With the overarching goal to meet healthcare demands of Americans, it is essential to understand who could benefit from health care via telehealth. Telehealth offers the opportunity to achieve quality aims, addressing barriers to care through innovative means and leveraging technology use in an increasingly technology-centric population. Nursing can play a key role in telehealth to improve care of patients in their organization. This is one organization’s example of the critical role nurses play in telehealth to improve assessment and access for patients awaiting evaluation in our neurology clinic. We will overview a nurse-led innovative program to screen, triage, and educate patients with chronic headache symptoms.

Telehealth at our institution is comprised of a team of experienced registered nurses (RNs). Our team applies high-level knowledge to each telehealth visit to support specialty clinic patients. In collaboration with physician partners, we developed and implemented an evidence-based protocol to assist the nurse in triage, disease management, and education and referral to correct specialist. For example, the neurology clinic receives more chronic headache referrals than they can accommodate on a monthly basis. In fact, patients with chronic headaches were waiting up to 18 months for an appointment in the neurology clinic. On further evaluation of patients seen in the neurology clinic, it was determined that many patients had symptomatology easily managed by the primary care provider. After review of the data, and given the identified limited access for these patients, a project team formed to develop a solution for chronic headache patients: a telehealth nurse program.

First, team education was critical. Education sessions focused on 1) clinical updates on current chronic headache assessment/treatment and evaluation, 2) overview of EMR technology tailored for chronic headache protocols for use by telehealth nurses, 3) collaboration with neurology clinic to understand work flows, e.g. registration and scheduling new referrals, 4) determination of criteria to enroll patients in the program, and 5) integration of key established practice processes in reviewing referrals. Second, marketing materials were created/sent to referring providers. Evidence-based chronic headache management tip sheets were created for providers and families. Non-clinical schedulers who are part of the team were educated on the chronic headache program and how to engage families and schedule the nurse screening calls. Finally, the team identified outcome measures to report success of the program.

Since implementation, we have identified more urgent needs of patients to communicate to providers and gathered additional information not included in the referrals from families to enhance clinic visits. Numerous patients meeting migraine and chronic headache criteria were identified. We educated families on basic headache management and general lifestyle adjustments. The RNs have established evidence to influence protocol changes. Meeting with families by telehealth has also substantially reduced the wait list, with necessary referrals still made. Also noted was increased family participation through higher percentages of answered calls and shortened call lengths. Utilizing case review, we continue to assess the program to identify areas for process improvement.

Background: The US Bureau of Labor Statistics found that there is an increasing demand of nurses in a wide range of settings, especially, those nurses who are specialized with the highest levels of experience and skills. There is strong evidence that nurses who are certified in their area of expertise provide safe, effective, patient-centered, timely, efficient, and equitable care. Healthcare delivery is shifting from inpatient to ambulatory care settings. Thus, nurses in telephone triage must prepare to meet with this challenge. It is beneficial to provide nurses with tools to help them prepare to become certified. Providing nurses review materials for the nationally recognized certification exam will help them to prepare well to achieve this goal. Certification allows the nursing profession to demonstrate its expertise in the specialty. Nurses with specialty certification are respected among their peers and other healthcare professionals. Most importantly, as the complexity of patients increases, it is imperative that nurses have the knowledge, competence, and skill to care for these patients.

Purpose: The purpose of the quality improvement (QI) project was to increase certified nurses in telephone triage.

Method: A QI project was conducted using the awareness, desire, knowledge, ability, and reinforcement (ADKAR) change management model to guide, prepare, and engage nurses to increase the certification rate in the unit successfully.

Results: 7 nurses have been certified in 2019 after the implementation.

Baseline data prior to implementation:
25 (100%): nurses expressed the desire
15 (60%): nurses certified in other specialties
3 (12%): nurses certification expired
7 (28%): nurses not certified and interested in certification
19 (76%): nurses were interested in having a second certification

Barriers: Cost, time, and family obligations

The implication for nursing practice: The network telephone care program is a service line for triaging veterans with complex conditions. Nurses have the knowledge and skill to manage the symptom calls, but not all are certified. These nurses do a tremendous job in assessing and providing proper disposition daily, and they deserve to be recognized for their efforts. Therefore, taking the certification exam will increase nurse satisfaction, increase patient safety, and will promote staff retention. Lastly, having funding for the certification review will be an incentive to enhance a strong desire for this professional advancement.

Conclusion: The results of the survey indicated that 25 nurses showed the desire in taking the certification exam and understood that change was needed to provide a high quality of care and demonstrate competence, knowledge, skills, and professional satisfaction.

Introduction: Ambulatory care centers with telehealth capabilities can be chaotic by nature, and phone conversations are a major part of a telehealth nurse’s workflow. Responding to phone interactions, especially those that are difficult, can become emotionally demanding. Nurses in telehealth are frequently challenged to handle difficult phone interactions in a professional manner. When interacting with a caller who presents in a challenging manner (e.g., loud tone, argumentative, disrespectful, using foul language), nurses should take ownership of the situation, regardless of what they believe to be the core of the problem. Clinical staff members must identify and attempt to treat the caller’s emotion, as well as the caller’s problem. Although clinicians find various resources in the literature for managing these situations, there are few references available that provide a comprehensive, yet easily accessible, summary of strategies and considerations.

Purpose: This poster will be a succinct and summative tool which outlines how to best handle challenging calls in an organized manner. Topics will include tips for professional communication, themes that are often common in these calls, legal considerations, documentation, termination of a professional relationship, and additional recommendations for ensuring professional accountability. Furthermore, suggested statements to avoid, as well as suggested statements to consider using, will be provided.

Implications for telehealth nursing: These strategies will assist clinicians to most appropriately resolve the callers’ needs while also maintaining the individualization of each call. After viewing this poster, attendees will be able to outline strategies to assist them in appropriately resolving a challenging call. Secondly, after discussion with the primary author, attendees will be able to analyze a previous call in their telehealth career and identify approaches for improving a similar call in the future.

Background: The US Preventative Task Force (2017) recommends 26 intensive lifestyle visits to improve pediatric obesity. Time constraints limit primary care pediatric providers from implementing intensive obesity care. A pediatric nurse practitioner designed a best practice alert imbedded into Epic® healthcare information systems throughout 14 hospital-owned pediatric primary care clinics aimed to improve obesity care delivery gaps. Alerts appear in Epic® charting during a well-child visit when a provider views a growth chart for a patient ages 6-18 years with a body mass index above or at the 95th percentile for age and sex, which is diagnostic for obesity. Alerts give providers an option to click an automatic referral pathway for interdisciplinary obesity care. The nurse practitioner simultaneously developed a telehealth clinic to deliver lifestyle counseling visits for providing efficient obesity care. Mixed methods including interviews, opinion surveys, electronic chart data reviews, a Likert-scaled provider telehealth visit satisfaction survey, and a modified family nutrition and physical activity tool measured for meaningful outcomes. Software technology platforms included SPSS® statistical software, SurveyMonkey®, Epic®, and SnapMD®. Fifty primary care providers received 1288 alerts to patients having obesity from June 1, 2019, through September 30, 2019, and referred 323 of those patients for endocrinology and telehealth visits. Thirty patients participated in 63 televisits. An increased frequency of low-fat milk consumption was the only significant health-promoting behavioral change when measured by Mann-Whitney U analysis. A post-intervention survey showed that 82% of responding providers (n = 17) agreed that the alerts and televisits are effective to increase obesity care access. The quality improvement initiative provided a promising model for a process change to improve pediatric obesity care practice in identifying pediatric patients at well visits having obesity and triggering a referral pathway for comprehensive, multidisciplinary care. The initiative can be strengthened by an alert allowing primary care providers to bypass specialty care evaluation in endocrinology and refer directly to intensive telehealth interventional lifestyles counseling when screening laboratory diagnostics are within normal limits. Closing obesity care delivery gaps using healthcare technology innovation like best practice alerts and televisits can benefit patient access and provider satisfaction.

Sarah Scheuermann (poster #65) discloses that she received a project grant from Sigma Theta Tau and had a stipend paid by her employer for tele-visits.

Purpose: Ineffective handoff communication is a critical patient safety problem resulting in delays in treatment, adverse events, increased cost, and inefficiency from redundant work. The purpose of this evidence-based practice (EBP) quality improvement project is to facilitate nurse-provider communication through the implementation and evaluation of a patient triage communication tool based upon situation, background, assessment, and recommendation (SBAR) methodology in the hospital-based outpatient clinic of a large academic medical center on the East Coast.

Description: Patients, caregivers, and providers utilize the outpatient clinic phone system as a primary point of contact for the acute care provider teams, leading to approximately 1500 incoming calls per month. A retrospective review of the electronic triage call logs demonstrated a lack of a structured communication method resulting in triage nurse to provider communications that were misunderstood or lacked valuable information. Additionally, the electronic medical record did not incorporate a triage documentation module. Interviews with leadership and staff as well, as observation of the triage process, identified the need for changes in key structures and processes to improve communication. A literature review focused on the applicability of the situation, background, assessment, and recommendation (SBAR) methodology to support the implementation of a communication tool. Findings demonstrated that SBAR methodology is an evidence-based communication tool that enhances nurse-provider communication by creating a common language for key patient information. A communication tool was adapted using SBAR methodology and uploaded into the electronic medical record by the clinic leadership. The EBP project was approved by the University of Maryland Baltimore (UMB) Institutional Review Board (IRB) for a non-human subject research determination. The target population was patients under the care of trauma teams A, B, C, D, and acute care emergency surgery. An implementation plan to address changes in structure and processes included a safety attitudes questionnaire to measure team culture, staff education, and weekly meetings to support the staff in the practice change.

Evaluation/outcome: Data collection occurred over a 12-week time frame to identify trends to improve process outcomes. Pre-implementation evaluation included the safety attitude questionnaire, a 36-item questionnaire addressing teamwork climate, safety climate, job satisfaction, stress recognition, unit management, hospital management, and working conditions. Questionnaire data (n=10) demonstrated a lack of teamwork (60%) and communication breakdowns (70%). A one-month retrospective chart analysis (n=100) demonstrated the number of nurse-to-provider (mean 1.91), provider-to-nurse (0.97), and nurse-to-patient communication (1.05) to close a telephone encounter. Additional retrospective analysis revealed the median length of time from triage nurse to encounter closure was 235.45 minutes (3.92 hours). Project data will evaluate the median length of time from routing the message to encounter closure and mean of each point in communication. Post-implementation, the safety attitude questionnaire will be re-administered to the triage staff. The implementation of the communication tool resulted in documentation changes within electronic medical record. The clinic leadership has expressed interest in implementing the tool for additional services to improve communication and patient safety.

Purpose: The purpose of this comparative descriptive study was to describe the current preparation, perceived knowledge, confidence, and stress of TT RNs. Investigators looked for relationships between those values.

Background: Telephone triage (TT) is a nursing skill which requires complicated critical thinking and independent judgment, with risk of serious outcomes if mistakes are made. It requires a skill set that is not included in standard nursing curriculum, nor learned through face-to-face care. Stressed nurses display more frequent cognitive lapses. Experts recommend in-depth didactic education and live call coaching to prepare RNs for TT practice; however, actual preparation of practicing TT RNs was unknown.

Methods: An online survey was emailed to all ambulatory care RNs in a large Northwestern health system. Nurses were asked to respond to questions regarding TT education completed, perceived knowledge, confidence, and stress. Two open-ended questions were included that asked them to elaborate on sources of stress and give recommendations for support. They were asked whether they were interested in completing more TT education.

Results: 47 RNs participated, resulting in a response rate of 11%. The majority of RNs reported having a bachelor’s degree and worked full time in specialty care, call center, primary care, or home care. The amount of TT education completed was highly variable, from none (n = 7) to over 30 hours. Most RNs had completed casual TT training (n = 38), about half had completed formal TT training (n = 24), and about a quarter (n = 12) had completed TT simulation. Deficits in knowledge and/or confidence were noted in several topics when applied to TT practice including scope and standards of telehealth, use of evidence-based practice, use of the nursing process, legal risks, best practice for challenging calls, documentation standards, identifying goals and plan of care, caller education, and appropriate delegation. RNs reported the most stress from dealing with serious patient issues which could result in bad outcomes if mistakes are made and from having periods of work with many hours of activity. Younger nurses and nurses who reported being overworked were more likely to report stress from other sources. Nurses who received formal or simulation education reported higher perceived knowledge. Participants recommended more TT education and decision-making support, more access to providers to ensure timely care, and work redesign to prevent interruptions related to multi-tasking. 94% of respondents indicated they would be interested in completing more education specific to TT.

Conclusions: Variability in TT RN preparation, deficits in knowledge and confidence in TT, and participant recommendations support the Core Curriculum for Ambulatory Care Nursing (2019) recommendation of a formal and standard orientation to telehealth. Workflow redesign to eliminate multi-tasking and increase provider availability may decrease TT RN stress and increase patient safety.

Learning outcomes: Attendees will be able to describe the preparation, perceived knowledge, confidence, and stress of practicing TT RNs in various ambulatory care settings in a large health system. They will be able to describe recommendations of those RNs to improve support for their practice.