Telehealth- high risk, high stakes- October 2011

1. Legal issues with Teletriage Telehealth- high risk, high stakes- October 2011

2. 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

3. 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.

4. 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.

5. The rights of teletriage… • Getting patients to the right level of care, at the right facility, at the right time with the right provider

6. 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

7. 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

8. 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.

9. 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?

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

11. 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

12. 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.

13. Avoiding misuse of protocols • Perform a thorough assessment before choosing a protocol • Remain open to new information

14. 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

15. 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

16. Nurse negligence claims • Failure to document • Delay in returning call • Delay in care

17. 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 evaluation Assessment Tools: SAVED, SCHOLAR, PAMPER, ADL, DEMERIT Protocol Use Documentation

18. 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

19. 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)

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

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

22. 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

23. 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

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

25. 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!)

26. 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!

27. 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)

28. 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

29. 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.

30. 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

31. Rules of Thumb (ROT) • A method or procedure based on experience and common sense. Not necessarily scientifically accurate.

32. 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

33. 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

34. Use the Nursing Process • Assessment • Working Diagnosis • Plan (per protocol) • Evaluation

35. 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!

36. 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!