1. Chris Rooney BSN, RN BC Health Services Millersville University of Pennsylvania

2.  Located in Millersville, Pa., 8400 students  3 miles from Lancaster City  1 1⁄2 hours from Philadelphia  2 1⁄2 hours from Washington D.C.  3 hours from New York City

3.  Staffing ◦ Full Time Medical Director - D.O. ◦ NP 1.75 FTE (12 mo and 9 mo) ◦ RNs 4.75 FTE ◦ Clerical Support 1.80 FTE (12 mo and 10 mo)  Visits per year 11,000  Hours 8a-5 p M-F  7 Exam Rooms Built 1968  Health Fee Funding

4.  Define Nursing Triage in the college health setting  Discuss treatment protocols after triage  Identify tools to expedite statistical analysis of triage and treatments small school style

5. Main Entry: tri·age Pronunciation: \trē-ˈäzh, ˈtrē-ˌ\ Function: noun 1 : the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors 2 : the sorting of patients (as in an emergency room) according to the urgency of their need for care patientsemergency room —triage transitive verb Merriam Webster Dictionary

6. Scope of practice - Direct Nursing Care Collaborative Role Health Educator Research/Consultant Advocacy Combining Triage with College Health Nursing

7. History taking with physical/mental/spiritual assessment with cultural competency Acute illness and injury care – chronic illness Health Education and Promotion – disease prevention Management and leadership of risk reduction, resources, facilities, environment, including safety, infection control, etc

9. Prioritization of services for individuals based on assessment and triage

10.  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

11.  State Board of Nursing Law Standard of Care ◦ National Council of State Boards of Nursing. https://www.ncsbn.org/312.htm https://www.ncsbn.org/312.htm ◦ Article 2, chapter 2  Medical Direction – what is your medical director comfortable with? ◦ Protocols/documentation ◦ Expertise of staff

12.  Case 1 ◦ Joe, 18 y/o male walks into your Health Center requesting an Albuterol Inhaler in no acute distress. 4:00 p.m. on Friday Afternoon before Spring Break. Providers – Physician, PA/NP – out of the building. Front Office staff and 2 RN’s

13. Literature Review of Protocols None specific to college health 2007 JCN -Clinical decision making 2008 IJN - Knowing the patient 2009JCN – Context vs protocols 2008 JTIICC – Triage Tools 2009 IJCN - Expertise

16. URI Assessment sheet

18. □ Agrees/Expresses understanding of POC □ F/U if persists or worsens ____________________ □ Appt with MD/DO/NP_________________ □ Social Distancing □ Home

19. Pandemic Influenza Triage Screening Tool 1.Has there been exposure/contact with anyone else with symptoms? 2.Is there a documented fever of 101 or higher? 3.Does the patient have any of the following: runny nose/nasal congestion, cough, sore throat? 4.Did the illness begin abruptly – how long present 5.Ongoing chronic illness? Diabetes, immunosuppression, asthma organ recipient, gastric bypass? 6.Difficulty breathing, severe N/V dark urine, fever more than 72 hours 7.Pregnant? 8.Does the student believe they need to be seen in person Yes to 1 and/or 2 – Follow Respiratory Nursing Procedure/Standing Orders Yes to 1,2,3, and 4 – less than 48 hours – same day nurse appt – Flu test and referral as appropriate Yes to 1, 6, 7, or 9 – Same day appt with provider Yes to 7 – consider immediate or ER Eval – clinical decision/symptoms

20. Telephone call at 11:00 a.m. from 21 year old female student, LeaAnn, reporting abdominal pain for 3 days. Slight nausea, right sided lower back pain, denies fever, (doesn’t have a thermometer.) Hasn’t been to class the last three days. States pain is so bad - can’t get out of bed. Can you ambulate? Can you get to Health Services?

21. The nurse asks more questions: VomitingNo Diarrhea No Dysuria Yes x 3 days LMP2 weeks ago - normal

22. What other questions are you going to ask before you determine course of action? Resource: Telephone Triage Protocols for Nurses Julie K Briggs Lippincott 2006

23. Appointment scheduled for assessment --- with provider if available/with nurse for triage.

30. UTI Flow sheet

31. GI/Abdominal Pain Flow sheet

32.  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

33.  Nursing Diagnosis?  Staffing?  Time?  Education  Mental Health  Chronic Conditions  Public Health Threat

36.  Create an assessment check list that when completed gives a numeric score that determines disposition.  Utilize the guide to determine disposition or treatment per standing order.  Does nursing already do that – mentally/experientially?  Do we have tools that are part of that system

37.  Centor Score – Pharyngitis Exudate Tender Nodes Fever >101 Absence of Cough None or 1 – symptomatic TX 2,3,4 – do Rapid Step + treat/- Consult Provider  Ottawa Ankle Rules  Pain in malleolar zone and one of:  Pain posterior 1/3 distal tibia/med malleolus  Pain distal Fibula/lateral malleolus  Inability to take 4 steps

40. 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 3 rd 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)

41.  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

42. 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.

43. 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.

44.  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

45.  Paper and pencil spreadsheet by the night nurse who “counted” the days activities. Monthly total/Yearly total Penetration rate? Utilization by individual students? Justification for resources?

46.  Encounter form   Demographic data  Diagnosis  Interventions and Disposition

48. Pros: Equipment on campus for test scoring Accurate data Included Penetration Good snap shot of Health Services Easy for staff to complete at end of visit Cons: Data – Scanned monthly – reports at end of term IT – physically cumbersome – carried across campus to scan Cost of Printed sheet/paper/HIPAA Change form – new form design/retool scanner/ Students hated completing the demographic portion of bubble sheet - SCANABLE PAPER FORMS

49.  Excel Spread Sheet – Concurrent use in Fall 09 with bubble sheets.  Outlook Scheduling – Started in Fall 2009 – prior had paper and pencil schedule ◦ No reporting capability ◦ Appt and treatment – not connected

50.  Interested in looking under the hood?

51.  Customized Scheduler with database - Asset management system  IT department configured Database with Open Source EMR  Web based – accessible from any PC on HS Intranet  Link the appt with treatment  Cost – IT support to configure/debug

52.  Discussion ◦ How do you quantify your nurse triaged patients? ◦ Do you evaluate effectiveness of your protocol? ◦ Satisfaction of students? ◦ Learning Outcomes? Other comments?

53.  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

54. Chris Rooney, BSN RN BC Millersville University Health Services chris.rooney@millersville.edu Thank you!