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Cultivating Collaboration

4. Merge Clinical and Technical Worlds

Forward thinking invention in telephone triage

Seeing differently, thinking together: Systems Applications Analyst Jake Hendriksen and Certified Nurse Midwife Amy Nelson bring different expertise and perspectives to the table to create a smarter OB triage solution than either could have developed on their own.

Tapping into a broader hospital network to build a safer telephone triage system

When we decided to standardize our OB telephone triage system, we wanted to get some ideas from an established program. Problem was, we couldn’t find an established program. Our literature research came up cold. Our conversations with colleagues at other institutions led nowhere, and we learned that many OB departments like ours didn’t triage by telephone at all— they simply told everyone to come in to the hospital.

We knew there was a better way—a telephone triage middle ground that would reduce unnecessary hospital visits and costs—but our current system wasn’t it. The questions we asked patients and the advice we gave had the potential to vary depending on the practitioner. The notes we took during triage were jotted only on paper. It just felt a little too loose.

55% reduction in unnecessary hospital visits

Our clinical decision-making algorithm, which ensures that patients are given appropriate advice on whether to come to the hospital, has reduced unnecessary hospital visits by 55 percent. There have been no instances where a patient was misdirected using the new algorithm, which demonstrates that it is a superior patient safety tool.

“In this day and age, when we know that standardized care leads to better outcomes, we just couldn’t keep working with such an unstructured system,” says Janet Fisher, labor and delivery nurse. At the same time, we also realized that if we wanted a truly forward-thinking telephone triage system, we’d have to invent it ourselves.

“When nurses get introduced to the interdisciplinary world, we can break through self-imposed barriers and solve seemingly impossible problems. Other people bring more pieces of the puzzle, so that together, we’re able to complete the picture.”—Janet Fisher, Labor and Delivery Nurse

Step outside of your department

It’s easy to get stuck in the status quo. Breaking out requires the help of others—people who can look at something you’ve been looking at for years and see it completely differently. That’s where our quality department came in. With their help, we began forming a vision for a computerized system: a tool that could leverage our best clinical thinking to deliver consistent patient advice.

“We started wondering if there could be an algorithm for telephone triage,” says Janet. But it wasn’t a question that the OB nurses or the quality team could adequately answer on their own, so they brought in more collaborative thinkers from the IT department. “We discovered a whole new level of resources that we didn’t know existed,” says Janet. “And they helped us expand the way we looked at our day-to-day practices.”

Make IT pros your new best friends

Our OB nurses and midwives understood the clinical situations that came up during triage, and our labor and delivery physicians helped refine them, but it was our IT team that turned it all into an efficient workflow. “We had the concepts figured out to a certain degree,” says Amy Nelson, a certified nurse midwife in our OB department. “They made it into a useful product.”

Working with systems application analysts Jake Hendriksen and Pearce Danner to create a standardized decision tree, our OB team looked carefully at all clinical scenarios, pinpointed the critical questions that needed to be asked and assigned an acuity to each scenario based on patient responses. For instance, if a patient mentioned decreased fetal movement, a new dialog box would come up to help the triage nurse probe more, with specific questions about the movement or lack of movement, and instructions to give to the patient, so she could try and increase movement.

“We started to think of general questions leading to the next set of more specific questions that impacted our final outcome of advice,” says Amy. “With Jake and Pearce’s help, we began to think in a more organized way.”

 

Invite junior staff members to be central players

It’s great to collaborate with experienced experts, but inexperience can be an asset, too. That’s why we also gave our quality intern, Danielle Freeman, a key role in the project. “We tend to get muddled in the systems we’re used to,” says Danielle. “And that makes it hard to think outside the box.” With her combination of youth and inexperience, along with the fact that she wasn’t on the clinical side, Danielle could see the project from an outsider’s view and contribute a fresh perspective. She also had undivided time to work on the nuts and bolts of the project and keep it on track.

 

Once the new computerized triage system was complete, Danielle developed staff education for 70 nurses, midwives and medical assistants, teaching them how to navigate the computer program, systematically run through the questions and document the patient call in the system.

 

Trust the system

Transitioning from intuitive to rules-based practices requires more than a new computer system and staff training. It also requires a change in mindset. We must acknowledge that a well-defined set of rules goes much further than individual instinct when it comes to ensuring patient safety. “It’s a hard shift, but our triage nurses are learning to trust the system,” says Pearce. “It eliminates subjectivity and reduces variables, so our patients get the best possible advice.”

Janet agrees and also acknowledges that this best-in-class advice couldn’t have been delivered to patients without bringing together clinical, technological and quality perspectives. “Even now that we’ve made it happen, we’re still in awe of this new tool,” she says. “This huge hospital is just brimming with ideas, and we can do great things when we bring different minds and skill sets together.”

Do you have a phone triage system in place? What do you think about this new system? Share your thoughts.