UAP Use in Telephonic Nursing

[Donnetterr]

Greetings, everyone! I am a senior-level nursing student seeking advice about the following situation. I apologize for the length.

Currently, I work as a Customer Service Representative (Unlicensed Assistive Personnel) for a telephone nurse triage service. My job involves being the first point of contact for consumers who call our nursing center. I take name, date of birth, address, phone number, and ask for a brief description of the reason for the call. I then inform the caller that a Registered Nurse will call them back "as soon as possible."

I am the only CSR with any medical training; most of our CSRs are high school graduates who have not even taken a medical terminology course. As I progress in my nursing studies, I am becoming concerned that a CSR has no business taking the initial information from the caller. Just today I had a caller who described her reason for the call as "heavy cramping, lady partsl bleeding, dizziness, and soaking a super-sized tampon at least every 15 minutes."

When I finished the call, I approached our charge nurse and told her I was concerned that the call may be urgent. I was immediately chastised and reminded that my role did not include priortizing call backs. A few minutes later, I heard this nurse on the phone with the caller, and I heard her tell the caller, "Our guidelines advise that you should call 911 immediately for transport to the Emergency Room." Had I not approached the charge nurse with this call, the message I took could have hung up for on our message list for up to 30 minutes, or sometimes longer, as our nurses completed other calls.

This situation has happened more than once when I've been working. I am concerned that some important calls may not have been appropriately routed to the charge nurse because our other CSRs do not know what constitutes a potentially urgent medical matter.

As an explanation of our service, when the caller enters our call queue, he or she normally hears a message stating, "If this is an emergency, hang up now and dial 911." If we are not in queue, the call comes straight to a CSR and the disclaimer is never played. My supervisor believes the disclaimer relieves our department of any liability; however, I think some laypeople do not necessarily know what consitutes an emergency, and they may be calling our service to see if they have an emergency.

To make this long story somewhat shorter, I am considering telling my manager that I do not feel comfortable taking the calls from the nurse line. Our department also acts as a physicians' answering service, and we page physicians, relay consults, etc. I feel comfortable performing that portion of my job. However, I am not comfortable with taking phone calls from a person who may be experiencing an MI, diabetic crisis, labor, manic episode (we get a wide range of calls) and telling the caller, "Our nurse will have to call you back."

Our department implemented the practice of using UAPs as initial point of contact over a year ago. Until that time, nurses took their own calls, and if all nurses were busy, the caller stayed on hold and was guaranteed to hear the disclaimer.

Experienced nurses, please advise me: Am I making a mountain out of a molehill? Or, do I have something to be concerned about?

[Bipley]

As for the legal issues, I think a lot of it depends on the contractual agreement between the consumer and your employer. How do they know to call you vs. their MD? Is it part of their insurance plan? I guess my question is this, what leads them to call you vs their doc?

For moral issues, again... it depends on the reason they are calling you vs. their doc.

[DusktilDawn]

After reading your post, I think you have raised a valid point. There could be serious situations that are not addressed as they should be.

I am the only CSR with any medical training; most of our CSRs are high school graduates who have not even taken a medical terminology course.

This is scary. With CSR's that have no/limited knowledge with medical terminlogy, the accuracy of the information they are transcribing can be affected. Also, they are unprepared to ask questions to elicit information that would be important in regards to the patient situation which would affect how this person would be prioritized.

My job involves being the first point of contact for consumers who call our nursing center. I take name, date of birth, address, phone number, and ask for a brief description of the reason for the call.

Patients are not always able to accurately describe the situation. Part of the assessment process involved with nursing is being able to facilitate or elicit accurate information from the patient. It's knowing what questions to ask, especially when the patient is being vague. For example: "I feel funny," what does that mean when a patient says this? What questions would you ask to further define what the patient means by this statement?

Just today I had a caller who described her reason for the call as "heavy cramping, lady partsl bleeding, dizziness, and soaking a super-sized tampon at least every 15 minutes."

When I finished the call, I approached our charge nurse and told her I was concerned that the call may be urgent. I was immediately chastised and reminded that my role did not include priortizing call backs. A few minutes later, I heard this nurse on the phone with the caller, and I heard her tell the caller, "Our guidelines advise that you should call 911 immediately for transport to the Emergency Room." Had I not approached the charge nurse with this call, the message I took could have hung up for on our message list for up to 30 minutes, or sometimes longer, as our nurses completed other calls.

BTW I do think that you did the right thing reporting this call to the Charge nurse and I disagree with her chastising you in this situation, especially since you mention that call-backs can take 30 min or longer. Who does prioritize call-backs? Does anybody prioritize call-backs or are the calls returned in order? As a nurse I would be seriously concerned with both these questions. For one thing how can I as a nurse prioritize if I have not talked to the patient? Second, I am basing my judgment on relayed information that is not directly from the patient or from another professional when it comes to returning the call.

As an explanation of our service, when the caller enters our call queue, he or she normally hears a message stating, "If this is an emergency, hang up now and dial 911." If we are not in queue, the call comes straight to a CSR and the disclaimer is never played. My supervisor believes the disclaimer relieves our department of any liability; however, I think some laypeople do not necessarily know what consitutes an emergency, and they may be calling our service to see if they have an emergency.

Is this supervisor a nurse or not that believes this? There are a lot of nurses that are not always familiar in regards to the laws and regulations that govern their practice. Has she any validation that a disclaimer would relieve your department of responsibility? Has she contacted a legal nurse consultant, medical malpractice attorney, or the SBON? You are correct when you say some laypeople do not necessarily know what constitutes an emergency and that they may be calling to see if they have an emergency.

I think you raised some very serious and valid concerns in regards to telephone triage nursing. I encourage you to express these concerns to your manager. Find out if she is aware of the legalities involved in having CSR's taking these calls. If possible research these legalities yourself.

[Daytonite, BSN, RN]

I understand your concerns. However, the information you are required to take from callers is demographic information. I think what is happening is that as you are becoming more educated in nursing school you are seeing what may be potential problems. You are attempting to fuse your role as a CSR with that of a licensed nurse. I think that's normal for someone in your position. However, when you first started doing this job, you didn't see these calls the same way that you are now, did you? It is only with additional training that you are starting to put some information together that you never did before. As a UAP you cannot give any kind of advice over the phone--that is clearly stated in the nursing law of your state, I am sure. You can convey the urgency expressed by a caller to the charge nurse which you did in the incident you described. That, insofar as your job is concerned, is the end of the story for you as much as you want to be involved in the outcome. I would fear that telling your manager that you do not feel comfortable taking the calls from the nurse line will, at worse, end your employment. I understand your anxiety that a caller be taken care of immediately in some cases, but it is the RNs who will have to answer if something goes terribly wrong.

I'm not trying to belittle your job, however, it is very rare that people who are in the throws of dying have the strength to pick up the phone to call a nurse line for help. Think in terms of the ABCs of resusitation. A person who is telling you they are bleeding and is able to speak with you fairly intelligently on the phone, is probably not going to be coding. There is also some other assessment and information that an advice nurse needs to get from this patient to establish the level of seriousness of the call. Also, even at the ER people generally have to wait a certain amount of time, determined by the triage RN, before the doctor gets to see them.

I think you are right to question how some of these calls are being handled. The way is to work within your system to get the system changed. However, due to your current position you are probably not going to taken very seriously. But, you can bring up your concerns at the appropriate places and times. If you overstep your bounds you will be putting your job in jeopardy. If you become a pest about this, it is going to be reflected in your evaluation. I would advise you to just stick this out and do the job you have been told to do until you either quit or graduate from nursing school when you can go looking for your first RN job.

[Donnetterr]

Thanks very much for your thoughtful replies.

I have ALWAYS had a problem with CSRs answering the nurse calls, but as my time here lengthens, it bothers me more and more. I am a second-career nursing student, coming from a background of a Bachelor's degree in psychology, an Associate's degree in Paralegal Studies, and 10 years experience as a corporate paralegal. In my former job, I was used to being a "pest" and was often rewarded for bringing things to light that needed to be dealt with, if not necessarily changed.

Our nursing center is a community service line for some callers, a free method of obtaining nursing advice. It is utilized quite a bit by consumers without medical insurance or primary care. Another component of our service is contractual work between physicians' offices and our triage center. Those callers are linked to us when they call their MD's office after hours.

I have decided to take the advice to do a little research into this matter. I have mentioned this issue to my manager in the past, and her response was not very receptive. She is a nurse, by the way, now working as an administrator.

Thanks again everyone!