It's 5 O'Clock Somewhere: Making Standardized Care Provision Available at All Times

In this new age of healthcare, the hour of the day should not impact the quality of care provided to patients. During the middle of the night, patients are often unsure of the severity of their symptoms and seek assistance from urgent care centers, emergency departments (ED) or on-call providers. Due to these limited options, patients are often forced to over-utilize the aforementioned resources, which in turn can place a strain on emergency services. It can also lead to an unnecessary financial burden for the patient. Alternatively, if a patient chooses to forego care, there is a risk for unfavorable outcomes. At one large academic medical institution, telephone triage nurses have been helping guide patients to the appropriate disposition and provide standardized care advice as a best practice for several years. However, this support has not been available to patients after five PM. Previously non-clinically trained call center staff would take patient calls after clinic operations ceased and would page on-call providers for medical advice. Unfortunately, this did not provide immediate access for patients to talk to a licensed healthcare provider about their symptoms, which often delayed patient care.

While utilizing the Iowa evidence-based practice (EBP) as a framework, a root cause analysis (RCA) was identified by the institution as a trigger issue and opportunity to improve patient care. Thus, the after-hours triage program (AHTP) was born. The goal of the program is for RNs to triage patient calls after clinic hours, while using evidence-based decision support tools (DST). Since these nurses came from varying backgrounds without ambulatory care telephone triage experience, they also have providers as a resource if they are uncertain on a disposition or if questions arise outside of their scope of practice.

Before program implementation, the telephone triage educator initially met with the hospital admissions team to discuss launching the AHTPs. The teams collaborated with local and national content experts to help with program development. Logistics of the program included defining hours, staffing, workflows, staff education, and determining departmental priority for initial launch. Training included the new triage nurses shadowing other experienced ambulatory care nurses performing telephone triage in different specialty areas. During implementation, the group decided to target primary care clinics first due to large call volume and variety of symptom-based calls. So far, the AHTP has received 113 calls from the general internal medicine (GIM) clinic since the launch date of October 2021. Positive feedback on nurse triage protocol utilization and documentation was provided during a follow-up call with GIM clinic providers. Due to the success of the program pilot in GIM, the family medicine (FM) clinic was added in November. The goal is to eventually roll out the program to all ambulatory care clinics at the institution. Implications from this project could include a future EBP project around analyzing reason for call from non-clinical call center staff and compare that to reason for call and disposition that the nurse determined after speaking with the patient.