedGoogle ScholarCrossref
7.
Wijers  N, Schoonhoven  L, Giesen  P,  et al.  The effectiveness of nurse practitioners working at a GP cooperative: a study protocol.  BMC Fam Pract. 2012;13:75.PubMedGoogle ScholarCrossref
8.
Varley  A, Warren  FC, Richards  SH,  et al.  The effect of nurses’ preparedness and nurse practitioner status on triage call management in primary care: a secondary analysis of cross-sectional data from the ESTEEM trial.  Int J Nurs Stud. 2016;58:12-20.PubMedGoogle ScholarCrossref
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