Telephone Triage and Advice: Patient Safety Strategies

Analysis of The Doctors Company closed claims data shows that miscommunication contributes to over 30 percent of adverse patient events in the office setting. We found that communications involving telephone triage and advice—which are critical to the patient’s overall care and management—present a significant area of liability exposure.

Telephone Triage

Telephone triage is the process of managing a patient’s call to the office to determine the urgency of the medical or dental issue, level of staff or practitioner response required, appropriate location or telehealth modality if the patient needs to be seen, and timing of appointment scheduling. It also includes documentation of the call in the patient record and incorporates efficient customer service while being emotionally supportive to the patient.

Implementing an effective telephone triage system in the office practice can improve practitioner-patient communications, quality of service, patient satisfaction, and continuity of care. It can also promote timely communication of clinical results and reduce emergency department (ED) visits, helping to efficiently manage costs while ensuring that the patient receives access to the appropriate level of care.¹

Telephone Advice

Telephone advice protocols are frequently used in ambulatory practices to ensure consistency in the information collected, recommendations made, and documentation of telephone interactions between patients and clinicians. Advice protocols help clinical staff decide where and when patients should access treatment.

Protocols can also provide warnings if further telephone advice may be inappropriate. For example, one set of protocols addresses common concerns in newborns, such as cradle cap, circumcision care, and umbilical cord problems. The protocol might include the warning, “Exercise extreme caution when assessing infants. Any suspicion of illness indicates that an in-person evaluation is appropriate.”

Patient Safety Strategies

Providing telephone triage and advice presents inherent risks because they require an accurate assessment of the patient’s concerns without the benefit of a face-to-face interaction with a healthcare practitioner. The practitioner is ultimately responsible for the telephone triage and any advice given to the patient. Implement the following strategies to minimize risks.

Scope of Practice. Failure to follow scope-of-practice requirements by nonclinical personnel is a common malpractice liability issue in practitioner offices. Additionally, adverse events involving scope-of-practice issues may prompt an investigation by a licensing board or other administrative government oversight agency. To minimize your liability, implement appropriate job descriptions for all categories of office staff, train your staff, document their training, and do not allow staff members to act outside their scope of practice. Monitor nonclinical staff for compliance.

Allow only licensed professional staff with appropriate training, experience, and competence in telephone assessment techniques to triage patients by telephone. Clearly define the necessary qualifications and training in the job descriptions and ensure that licensed clinical staff who give telephone advice conform to the state’s practice acts.

Unlicensed personnel should never be allowed to triage by telephone or provide telephone advice. According to Don Balasa, JD, MBA, CEO and Legal Counsel for the American Association of Medical Assistants (AAMA):

I define triage as a communication process with a patient (or patient representative) during which a health care professional is required to exercise independent clinical judgment and/or to make clinical assessments or evaluations. It is my legal opinion that it is not permissible for medical assistants to be delegated triage (as I define the term).

I define non-triage communication as a process during which a non-provider health care professional follows provider-approved protocols or decision trees in verbatim-receiving and verbatim-conveying of information. In non-triage communication, the health professional does not exercise independent clinical judgment. It is my legal opinion that it is permissible for knowledgeable and competent unlicensed professionals such as medical assistants to be delegated non-triage communication.²

Written Triage Protocols. Provide written triage protocols for unlicensed staff members who take initial calls. Train staff on questions to ask the caller and when to refer a call to the practitioner immediately. The practitioner will then know that if summoned to take a call, the patient has an urgent or emergent need. Include specific examples of questions to ask the caller and recommended responses for minor problems. Outline the types of calls that require an office visit, a transfer to the licensed practitioner for a more detailed evaluation, or an instruction to call 911 for immediate emergency response.

Office staff must have clear guidance and repeated simulation training for situations that require calling 911 for immediate emergency support. If the clinician determines that the situation is emergent, the patient should be directed to call 911 or promptly present to the nearest ED. The instruction should be clearly documented in the patient’s record. Some conditions that may warrant calls to 911 include allergic reactions, abdominal or chest pain, eye injuries or visual disturbances, head injuries, burns, active bleeding, loss of consciousness, convulsions, signs or symptoms of infection, fever lasting more than 48 hours, early onset of labor, casts that are too tight, stroke symptoms, or shortness of breath and/or wheezing. Additionally, if the patient is unable to dial 911, a staff member should keep the patient on the telephone while another staff member calls 911.

If a patient is being referred to the ED for care, the practitioner should contact the ED attending practitioner to provide a presumptive diagnosis, a description of symptoms, and the information obtained by the practice during the telephone encounter. This will ensure a smooth and seamless transition to the next level of emergency service.

Written Advice Protocols. Telephone advice protocols are not intended to lead to medical diagnoses. This limitation should be made clear to all staff and to any patients who call. If using published protocols, practitioners should review and adapt the protocols to meet the specific needs of the practice and ensure that the protocols are in accordance with the standards of care for their specialty and recognized authoritative sources.

Instruct staff members to follow the written advice protocols and check with the practitioner first if they have any doubts about instructions or advice. Failure to do so may be considered the practice of medicine or dentistry and practicing beyond the staff member’s scope of practice. The clinician may be held vicariously liable for any adverse consequences depending upon the circumstances.

End all calls by providing patient instructions on when to call back or seek emergency care if symptoms worsen or persist.

Staff Training. It is recommended that practices review the protocols with staff at least annually and document the topics discussed and a list of attendees. Practices should utilize role-playing and simulations to rehearse challenging patient calls. They may also conduct quality checks by using mock callers to ensure calls are managed properly.

Patient Considerations. Explain to your patients that not all issues can be treated over the phone and that the practice must determine whether the circumstances mandate that a patient be seen in person. This notification can be made during the call and in new patient paperwork.

When a patient or other caller seems overly anxious or dissatisfied with the telephone advice provided or if the patient believes the situation is urgent and requires more immediate and in-depth attention, arrange for a face-to-face encounter.

If a patient calls a second time with a complaint not resolved by previous telephone advice, require staff members to refer the call directly to the practitioner. If a patient calls a third time with a complaint not resolved by previous telephone advice, require an in-person examination.

Use the Teach-Back Method (“repeat-back”) to confirm that the patient received the message accurately and document the patient’s understanding. Never leave messages with important clinical information on the patient’s voicemail where it is not confirmed that the patient received and understood the communication. The patient may not listen to the message or understand its content. Always follow up if you are unable to reach the patient directly.

Resources and Clinical Decision Support. Practices have various options for establishing triage services and advice protocols within their office and specialty. Sources available in the marketplace for triage protocols and implementation of services include artificial intelligence using triage algorithms, EHR systems, professional societies, commercial products, and contracted services. Practitioners are encouraged to evaluate the practice’s needs and carefully review available resources with those concerns foremost in mind.

Use reputable services that hire only licensed healthcare personnel and follow protocols that adhere to the standard of care for the practice specialty. Practitioners should review call protocols periodically as the practitioner is responsible for the instructions given to their patients by the service.

Clinical decision support systems (CDSS), a digitalized tool, may aid in clinical decision making. According to the HealthIT.gov Clinical Decision Support webpage:

Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information, among other tools.³

Keep in mind that when using a CDSS, the practitioner’s assessment may not be exactly consistent with the CDSS prompts, or the patient’s condition may fall outside the given parameters and not “check off all the boxes.” In these circumstances, practitioners should document their rationale for clinical decisions. A practitioner’s good judgment is always an essential part of patient assessment.

Document Telephone Interactions. Regardless of when or where the contact occurs, record all telephone interactions in the patient’s record promptly. Timely charting is critical to communicate the encounter to other clinicians.

In a claim resulting from telephone triage or advice, an undocumented interaction can lead to a situation involving the patient’s word against the staff member’s or practitioner’s word. Plaintiff’s counsel will be quick to point out the old adage, “If it’s not recorded, it never happened.” Documentation is vital in defending any claim that might be filed later.

Documentation should include the date, time, patient’s name, name of caller, the caller’s relationship to the patient, complaints, concerns, and questions. Thoroughly document the advice given, including any critical negative information that helped determine the advice provided. Examples: “Mother stated the child has no fever, no lethargy, or neck stiffness” and “Mother stated the child has a good appetite and is taking fluids.”

Also, it is important to implement a system to ensure that all clinical calls received after hours are documented in the patient record.

Policies and Procedures. Implement written policies and protocols for office and clinical staff to follow when triaging calls and providing advice. Conduct periodic chart audits to ensure that policies and protocols are followed. Review the guidelines at least annually and revise as circumstances warrant.

For more information about communicating effectively, read our article “Telephone Communication for Healthcare Providers: Safety Strategies” and our Effective Patient Communication: Strategies for Challenging Situations guide. For assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.