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• <50% of cancer related calls are resolved at inial point of contact • >30% of paent symptoms do not have a protocol in place • Both facts above support the need for: - Addional protocols (i.e., edema, congeson, mental status changes) - Annual revision of exisng protocols to broaden nursing scope • Connuaon of quarterly nurse triage audits • Integrate clinic and triage nurses into meengs to define roles/ expectaons and resolve issues Access Redesign Methodology Protocol Development Process Telephone Nurse Triage Model • This process consisted of a team of nurses and providers from many areas of experse ulizing evidence-based pracce guidelines. • Inconsistent applicaon of processes and standards for triaging paent phone calls in the Vanderbilt Medical Group (VMG) ambulatory environment • Lack of established guidelines for addressing paent phone calls • Variable and inconsistent levels of care-advice based on nursing experience, not on evidence-based pracce guidelines • Inconsistent and informal process to manage paent calls, which resulted in: • Delay of paent care • Symptom management based on urgency • Medicaon management • Numerous quesons/concerns • Call management system that was not measurable; inability to track/idenfy nurse-related phone calls VMG consists of approximately 125 ambulatory clinics throughout the community and surrounding areas, which generate over 1 million points of contact annually. • Progress: to date, the clinics that have had Performance Improvement Office (PIO) involvement equal only 23% of the annual visit volume. • Remaining Efforts: 77% of clinic volume remains as work to be completed; in which there is no ability to self-select to speak with a licensed nurse or disnguish between call types. THE SCOPE: THE PROBLEM: THE METHODOLOGY: Evidence-Based Telephone Nurse Triage Protocols: FINDINGS & RESULTS: CONTRIBUTORS: Stephanie Hyde, RN, ADN Helena Bruner, RN, BSN, OCN Patricia Myers, RN, BSN Debbie Brandle, RN, ADN, OCN Susan Cosenza, RN, BSN Dauphne McGavic, RN, MSN Cheryl Bates, BS, Central Appointment Scheduler Amy Spence, Central Appointment Scheduler Access Model Triage Model • BEFORE: From an informal system with numerous levels of undefined roles and funconality • AFTER: To a standardized system with well defined roles and funcons • At point of contact, paents are given a mely plan of care and appropriate disposion. Work Thus Far • Protocols include: 1. Bleeding 2. Conspaon 3. Diarrhea 4. Dysphagia 5. Fague/Malaise 6. Fever 7. Nausea & Voming 8. Pain 9. Mucosis/Xerostomia 10. Rash/Skin Irritaon 11. Drains Access Center Nurse Triage Transion to Current State Total Call Volume for Vanderbilt Cancer & Breast Access Centers 23,227 22,375 23,852 22,380 23282 24509 21205 24540 23510 22422 22598 21863 23898 22901 0% 5% 10% 15% 20% 25% 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 22,000 24,000 26,000 Total Access Center Calls Abandoned % Breakdown of Nurse Triage & Scheduling/Ancillary Call Volume for Vanderbilt Cancer & Breast Access Centers 14842 14556 16290 15102 15912 16053 13834 15834 15578 14884 15166 14050 15740 14832 8385 7819 7562 7278 7370 8456 7371 8706 7932 7538 7432 7813 8158 8069 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 0 5,000 10,000 15,000 20,000 25,000 Scheduler & Ancillary Calls Nurse Triage Calls Abandonment Rate Telephone Nurse Triage Audit Results Paent Call Status Emergent 2.3% Urgent 20.4% Non-Urgent & Home Care 77.3% Triage RN Completes Patient Encounter 25.1% Further Action Required by Clinic RN 44.8% Further Action Required by NP/PA 22.1% Further Action Required by MD 8.0% Telephone Nurse Triage Audit Results Paent Encounters - Level of Compleon Telephone Nurse Triage Audit Results Call Type Prior Authorizations 2.9% Ancillary Groups 4.0% Prescription Requests 3.0% Orders 6.1% Appt/Test Scheduling 19% Call Back 18.1% Results 11.3% Medical Records Issues 4.2% Medication Question 6.0% Symptom/Sick 16.0% Telephone Nurse Triage Audit Results Protocols Used Bleeding 2.9% Constipation 4.1% Diarrhea 4.6% Dysphagia 0.9% Fatigue/ Malaise 3.7% Fever 5.2% Mucositis 2.2% Nausea/Vomiting 8.0% Rash 1.2% Drain 0.6% Pain 32% Other (Specify in comments) 36% AMBULATORY NURSING TRIAGE DEVELOPMENT ESTABLISHING CONSISTENT EVIDENCE-BASED STANDARDS OF NURSING CARE AUTHORS: Nancy Muldowney, MLAS, BSN, RN; Jennifer Mitchell, MSN, ANP-BC, GNP-BC Vanderbilt-Ingram Cancer Center Transion The Vanderbilt-Ingram Cancer Center (VICC) is a leading mul-site oncology center with over 6 cancer sub- speciales and more than 90 providers. Not only is the only Naonal Cancer Instute-designated Comprehensive Cancer Center in Tennessee, it is also a member of the Naonal Comprehensive Cancer Network, a non-profit alliance of 21 leading centers working together to improve quality and effecveness of cancer care. • Hand Off • Message • Hand Off • Message • Hand Off • Message • Hand Off • Message VICC 6% Urology 2% Breast Center 1% Women's Center 3% Williamson Primary Care 4% Otolaryngology 5% General Surgery 2% All Other 77% Nurse Triage Nurse Triage Centralized Clinical Effecve Evidence-Based Protocols Dedicated Staff Paent-Centric Measurable • Four Key components are included in the centralizaon of access. The Nurse Triage component addresses quality of care based upon naonal standards and guidelines. Before Aſter

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Page 1: AMBULATORY NURSING TRIAGE DEVELOPMENT - mc.vanderbilt.edu · triage Recordsaudits • Integrate clinic and triage nurses into meetings to define roles/ expectations and resolve issues

• <50%ofcancerrelatedcallsareresolvedatinitialpointofcontact

• >30%ofpatientsymptomsdonothaveaprotocolinplace

• Bothfactsabovesupporttheneedfor:- Additionalprotocols(i.e.,edema,congestion,mentalstatuschanges)

- Annualrevisionofexistingprotocolstobroadennursingscope

• Continuationofquarterlynursetriageaudits

• Integrateclinicandtriagenursesintomeetingstodefineroles/expectationsandresolveissues

Access Redesign Methodology

Protocol Development Process

Telephone Nurse Triage Model

• Thisprocessconsistedofateamofnursesandprovidersfrommanyareasofexpertiseutilizingevidence-basedpracticeguidelines.

• InconsistentapplicationofprocessesandstandardsfortriagingpatientphonecallsintheVanderbilt MedicalGroup(VMG)ambulatoryenvironment• Lackofestablishedguidelinesforaddressingpatientphonecalls• Variableandinconsistentlevelsofcare-advicebasedonnursingexperience,notonevidence-based practiceguidelines• Inconsistentandinformalprocesstomanagepatientcalls,whichresultedin:• Delayofpatientcare

• Symptommanagementbasedonurgency• Medicationmanagement• Numerousquestions/concerns

• Callmanagementsystemthatwasnotmeasurable;inabilitytotrack/identifynurse-relatedphonecalls

VMGconsistsofapproximately125ambulatoryclinicsthroughoutthecommunityandsurroundingareas,whichgenerateover1millionpointsofcontactannually.• Progress:todate,theclinicsthathavehad

PerformanceImprovementOffice(PIO)involvementequalonly23%oftheannualvisitvolume.

• RemainingEfforts:77%ofclinicvolumeremainsasworktobecompleted;inwhichthereisnoabilitytoself-selecttospeakwithalicensednurseordistinguishbetweencalltypes.

THE SCOPE:

THE PROBLEM: THE METHODOLOGY:

Evidence-Based Telephone Nurse Triage Protocols:

FINDINGS & RESULTS:

CONTRIBUTORS:StephanieHyde,RN,ADNHelenaBruner,RN,BSN,OCNPatriciaMyers,RN,BSNDebbieBrandle,RN,ADN,OCN

SusanCosenza,RN,BSNDauphneMcGavic,RN,MSNCherylBates,BS,CentralAppointmentSchedulerAmySpence,CentralAppointmentScheduler

Access Model Triage Model

• BEFORE:Fromaninformalsystemwithnumerouslevelsofundefinedrolesandfunctionality

• AFTER:Toastandardizedsystemwithwelldefinedrolesandfunctions

• Atpointofcontact,patientsaregivenatimelyplanofcareandappropriatedisposition.

Work Thus Far

• Protocolsinclude:1. Bleeding2. Constipation3. Diarrhea4. Dysphagia5. Fatigue/Malaise6. Fever7. Nausea&Vomiting8. Pain9. Mucositis/Xerostomia10.Rash/SkinIrritation11.Drains

Access Center Nurse TriageTransition to Current State

Total Call Volume for Vanderbilt Cancer & Breast Access Centers

23,22722,375

23,85222,380

2328224509

21205

2454023510

22422 2259821863

2389822901

0%

5%

10%

15%

20%

25%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

22,000

24,000

26,000

Total Access Center Calls Abandoned %

Breakdown of Nurse Triage & Scheduling/Ancillary Call Volume for Vanderbilt Cancer & Breast Access Centers

14842 1455616290 15102 15912 16053

1383415834 15578 14884 15166 14050

15740 14832

8385 78197562

72787370 8456

7371

8706 7932 7538 74327813

81588069

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

0

5,000

10,000

15,000

20,000

25,000Scheduler & Ancillary Calls Nurse Triage Calls Abandonment Rate

Telephone Nurse Triage Audit ResultsPatient Call Status

Emergent2.3%

Urgent20.4%

Non-Urgent & Home Care

77.3%

Triage RN CompletesPatient Encounter

25.1%

Further Action Required by

Clinic RN44.8%

Further Action Required by NP/PA

22.1%

Further Action Required by MD

8.0%

Telephone Nurse Triage Audit ResultsPatient Encounters - Level of Completion

Telephone Nurse Triage Audit ResultsCall Type

PriorAuthorizations

2.9%Ancillary

Groups 4.0%

Prescription Requests 3.0%

Orders 6.1%

Appt/Test Scheduling19%

Call Back 18.1%

Results11.3%

MedicalRecords

Issues 4.2%

Medication Question6.0%

Symptom/Sick 16.0%

Telephone Nurse Triage Audit ResultsProtocols Used

Bleeding2.9%

Constipation4.1%

Diarrhea4.6%

Dysphagia0.9%Fatigue/Malaise

3.7%

Fever5.2%

Mucositis2.2%

Nausea/Vomiting8.0%Rash

1.2%Drain0.6%

Pain32%

Other (Specify in comments)

36%

AMBULATORY NURSING TRIAGE DEVELOPMENTESTABLISHING CONSISTENT EVIDENCE-BASED STANDARDS OF NURSING CARE

AUTHORS:NancyMuldowney,MLAS,BSN,RN;JenniferMitchell,MSN,ANP-BC,GNP-BC

Vanderbilt-Ingram Cancer Center

Transition

The Vanderbilt-Ingram Cancer Center (VICC)isaleadingmulti-siteoncologycenterwithover6cancersub-

specialtiesandmorethan90providers.NotonlyistheonlyNationalCancerInstitute-designatedComprehensive

CancerCenterinTennessee,itisalsoamemberoftheNationalComprehensiveCancerNetwork,anon-profit

allianceof21leadingcentersworkingtogethertoimprovequalityandeffectivenessofcancercare.

Access Center Clinical Calls

Common EBP Nursing Assessment & Questions

Patient Has Options at Point of Contact

Plan of Care Clarification

Questions & Follow Up

Protocols &

Directives

Rx Renewals

& Med Mgmt

CAS PSR

Back Lines

AA & OA

Clinic Primary Outbound & Multiple Call Backs,

Patient Delays

•HandOff•Message

•HandOff•Message

•HandOff•Message

•HandOff•Message

VICC6%

Urology2% Breast

Center1%

Women'sCenter

3%

WilliamsonPrimary

Care4%Otolaryngology

5%

GeneralSurgery

2%

All Other77%

Nurse Triage

Nurse TriageCentralizedClinicalEffectiveEvidence-Based Protocols

DedicatedStaffPatient-CentricMeasurable

• FourKeycomponentsareincludedinthecentralizationofaccess.TheNurseTriagecomponentaddressesqualityofcarebaseduponnationalstandardsandguidelines.

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