Chapters Transcript Video IBD Breakout: Effective Phone Triage For Your Practice IBD Breakout Session: Effective Phone Triage For Your Practice *Not Eligible for CME Credit Good morning, everyone. Welcome to 23rd annual education meeting in gastroenterology, especially for nursing session. We're gonna talk about effective phone triage for you. Your very uh busy practice. My name is Suzie Lee. I'm a nurse practitioner at the I B D center. And um in this uh presentation, Andrea Banti will join second half of my pre our presentation, we have no financial disclosures. The objectives are um we need to understand basic knowledge of I B D and we would like to define the role of I V D triage nurse. And we will also discuss triage tools and techniques for a more effective and efficient communication to the rest of health care teams and the patients. General overview of I V D inflammatory bowel disease is a chronic disease and a G I system that affects more than 1.6 million patients in the United States and more than six million people are affected by I B D globally. And a recent study of cases showed in the United Kingdom that diabetic cases have risen by 33% between 2006 and 2016 in the United States. The CDC also has a similar finding. So we can conclude that trend. It appears to be similar worldwide. The typical ages of onset is between 15 and 35 not to forget, the second onset of um I B D happens later in their life. We call um late onset of I B D which is the 6th and 7th. It is associated with a significant financial burden on the health care system. Study showed about 70% of a patient with a Crohn's Disease and about 30% of a patient with the ulcer radio colitis will require surgical intervention at least once in their lifetime. And as compared to other G I disease I B D patients also have a higher medical care utilization. Since there is no cure in the I B D, the I B D patient required to be on medical therapy or sometimes surgical therapy to keep disease under control. The management of I B D requires regular office visits, occasional emergency department visits. Also hospitalization as well as the frequent inter visits, communications between patients and health care providers, pharmacies and insurance companies given the complexity of diagnosis and treatment involved in the I B D, both patients and providers including nurses and the support staff. We face many challenges including patients understanding of their disease and adherence to a treatment. More effective and efficient patient triage triage nurse need to have a good understanding of I B D. So when they receive a phone call, they know which are the pertinent data and when to react urgently or when to um put it off for a few days. So that will give um strategy for your triaging. There are two main types of I B D. First is the Crohn's disease and then second is radio colitis. Let's uh go over one by one and then we'll go over some symptoms and what to look out for ulcer. Radio colitis occurs in the large intestine and the rectum damaged area usually are continuous, starting from the rectum and inflammation is present only in the superficial layer of the lining of the choon. Therefore, it is not usually thin. The fistula is not usually thin in the setting of the ulcer colitis. Common symptoms that you will observe. It would be bloody, diarrhea, mucus, fecal urgency, fecal incontinence, abdominal cramping, mostly left lower quadrant. But if it is a pan colitis, if it is the whole, uh colon is involved, you will see extensive and generalized abdominal pain. There. More severe symptoms include nocturnal bowel movement. Patients will be woken up from sleep two or three times at night and malaise and fever fever. Sometimes we, it's a good indicator to see what kind of uh causes are. First, it could be inflammatory fever which is usually 99 5 to 1 oh one that we call a low inflammatory fever or if the fever is higher than one oh 21 oh three then most likely it's caused by infections. Also, another thing we recognize is the, um, very common, um, symptoms are fissures and excoriation of the perennial area and, er, rectal area from frequent bowel movement, but especially rectal ati or fistula would be more suggestive of Crohn's disease. Second, um, one is a Crohn's disease and a Crohn's disease can occur any part of G I tract from the mouth to the aid and most commonly is affected in a terminal ileal area. Um A roughly stat statistic shows about 30 to 35% of the Crohn's disease. Um occurrence is in a terminal illegal area and damaged area appears to be patchy instead of a continuation, conti contiguous um pattern. As you see in the U C and inflammation may reach through the multiple layers of a wall. That's when we see a fistula fistula is um the communication between bowel to the bladder or communication between bowel and bowel or communication between bowel and actually skin layer. So you will see um the fistula coming out of your surface of the skin and um maybe um associated with uh more systemic symptoms such as the anemia, low grade fevers, unintentional weight loss, and ex extraintestinal manifestation such as the joint pain, red eyes or episcleritis or Riis or skin manifestations such as the every, every or common symptoms of a small bowel obstruction is also something that you have to look out for. It is abdominal pain bloating, nausea, vomiting, a cessation of a bowel movement inflated. Sometimes patient will have a partial small bowel obstruction obstructive symptoms, which also needs to be addressed for address. And then I bring it up to a physician's, uh, attention, anal symptoms. Usually the anal fistula and a peral acid when somebody has a peral a that they complain, uh, lots of pain in the sitting or there's a palpable mask or fevers or in duration and warm to touch. The role of a triage nurses, multifactoral. Um As we all know that um nurses role is um multiple and we wear multiple hats, especially in the recent years that um pandemic that we went through is we've shown to the nation that we wear multiple hats and then we are the front line of care patient. We are the first uh patient contact as well as a gatekeeper and quarterback of the patient care coordination and coord we coordinate and communicate with the health care team and the patient to ensure the treatment plan is carried out and triaging more appropriately and timely. Therefore, we cannot emphasize enough that efficient triaging uh requires effective and clear communication. And we also are um our um to a patient, especially for I B D. It's a uh chronic long term disease. So we really need to educate our patient, the patient will understand and then they will stay in the um process and the treatment. And we also have to motivate our patient to ensure they stay with the uh treatment plan. And nurses are also a great listener and a provide patients and emotional support. As I indicated, education is a major component in triaging nurses role nurses have to assess the patient level of understanding and readiness to learn and identify any obstacles. Since diabetes is a chronic illness, alternating player and remission patient tend to get depressed and unmotivated. Thus, the triage nurses have to be able to affect patients, emotional mental, as well as a physical need. Then, um especially when we have um electronic charting and we have a um increase the number of uh patient messages coming through our portal. And we also have a numerous phone calls that we have to address. Then we need to know how to prioritize our calls and we have to categorize calls so we can effectively manage and triage our calls to address the um proper medical treatment. There are four types of calls that we um listed here. Um The first one is emergent. Usually it's an in vision reaction in vision center calls you that's stating that um your patient is having difficulty breathing or have a rash or a chest pain, then you have to elevate that um to your providers as soon as possible. So the proper treatment will be delivered. And critical lab value that your lab will call any positive c infection or a low hemoglobin or we encountered as low as four or five, then it requires immediate attention and then require a follow up and urgent means. The patient reporting an increased symptoms and they're starting to have a photo by movement watery. And then um if we wanted to uh captured and preventing worsening of their symptoms, we have to act fast, meaning patient needs to be seen by a provider next 24 to 48 hours for proper management of their disease. And the routine calls include patient has a question about a non urgent medication education question or they have a question about upcoming colonoscopy or surgery. They also have some um questions about um their uh going to travel oversea. What kind of things they need to um learn about. So those those kind of things that we call it um routine and other calls we will see will hear and see will be refill request or prior authorization or work school, excuse note or um a uh accommodation note. Then we will usually triage those. And also not to mention this um diet question, then we will triage those questions to a dietician or um social worker. When triage nurses are bombarded with multiple patient calls, utilization of effective communication technique is essential. Here in our presentation, we're gonna um go over a bar and then we will also um show you acute illness template. Our ID D center has um invented a few months ago as we all know, as far as originated from military and then it is very effective and efficient way of communication and um S bar tool. The S stand for situation B, stand for background, A stands for assessment, R stands for recommendation bar tool provides a framework between patient and triage nurse as well as the triage and members of the health care team as usually the name of the uh patient first. And then why are you calling a reason for the call? And B it's a background, what kind of diagnosis they have? And then also patient has um any uh maintenance medication and have they been consistent with the medication? Have they missed any medication and why? Uh what are the final habits? Um They're having um two or three bowel movement. That's their baseline. How much is more from baseline? And also there are uh potential triggers to the treatment, uh current symptoms such as antibiotic use or NSAID use or um a long period of a stressful event. And then finally, we have to gather up all the recent labs or imaging studies or endoscopy procedures and then we will come to an assessment. So it is an R N assessment. It's not a physician or a nurse practitioner assessment. So you, you can just make an assessment based on S N B, you will come up to an assessment, then, then you will um make a decision based on priority. Um What do you recommend to the patient? It's an urgent or emergent, then you have to bring it to um providers attention right away and then the routine and then um non can be escalated to the provider in a timely manner. And then another uh format that I um we developed what's called acute illness template. This template is a very useful template to communicate um in more of a written format and acute illness. The template is that our Ibe D Center has developed and it serves as an organized comprehensive assessment tool and it provides complete communication tool of a patient condition among and then we can do um distribute it among a health care team. So um with you this to S R and acute care illness template, we will be able to treat patients. And the next uh slide Andrea B is going to go over how we can best triage our patient based on our organized and effective um template and as far as um information. And yes, so this is an example of an algorithm that our clinic made to um kind of categorize the four different things already referred to. Um and categorize the different types of calls and messages to the clinic. Um Starting at the left, we see this is what initiates the use of the algorithm if somebody calls or messages and it goes to the triage team. Um So at the top in red, we see what do we do? What is the R and the S bar? Or the nurse's recommendation if there's an immediate need like an infusion reaction. Um So we ask the triage team to find the easiest available provider, which is usually a nurse practitioner. And if the nurse practitioners are unavailable, try to find the primary physician or even the on call physician if they're still not having luck and getting really um immediate access to care. Um The second category in blue is urgent and this is one that we really want to focus on somebody calling in with new or increasing symptoms related, potentially related to their I B G. So the the nurse will do the R N assessment and then ask the, the scheduler to make an appointment within 48 hours with the nurse practitioner that predominantly cares for this patient. Um Then we like the triage team to route their notes so we can see um everything they've already assessed from the patient. And then um uh if the primary nurse practitioner is un unavailable within those 48 hours, try to schedule with a different nurse practitioner because we're lucky enough to have three nurse practitioners in our particular setting. Um No, the the next category in green is routine calls. Um We encourage our triage team to look for when the patient was last seen in the office. And it's a good rule of them to try and see patients with chronic illness at minimum every six months. So if they're calling in with some routine non urgent questions and it's been over six months since they were seen, we like to make a routine follow up visit. That's not necessarily um within 48 hours but enough to accommodate the patient's questions. And um another thing the triage team can do is refer to the last office visit note to see if some of the answers to the questions are already there in the assessment and plan. Um And then the last category in purple are those generic requests. Um Some of these requests don't need to go to the provider at all and maybe it's a request for a prior authorization. So these are the least urgent calls and can be um done according to whatever the request is at a more leisurely. So this first case is going to focus on a more urgent call. L M is calling with a complaint of 5 to 6 loose non body bowel movements a day with associated left lower quadrant cramping urgency and 1 to 2 bowel movements, waking her up at night. Um It's been worsening over three weeks. She's a 24 year old female with a history of ulcerative colitis diagnosed three years ago. She's maintained on 4.8 g of Lialda a day and she's been taking it compliantly. She typically has 1 to 2 formed bowel movements a day without bleeding urgency or cramping. And her last colonoscopy was six months prior which showed remission or no active inflammation. Her last set of labs were also six months ago with normal findings including inflammatory markers, her CDC and C MP um and she denies recent travel or aspirin product use or NSAID use. She was recently prescribed a course of antibiotics for a urinary tract infection. The nurse's assessment is that she or he believes that L M is having a flare of her U C triggered by antibiotic use and using the algorithm, she designates this call as urgent and routes the call to the schedulers to try and accommodate the patient within 48 hours. One thing to consider in this situation is developing R end protocols with your care team so that if um there's, there's certain symptoms that can trigger a protocol, nurses can put in orders without asking the provider first. Um So in this situation, one example of an R N protocol may be ordering stool studies to look for the cal protection or the infectious workout like C diff in a stool culture. This is the acute illness template that Susie already showed us, but now it's filled out. Um So the nurse was able to quickly focus her questions and fill out the template. Symptoms started three weeks ago. Everything that we saw is clearly um listed on this template and then on the bottom, the nurse notes um some additional findings that she she heard on the call like the recent course of antibiotics for U T I also noted that the preferred lab was just in case um any additional labs needed to be ordered. Um And then the triage nurse routed her assessment to the nurse practitioner and the scheduling team to accommodate the call. This as a provider. When I see this, I can quickly look and know where all of the different sections are to see um what's going on with the patient and help me um focus in on the care when I'm seeing them in the office as a nurse practitioner. This is just a small sample example of one of the nursing protocols we're developing in our clinic. Um And this one is specific to um new onset or worsening diarrhea. In which case, the nurse was able to order the school studies before the visit even started. Now looking down in green, we're gonna focus in on some routine calls to the office. Um Again, the recommendation is, when was the last office visit is the um answer in the last office visit? No. And if it's been longer than six months, maybe let's get the patient in um for a routine office visit. So T L is calling to inquire if he can take Advil for an acute injury to his right knee. He's a 24 year old male with Ilio Crohn's disease. His last colonoscopy was done two years ago and showed partial but incomplete healing from his tic Kim injection. He was lost to follow up after his colonoscopy but feels well and tells the triage nurse that he doesn't have any symptoms, but he's just calling because his knee hurts, he's clinically stable. Um, this is the nurse's assessment. She believes he's clinically stable but has questions about his care and is overdue for a follow up visit. So, the recommendation was to let the patient know that, um, his question would be routinely routed to a provider. Um, and to recommend that office visit. Another thing to consider for some of these routine calls is that um you're getting a lot of repeat questions um is to work with the care team to develop a dot phrase. So maybe um the patients are asking the same questions and there's an opportunity for education. Um So, so making a standardized response can help kind of streamline the care. So here's an example of a dot phrase um specifically around um surrounding the use of N Z in the setting of I B D um which happens to be discouraged. So what happens if a patient can't wait to move through the algorithm, get scheduled for a bed visit? Um There are certain situations in I B D where it's more of an emergency and they need care right away. Um So this is just uh an example of these symptoms that may trigger um the the triage nurse to send the patient straight to the er um to, to get um inpatient care or emergency care in the er, so, um some of these situations are new onset, severe or nonstop diarrhea, continuous vomiting and uh inability to keep fluids down, dehydration, such as extreme thirst, dark colored urine, dizziness and, or confusion, a fever to one oh one. And sometimes that's for an unknown reason. Um, heavy rectal bleeding that does not slow down or new or worsen severe abdominal pain that does not get better. In conclusion, patient care is a team based approach. Always introduce yourself your credentials. Your role on the team as a triage team, we can provide supportive listening, patient education and set expectations for when the patient can expect to hear from a provider or connect with a provider. A triage team can get many different requests each day. So algorithms can help prioritize the request and organize how to efficiently um accommodate their needs. Protocols can help accommodate orders before the request is seen by a provider to streamline care and use best practice and clinic device dot phrases for common requests and questions can um also streamline care and eliminate the need to answer the same question over and over and over again or route the question to a provider. Do we have any questions? Ok. Yeah. You know, I only see two people in the room. Oh, I thought I was just presenting to you chad um If anyone doesn't have any questions, then we can end early and go to lunch. Created by
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