College Health Nursing – Pearls of Triage, Treatment and Stats Chris Rooney BSN, RN BC Health Services Millersville University of Pennsylvania Welcome Handouts – sign email sheet and you will be given access to the power point and assorted copies of information via Google Documents/Windows Live. Green initiative It’s 5 o’clock somewhere ---- and soon it will be so let’s have some fun while we are here. First, let me find out a little bit about who you are and your institutions. Size: Larger than 20000 students ? 10000 to 20000 5,000 - 10000? 2000 – 5000 < 2000 Who does not have electronic scheduling? EHR? Director: Physician? NP RN Other Has a triage policy? Looking for one????? Struggling with statistics and reports? Facilitated Discussion --- Please use the microphones provided - 1

College Health Nursing Scope of practice - Direct Nursing Care Collaborative Role Health Educator Research/Consultant Advocacy Combining Triage with College Health Nursing 1990 article - Historical perspective - College Health Nursing was not recognized as a nursing specialty until the early 90’s 1936 = First Nurse attended and presented at ACHA recognized as Nursing section in 1959 Theoretical basis of nursing – Florence Nightingale - non curative practice in patient is put in b est condition possible for nature to act Mid 20th Century – Hildegard Peplau - therapeutic interpersonal process to make health possible 1966 Virginia Henderson - assisting to gain independence 1980 – Dorothy Orem – direct service in form of self care needs ANA -recently 1990 – diagnosis and treatment of human responses to actual or potential health problems 1986 – demonstrated expertise in college health nursing practice – interested in health problems of young adults and very diverse population in higher ed. Scope –Good health crucial to education Dynamic and changing as our students change Self reliance for own health care – educate to be responsible consumers of health care Developmental growth – risk taking behaviors

Factors to consider Staffing Staff – provider type Time – hours of service , time of day Method of contact Walk in Phone interaction Chief Complaint - Assessment Appointment/walk-in Need for ancillary services - immediate lab/x-ray Other considerations Transportation Distance to acute care/ER Who’s available to see patients in the Health Center Physician PA NP RN MA Does your assessment indicate immediate treatment ? ER Most of us can easily triage those in need of ER care What time is it --- 4 p.m. and you close at 4:30 Do you have an available appt? When??? Phone or in person --- Can you see them? Can you touch? How is your triage ability lessened/enhanced?

Baseline considerations State Board of Nursing Law Standard of Care National Council of State Boards of Nursing. https://www.ncsbn.org/312.htm Article 2, chapter 2 Medical Direction – what is your medical director comfortable with? Protocols/documentation Expertise of staff Ensuring access to the appropriate level of care Utilization of resources - *** Comprehensive nursing assessment is an extensive data collection (initial and ongoing) for individuals, families, groups and communities addressing anticipated changes in client conditions as well as emerging changes in a client’s health status; recognizing alterations to previous client conditions; synthesizing the biological, psychological, spiritual and social aspects of the client’s condition; evaluating the impact of nursing care; and using this broad and complete analysis to make independent decisions and nursing diagnoses; plan nursing interventions, evaluate the need for different interventions, and the need to communicate and consult with other health team members. B. Collaborating with health care team to develop an integrated client-centered health care plan. ‘ 2.2.2 Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation The registered nurse: A. Conducts a comprehensive nursing assessment that is an extensive data collection (initial and ongoing) regarding individuals families, groups, and communities. B. Detects faulty or missing patient / client information. C. Applies nursing knowledge effectively in the synthesis of the biological, psychological, social and cultural aspects of the client’s condition. D. Uses this broad and complete analysis to plan strategies of nursing care and nursing interventions that are integrated within the client’s overall health care plan. E. Provides appropriate decision-making, critical thinking and clinical judgment to make independent nursing decisions and nursing diagnoses. F. Seeks clarification of orders when needed. G. Implements treatments and therapy, including medication administration, delegated medical and independent nursing functions. Medical Direction - Development of protocols for triage and initial assessment by nursing staff - HOW do you do that: skill set tools /resources/best practices/evidence based research Bayesian Model - vs Gut “Knowing the Patient” Experiential Knowledge

Literature Review of Protocols None specific to college health 2007 JCN -Clinical decision making 2008 IJN - Knowing the patient JCN – Context vs protocols 2008 JTIICC – Triage Tools 2009 IJCN - Expertise clinical Protocols - Aid in nursing judgments? - No literature specific to Clinical Medicine/College Health – Most in Pre-hospital trauma/ER’s, Mental Health Review of literature Journal of Clinical Nursing 2007 Nurses critical event risk assessment a judgment analysis Nursing clinical judgment – need to take into account the quality and quantity of clinical expertise - recommend normative rules for revising possibilities Nursing needs to remove the rhetoric of “expertise” and “holism” and rely more on predictive validity, accuracy and competence in clinical decision making. International Journal of Nursing Terminologies and Classifications June 2008 Conceptualizations of Decision Making in Nursing,: “Analytic Models” and “Knowing the Patient” Journal of Clinical Nursing Volume 18 Issue 10, Pages 1490 - 1500 Published Online: 8 Apr 2009 While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses' decision-making process. This has significant implications for the political goal of standardization. The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses' decision-making processes in parallel to paying attention to the influence of context. Journal of Trauma, Injury, Infection and Critical Care Dec 2008 Purtill Triage tool - should be simple, easy to use, easily taught and high level of sensitivity and specificity. The tool - 93.8 sensitivity and 99.5 specificity International Journal of Clinical Nursing April 2009 Nursing Prioritization for the need for care: a tacit knowledge embedded in clinical decision making literature Lake/Moss/Duke Found Decision making as a non-sequential skill throughout unfolding patient situations and was a hallmark of expertise PEARL -----Know the competency of your staff, Develop Protocols that are simple, easy to use and apply, Monitor effectiveness/use

PEARLS of Triage and Treatment Vital Signs imperative Policy/Guidelines – follow documentation form Guideline resources abundant but not specific to college health Nursing judgment/clinical decision making - within the scope of practice of Registered Nurse if based on assessment findings and nursing guidelines

Other sources of Algorithms Institute for Clinical Systems Improvement www.icsi.org Flow charts and algorithms for triage Rapid Assessment A Flowchart Guide to Evaluating Signs and Symptoms Lippincott 2004 $45 Adult Telephone Protocols: Office Version (Spiral-bound) ~ David A Thompson $85 (Amer. Acad. Of Peds) Telephone Triage Protocols for Nurses Julie K Briggs Lippincott 3rd Edition $50 Emergency Severity Index, Version 4: Implementation Handbook Chapter 2. Triage Acuity Systems http://www/ahrg.gov/research/esi/esi2.htm (Adaptable ED acuity systems with Practice Cases) Validation of a Prehospital Trauma Triage Tool: A 10-Year Perspective Mary-Anne Purtill, MD, Kent Benedict, MD, Tina Hernandez-Boussard, PhD, MPH, Susan I. Brundage, MD, MPH, Kritaya Kritayakirana, MD, John P. Sherck, MD, Adella Garland, MD, and David A. Spain, MD The Journal of TRAUMA Injury, Infection, and Critical Care Volume 65 • Number 6 Tools that are burdensome or are difficult to understand may be rendered useless. To be effective, a trauma triage tool should be simple, easy to use, easily taught, and provide an appropriate level of sensitivity and specificity.

Culturally Competent Triage Assessment needs to include cultural/ethnic variations Example: Muslims may believe that sickness is a test from God, seen as a purification from sins and require a cure from God Students’ limitations in ambulation and communication and differentiation between acute and chronic neurological conditions are the main challenges in the triage of students with special needs and disabilities. Language Barriers – Use of interpreters – Time – use internet translators Google’s Language tools AltaVista Translator TTY/Deaf Awareness, sensitivity, diversity Cultural traditions are responsible for one’s experience, preferences, values and behaviors. ASSESSMENT IS KEY TO CULTURAL COMPETENCY Being culturally and linguistically competent is an assurance of the credo “do no harm” CLAS Standards Culturally and Linguistically Appropriate Services 14 mandates from Dept of Health and Human Services Office of Minority Health

Best Practices/Telephone Triage Document calls and the triage decision in the medical chart, indicating the protocol used and the advice provided. Use the caller’s own words to describe the reason for the call. Develop triage algorithms to assist the RN, NP/PA/Physician in appropriate documentation of telephone conversations. Develop a written policy defining the role and limitations of non-clinical or unlicensed staff, as well as specific symptoms requiring immediate attention. Review all telephone triage decisions for appropriateness of actions taken. Review all scheduling encounters for appropriateness and timeliness of appointments. Allow only qualified staff to provide telephone advice.

Examples of nurse initiated interventions to expedite care at triage may include: Administration of analgesia; antipyretics; oral rehydration; oxygen therapy Diagnostic testing: Rapid Strep or Flu, Blood glucose measurement; Urinalysis First aid (BLS, splinting, RICE, eye irrigation) wound management Self Care – OTC’s, Discharge instructions, education F/u care recommendations – when, why, with whom All nurse-initiated interventions should be in accordance with organizational guidelines and policies.

Gathering Statistics General lack of evidence based research in terms of Nursing Triage and Treatment outside of emergency rooms. Non existent in College Health No financial reimbursement for nurse visit Variety of scope of service across campuses Centrality to mission and goals of Health Services What information How to gather What to do with it May 09 - UFL colleague (Kat Lindsey) informal EHR Benchmarking study --- 20% without EHR Those that have are satisfied or very satisfied ~~ %75. Those with EHR ---How do you gather triage data??? Determine what you want to garner Measure the adherence to guidelines/protocols? Outcome of triage – predictive value of algorithms Scheduling effects – planning, resource allocation, justification for staffing

Pearls Nurses – Assessment and triage of students in college health settings is within the scope of registered nursing practice. Develop simple easy to use algorithms and base documentation on their use. Alter in the event of significant medical occurrence – Pandemic – create tools Maintain cultural competency Quantify and evaluate effectiveness Need to research and publish evidence based data in College Health Nursing Triage Encourage collaboration with Nursing Staff in creating Triage Protocols Chris Rooney BSN RN BC chris.rooney@millersville.edu