by Henry W. Allison

Background

The idea of a nationwide survey via the web came up as an afterthought when considering ways of networking with other triage nurses. So, as any nurse would, I jumped at the thought of trying something new. Thus the Telephone Triage Survey was started. Assistance came from: Andrew Lopez from http://www.nurseone.com/nurseone.htm who posted the survey on a number of different nursing listservs. The survey was picked up by Kathi Webster and listed in the August issue of the Telephone Nursing Telezine. And, I scoured the web guestbooks for nurses that in any way referred to the facility they worked or telephone triage, and e-mailed the individual nurses a copy of the survey questions. (Over 150 individuals were e-mailed copies of the survey, and the survey was posted on 15 nursing listservs, and in as many guestbooks for nurses that I could find.)

Response by Location

Responses to the survey were good. There were a total of 48 responders to the survey questions. The number at first does not seem like much until you look at it in the total picture of things.

• There were 25 states represented as well as Canada and Australia.

Areas Responding	# Responding	Percent
Sydney,Australia	2	4.17%
New Brunswick, Canada	1	2.08%
Arizona	1	2.08%
Arkansas	1	2.08%
California	4	8.33%
Connecticut	1	2.08%
Delaware	1	2.08%
Florida	3	6.25%
Georgia	2	4.17%
Illinois	3	6.25%
Iowa	1	2.08%
Kansas	1	2.08%
Maryland	1	2.08%
Massachusetts	1	2.08%
Michigan	5	10.42%
Minnesota	3	6.25%
New York	2	4.17%
North Carolina	1	2.08%
Ohio	1	2.08%
Pennsylvania	2	4.17%
South Dakota	1	2.08%
South Carolina	1	2.08%
Tennessee	1	2.08%
Texas	1	2.08%
Virginia	1	2.08%
Washington	4	8.33%
Wisconsin	2	4.17%

The range of those responding were as various as the locations:

Positions Worked	# Responding	Percent
ER	5	10.42%
Call Center	26	54.17%
MD office	4	8.33%
Poison Control	1	2.08%
Insurance Co.	7	14.58%
Outpatient Services	2	4.17%
Hospital Screening Co	3	6.25%

24 hour Availability

Now down to the nitty-gritty facts of the survey. Of those responding to the survey: 60.42% of the facilities provided the service 24 hours a day. Of the remaining 39.58% there were many combinations of ways in which the hours were decided. Of those specifying, it seemed that there was about a 50/50 split on operating days/evenings or evenings/weekends/holidays. Over 10% of those surveyed said that their facility was working on providing telephone triage service with 24 hour coverage. Two responders indicated that their center was a 24 hour service with their off hours being covered by a contracted call center in another state.

Availability 24 Hours	# Responding	Percent
YES	29	60.42%
NO	19	39.58%

After Hours and Guidelines

Next, Physician after hours call coverage was addressed. There was 54.17% that indicated they did physician call coverage. 25% attempted no physician coverage at all. Some centers did only limited call coverage for a select group or groups of physicians- 14.58% to be exact. This limited coverage at times was indicated to be by contract with individual physicians or by groups. There was even one center that kept different standards to triage by for each physician according to contract.

Then there was an indicated 6.25% of those responding that did not follow any set guidelines. There were the words "winging it" or "each nurses discretion" or "when time permits" that popped up in the answers. These nurses apparently were working without the safety net of guidelines or policies regarding how triage and decisions were made. For those that follow this route, PLEASE go to a legal seminar. (This is where I really want to get up on my soap box! I'll spare you.)

Takes After Hours Physician Call	# Responding	Percent
YES	26	54.17%
NO	12	25.00%
Attempts triage	3	6.25%
Limited Call Coverage	7	14.58%

Charges for After Hours

For those that do the after hours physician call coverage, a number of things come to mind. First, does the call center charge physicians for this service. 45.8% of those responding said, "No." 25% indicated a charge that varied from a per call charge of $2.00 to $6.00 to monthly charges that ran from $50.00 to $315.00. The average per call charge was $3.00, and most indicating a monthly charge indicated between $50.00 to $100.00. The words that frequently were written in this question was: "Not enough!" 4.17% of responders had no idea if the center charged physicians for the service or not.

Charge MD for Service	# Responding	Percent
YES	12	25.00%
NO	22	45.83%
UNKNOWN	2	4.17%
NA	14	29.17%

Triaged or Not

Next with call coverage was the concern over triaging all callers that called an MD or not. 60.42% indicated triaging callers. Only 2.08% indicated that no triage was done. (This group did not indicate any additional information as to whether the physician was beeped with messages, or what was done.) 10.42% indicated that they would triage the caller, and then beep the MD to give a verbal report, and/or get an approval on dispositions. 6.25% indicated that the MD was beeped only- no triage was done. Then there was the 10.42% that indicated again "Nurse's discretion".

Let me stand on the soap box for just a minute:
This is to the number of the nurses responding that specifically spoke of doing things at their discretion with no policies to cover how choices are made. The majority of responders that replied that triage was at the Nurse's discretion spoke of each nurse "Winging it!" PLEASE--- For all of the nurses that "Wing it!"... go to a legal seminar. You need policies and guidelines, or you need to let the physician's handle all triage calls until the policies and guidelines are in place.

Triage Patients/After Hours	# Responding	Percent
Triage	29	60.42%
Do not Triage	1	2.08%
Beep after triage	5	10.42%
Beep MD only	3	6.25%
N/A	5	10.42%
Some triage- Nurse's discretion	5	10.42%
One service indicated health info only to the general public, not triage services.

Ages of Patients

Services were inquired upon as to whether both adults and pediatrics were triaged. Responses were so various as to combinations, they were broken down as follows:

Patients Age Grouping	# Responding	Percent
Adults (over 21 years old)	32	66.67%
Pediatrics (Up to 21 years old)	37	77.08%
Some pediatrics (various age combinations)	1	2.08%
(Calculations based on affirmative response per question, divided by total number of responders.)

Three centers (6.25%) did indicate that although both adult and pediatrics were done, there were separate units for each.

Open to General Public

Coming from a mind set of a call center that is open to everyone, I was personally surprised at the low numbers of those responding that indicated the call centers were available to the public. Only 43.75% of the call centers are available to the general public. The remaining are: Insurance based: 10.42%; Outpatient Services (Day Surgery Units, Home Health Services): 8.33%; Hospital Screening Service: 2.08%; Managed Care (Contracted with an Insurance Co to handle triage and management of services):4.17%; and the general NO (including such services as: Maternity-birth info lines, MD offices, Physician after hours call centers that are private subscriber services, etc.): 31.25%.

Available to General Public	# Responding	Percent
YES	21	43.75%
NO	15	31.25%
Insurance Co only	5	10.42%
Outpatient Serv only	4	8.33%
Hospital Screening	1	2.08%
Managed Care	2	4.17%

Coverage Area

Coverage area brought about a variety of responses as well. (Many centers indicated more than one selection, as areas covered are various. The following were figured by areas covered divided by number of those responding to the survey.)

Coverage Area	# Responding	Percent
Rural	28	58.33%
City	31	64.58%
State	12	25.00%
More than one state	8	16.67%
National	5	10.42%
International	4	8.33%

Call Time

During this time of rush-rush-rush and get the most for the money, it seemed appropriate to inquire as to the average call time tracked by each center. To my surprise, 16.67% of those responding do not track call time. Of those that do track call time there was a general consensus that the nurses are being pushed for shorter and shorter time frames for calls. What really seemed overwhelming was one call center that was insurance based where the nurse handles between 80-120 calls in each 8 hour shift as an average.

Call Time	# Responding	Percent
< 5 min	6	12.50%
5 < 10	22	45.83%
10 < 15	6	12.50%
15 < 20	3	6.25%
20 plus	3	6.25%
Not tracked	8	16.67%

Years in Operation

Telephone Triage seems like such a new service to many of us. In fact, it has been around for years in one form or another used by insurance companies, physician's offices, emergency rooms, as well as others. Granted the largest growth seems to have occurred over the last few years, as indicated by the number of those responding to the question of years in operation.

Years in Operation	# Responding	Percent
< 1 year	14	29.17%
1 < 3 years	15	31.25%
3 < 5 years	3	6.25%
5 < 10 years	7	14.58%
10 < 15 years	2	4.17%
15 < 20 years	1	2.08%
20 years +	3	6.25%
not sure	3	6.25%

Marketing

Since we all are working on growing our call centers/services, it seemed only appropriate to see what variety of ways were used for marketing. Of those specifying, the fastest increase in call volume was delivered by TV/Newspaper advertising. However, for the long run of new clients achieved per advertisement, most indicated Yellow Pages. It seems that of the call centers that advertise, most choose a combination of efforts. Many use the refrigerator magnets in direct mail pieces, while others use large scale multi-media campaigns. ( I was most impressed by the group that did the parade float.) Some used no marketing what so ever, instead ER would transfer calls with health questions or triage questions. Some services directly received all after hours calls to the physician's offices. Still others were a Physician marketed service only, then the physician was responsible for either forwarding his calls to the service, or getting the phone number out to his patients.

Marketings	# Responding	Percent
ER transfer of call	4	8.33%
TV	14	29.17%
Radio	8	16.67%
Direct Mail	15	31.25%
MD	7	14.58%
Insurance	8	16.67%
Elevator Signs	2	4.17%
Marketed to MD	7	14.58%
Brochures	5	10.42%
Newspapers	12	25.00%
Billboards	2	4.17%
Yellow Pages	12	25.00%
Panels on City Buses	2	4.17%
None	8	16.67%
Forwarded MD office calls	2	4.17%
Marketed Insurance Package	3	6.25%
Parade float	1	2.08%

JCAHO Survey

The question most people were the most interested in was if the center/service had a JCAHO survey. Of those responding YES, most indicated that their facility was surveyed, so they figured the call center was reviewed at that time. Only 3 of the 11 responding positively to the survey, indicated direct contact with JCAHO surveyors. Two indicated poster presentations to JCAHO regarding the center with no further review of the call center.

Another indicated ER was reviewed by JCAHO. Due to the manner in which calls were taken as observed during that review, a call center was initiated. (2 did indicate being reviewed by NCQA.)

JCAHO Surveyed	# Responding	Percent
Yes	11	22.92%
No	26	54.17%
Not Sure	11	22.92%

Personal Note to all readers:

I am hoping this survey will be able to help all call centers/services in recognizing where each facility fits in the overall view of things, and will assist with continued growth.

I owe a special thanks to Kathi Webster of http://www.katsden.com and Andrew Lopez of http://www.nurseone.com/nurseone.htm, both of whom assisted in getting the survey questions out and the responses forwarded back to me. Without them, this survey would not be as complete as it is. I also want to thank all the nurses that took time to respond. A big thank you to all of you.

For those with questions, I will be happy to answer any questions I can. You can contact me as follows:

Henry Allison
E-mail: hallison@texoma.net
Address: Rt 2 Box 266-T
Pottsboro, TX 75076

In The Telephone Triage World

New Books

One of my favorite people in the Telephone Nursing world seems to be keeping her name in the news and staying quite busy these days. Sheila Wheeler RN has recently released three new books, published by Aspen Publishers.

The titles of her three part books are:

• Telephone Triage Protocols for Infants and Children: Birth to 6 Years
• Telephone Triage Protocols for School-Age Children: 6 to 18 Years and
• Telephone Triage Protocols for Adults 18 Years and Older

I've featured these books and others at an online bookstore with other telenursing titles, so if you're reading this from your favorite web browser, do stop by! -- the Editor

Sheila Wheeler's website is at: http://205.186.245.11:80/teletriage/
Aspen Publishers, Inc. is at: http://www.aspenpub.com
Telephone Nursing Bookstore at: http://www.katsden.com/telenurse/ttbookstore.html

Selected Conferences

Contemporary Forums - Telephone Triage Conferences
When/Where: September 28-30, 1997 in Seattle WA
October 12-14, 1997 in St. Louis, MO
November 6-8, 1997 in Washington DC
Intended audience: all telephone triage practitioners, no matter what the setting,HMO, Home Health, ED, Public Health, Community clinic or office. For nurse entrepreneurs, system managers and administrators
For more information contact: Contemporary Forums at (510) 828-7100
URL at: http://www.cforums.com
*****THIS IS A CONFERENCE THAT IS NOT TO BE MISSED
BY ANY TELEPHONE NURSES! THE BEST!**** [Editor's comment]

Maximize Your Success in a Managed Care Environment by
Creating Effective Medical Call Centers
WHAT: - Determine your medical call center's goals and objectives
- Understand the benefits for outsourcing vs. internal call center operations
- Learn about the latest issues, challenges, and additional functions for your call center
- Develop a communications strategy to market your call center
- Gain insight into the next generation of medical call centers
WHEN: October 30-31, 1997
WHERE: Westin Horton Plaza San Diego, 910 Broadway Circle, San Diego, CA 92101
CONTACT: Call 1-800-599-4950

Telephone Management as a Critical Part of 21st Century Patient Care
WHAT: An opportunity for all health care staff to enhance their critical telephone management skills. Focus on: Legal Perspectives, Communication Skills, Documentation Strategies. For all personnel working with patients on the phone (nursing and support staff). Speakers include Carol Stock, JD, MN, RN. a national known expert on legal issues and telephone management and Patricia Lynch Grover, Manager of Customer Service from Frontier Telephone of Rochester.
WHEN: Friday, November 14th, 19978:00-4:30
WHERE: Rochester General Hospital Hinshaw Auditorium. 1425 Portland Avenue Rochester, NY 14621
CONTACT: Call Division of Education with questions @ x716-338-4381

[Some conference information is obtained directly from the Web. The editor of TNT is not responsible for any errors related to conference detail and all information should be confirmed with conference directors]

Internet On the Line

Halloween

October 31st is celebrated in some countries as All Hallow's Eve. This October Festival of the Dead website celebrates the transition of autumn to winter with information on the history of Halloween, stories and crafts for kids, and an interesting collection of facts about this holiday. Happy Hauntings can be found at the Halloween O Webbery. Spooky things abound with this large collection of Halloween related web sites. For those nurses who feel they'd like to bring in a special treat to their co-workers this month, check out Gory Goodies. And don't forget to pass the Bleeding Heart jello. Perhaps to a cardiologist.
October Festival -->http://members.aol.com/JillDakota/hallows.htm
Halloween-O-Webbery -->http://www.primenet.com/~trix/hallo.htm
Gory Goodies -->http://www.primenet.com/~trix/hallorec.htm

Wild Stuff

The Wildlife Web covers links and information for a wide variety of animal Web sites including: amphibians, birds, fish, invertebrates, mammals, and reptiles. Expect to find many sounds and high quality photographs of wildlife.
WildLife Web --> http://www.selu.com/~bio/wildlife/

Foliage Season

Vermont is known as the Green Mountain State. But when autumn rolls around, it becomes the golden, red and yellow state from the changing foliage. This beautifully illustrated online magazine can help you take a virtual tour through the glorious New England forests during its most beautiful season.
Vermont Life --> http://www.vtlife.com/

Humor in FrontLine Stories

Humorous Advice

The Internet seems to be an endless well of "free advice" on healthcare issues.

The Ask Dr. Joe site is like Dear Abby with a bad attitude. A disclaimer admits "a comic character. With a foul disposition. Please refrain from serious questions about serious issues like divorces, chemotherapy, or (actual) amputations. You'd think we wouldn't have to put this here, but you should see our mail."

Duh, how about changing your title?

Employment Line

==Colorado==

Medical Systems Trainer, Pueblo, CO - Be part of a start-up call center. Responsible to design, implement, and manage an on-going educational training program. You will be accountable for standardized quality training and will manage the clinical algorithms CQI program and contribute to testing. RN required. Travel up to 60%.
Please call:
Jill Mooney at
STATSearch
7 Colby Court, Suite 4-204
Bedford, NH 03110
603-666-5500 Voice 603-623-5322 Fax
or email at hunter@statsearch.com

==Florida==

All Children's Hospital in St Petersburg FL is seeking RN's for their telephone triage program which is currently setting the clinical standard of excellence for Pediatric services. This position offers RNs the opportunity to manage after hour pediatrician office calls providing education, information, guidance, emotional support, and counseling.
For more information contact:Nurse Recruiter at 813-892-8222. Resumes may be sent to All Children's Hospital, Human Resources, 500 6th Street South, POB 31020, St Petersburg FL 33731-8920.

==Indiana==

Manager of Referral Systems and Physician Relations
RN needed to manage expanding medical call center in South Bend, Indiana. Must have experience managing RN's and be proficient in using a computer and quick to learn new software applications. Must also have experience working with physicians and making presentations to medical groups.
Position is with Memorial Health System in South Bend, Indiana
Please mail resume to Diane Stover, Memorial Health System, 615 N. Michigan Street, South Bend, IN 46601 or Call Carol Lyle Ford at 219-284-3274.
Memorial is a community-owned independent health system with over 2,200 employees.

==Texas==

TELEPHONE TRIAGE STAFF NURSE
Houston Call Center is seeking an RN interested in joining our team, for an afternoon/night shift position. We take an average of 6,000 clinical calls monthly and are starting our 5th year of operation. We are supported by a state-of-the-art communications system and on-line guidelines to assist the nurse in providing the caller with health information, and triage/referral services.
Qualified candidates will have:

• a current Texas RN license
• at least two years clinical nursing experience
• computer skills and familiarity with Windows
• excellent verbal communication skills and customer service skills

Send resumes to Fax Number 713-756-5787
Further information is available at 713-756-8844

==Utah==

Come and ski Utah while working for a busy and rapidly expanding 24 hour call center.
IHC TeleHealth Services is part of Intermountain Health Care (IHC), which is widely known for its community based health information, triage/referral service. IHC TeleHealth Services has expanded into facilitating personal health management across the health care continuum for IHC Health Plan members in Utah, Idaho and Wyoming, while maintaining our community service line. IHC TeleHealth Services answers between 1100-1400 calls per day.
We are currently hiring RNs for full and part time evening positions. Both these positions are benefit eligible. Minimum qualifications include a current Utah RN license with a minimum of 3 years high acuity nursing experience. Must enjoy working with people on the telephone. Must be able to sit for extended periods of time and talk while typing with few errors.
Send all inquires via E-mail to aajcall@ihc.com or call Jan at 801-978-4045.
Please include your name and phone numbers where you can be reached.

== AZ, CA, CO, IL ==

Access Health, Inc: With call centers in Sacramento, CA, Phoenix, AZ, Arlington Heights, IL and Broomfield, CO, we are a leading provider of consumer information and referral programs for the health care industry. Since 1986, our employees and products have been satisfying consumers' needs for the information necessary to make appropriate health care decisions. Our registered nurse counselors utilize our telephone-based products to provide reliable medical information, and help consumers find appropriate health care within a network of programs and services. We believe that when individuals are empowered with information about the condition their options and the resources available to them, they can make enlightened decisions before seeking treatment. Opportunities exist in a variety of shift options for Registered Nurses with exceptional communication skills. You must have a current license in the state you desire to work, with a minimum of 5 years acute care experience, and basic computer and typing skills. In return for your expertise, we offer you competitive salaries with shift and weekend pay differentials and premiums for holidays. If you're interested in joining a nursing team that is focused on contributing it's talents for a healthier population, give us a call or send us your resume.
Our job line is 800/246-5627. Or you may fax your resume to (916)856-3680. Our corporate headquarters is located at 11020 White Rock Rd., Rancho Cordova, CA 95670

[EDITORS NOTE: All employment opportunities have been submitted directly to the Editor of TNT for inclusion. Please check with the manager or recruiter listed for all details and job requirements. TNT takes no responsibility for verifying information submitted. Applicants must deal directly with listed "reply to" or inquiry contacts. There is no fee charged for posting employment desired or available, but submissions must be of an acceptable size and format for the ezine.]

Can't Get Enough on Telephone Nursing?

Review Previous Issues of TNT

August 1996 - Introductory Issue
September 1996 - Featuring: OB Telephone Nursing
October 1996 - Hospice and Telephone Nursing
November 1996 - Telephone Nursing and Seniors
December 1996 - Special Holiday Issue
January 1997 - New Year, New Approaches [Telenursing/Telemedicine]
February 1997 - Spring Ahead!
March 1997 - Marching Forward
April/May 1997 - Celebration of Nursing
June/July 1997 - Men's Health
August 1997 - Summertime
September 1997 - Culture on the Phone

The Web Page

The Telephone Triage Nursing Web Site is at http://www.katsden.com/telenurse/index.html

Next months topic:
Colds, Cough and Flu

WANTED!

Submissions of interest to Telephone Nurses in all occupations and environments. Preferred material is from Registered Nurses, Physicians and other health care professionals currently involved in the specialty. Require all submissions by the 10th of the month for next issue inclusion. Check out TNT Submission Guidelines  

 The contents of The WEBster's Telephone Nursing Telezine MAY be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording in information storage or retrieval systems, provided that all mention to TNT is maintained, the file is shown in it's entirety, no modifications whatsoever are made, and educational use is intended. This DOES NOT includes the option to "mirror" this web site or store copies at another Internet location. Photographs, graphics or inline images are not be used seperately from the publication in which they are imbedded nor download/modified for seperate use. This publication may NOT be sold or used in commerical publications or ventures without specific permission of the Editor. Mention of the existence and location of this web site and ezine in a commerical venture is acceptable and encouraged. Telephone Nursing Telezine is published on the Internet at: http://www.katsden.com/tnt/index.html

Copyright © Kathi Webster, 1996, 1997. All rights reserved.