Telephone Advice: Is it Safe?


By Pat McLean, CNPS Executive Director

Telephone advice in health care is always risky. Until the last few years practitioners - with a few exceptions such as poison control personnel - were generally warned not to give telephone advice to anyone. The possibility of harm resulting, and of a lawsuit against the health care provider, was just too great a risk.

Then why are many health care professionals now doing this? And what has changed? Shorter hospital stays now mean many who were formerly dependent on health care professionals are having to cope at home with minimal support. As a result, there is a growing public need for telephone advice and information. Many health care agencies are looking at ways to meet this demand.

Technology is also a factor. In a world where people are getting medical questions addressed on the Internet and where more people communicate by voice mail and e-mail, there is greater consumer expectation of an instant response. Telephone advice is considered a cost effective way to provide care, provided the risks are adequately managed.

What are the risks?
A patient may suffer harm (and may sue) as a result of inappropriate advice based on an inaccurate assessment; inappropriate advice due to lack of appropriate knowledge on the part of the responder; improper referrals (causing treatment delays); or failure to refer.

In a recent Ontario case, where a baby died from dehydration due to problems with breastfeeding, and the lactation consultant's follow-up with the first-time mother was exclusively by telephone, one of the recommendations of the coroner's jury was that "evaluations over the phone should be discouraged because of the potential for miscommunication."1

Once you accept a phone call and enter into a discussion with a client, you are legally accountable for what you say and for what you omitted to say, because the person speaking to you is relying on your special knowledge and expertise. It is important to always keep the purpose of this service in mind: it is to advise, educate and/or assist clients to make the best health care choices, it is not to diagnose. Nurses providing telephone advice are expected to identify the problem, assess the level of risk, and refer the caller to the appropriate resource.

Risk factors
Some of the risk factors that make assessment more difficult by telephone include:

  • The inability to visually assess callers. Many of the assessment skills you have been trained to use are based on visual clues or observations. The nurse on the phone is essentially blind and handcuffed, able to use only the senses of hearing and speech to make an assessment. 2
  • Callers may not give you accurate information. Many lay persons, due to their lack of understanding, may tell you things that are not true, but which reflect their feelings about how it seems to them.
  • Callers may not give complete information. If you are only getting part of the picture, your assessment of the situation is likely to be inaccurate.
  • Callers may give information that is grossly misleading and does not truly reflect the problem. They may focus on irrelevant things and omit key information. For example, a person who had just tried to hang himself called a nurse in a hospital emergency unit complaining of, and seeking advice for, a sore throat. The nurse told him to come in and see the doctor in the morning.3  
  • The caller may not be the person with the problem. They may put their own interpretation on what is happening. They may avoid telling you things they find embarrassing to discuss, for social or cultural reasons. They may not know the relevant information, if the person with the problem has not told them, or if they can't see it.

    In Poole Estate v. Mills Memorial Hospital,4 the husband of a diagnosed depressive called the emergency room because his wife had taken an overdose of antidepressants. His only question was, "What would happen if someone took six 50 mg. tablets of imipramine?" He grossly underestimated the amount she had taken (over 80 tablets) and did not take her to the hospital until it was too late because he thought she would be embarrassed if people in the community found out about her illness. The nurse taking the call took it only as a request for drug information because of his matter-of-fact tone. The court held the husband 70 per cent liable and the nurse 15 per cent liable for failure to pursue the matter further.
  • You may not ask the proper questions to accurately assess the situation. A great deal of skill and experience is required. An example is where a nurse failed to ask about symptoms of dehydration when a mother contacted a facility regarding her seven-week-old infant's diarrhea and vomiting. The child died later that night.
  • Callers may not be who they say they are, out of embarrassment or fear of punitive consequences. They may say they are a friend or a distant relative, when it is they who have the problem or who caused it.
  • There may be language problems that may or may not be apparent. You cannot see the callers' expressions when they don't understand you.

Studies have shown that the most common nursing pitfalls in giving telephone advice are: using leading questions instead of getting callers to describe symptoms in their own words; using medical jargon; collecting an inadequate amount of data; not talking to callers long enough to get to the root of the problem; jumping to conclusions; stereotyping callers or their problems; failing to talk directly to the person with the problem; accepting callers' self-diagnosis; second-guessing callers; over- or under-reacting to the information given; and language barriers.5 

It is important to recognize that most risks can be managed, at least to a certain extent. The evidence of nurses working in poison control centres and providing well-child care over the phone in public health has shown that telephone advice is a safe and effective way to help people make decisions about their health needs, provided it is offered by well-prepared nurses supported by appropriate agency policies and resources.6 

Protocols and policies
Standardized written protocols or guidelines should be established to deal with calls to assist in ruling out the most serious conditions first, indicate at what point patients should be advised to see their physician, and ensure consistency of information given. To just "wing it" is unsafe practice. Telephone nurses should work toward development of a standard questionnaire that elicits the most information in the least amount of time.

Care should be taken by employers to ensure nurses taking calls have the specialized knowledge, skill and experience necessary to advise callers appropriately. Nurses' licensing bodies have determined that registered nurses have the necessary preparation to carry out this role, but each agency needs to have policies in place that indicate who may provide telephone advice and under what circumstances.

Policies need to take staffing needs into account and recognize that a considerable amount of time may be needed to deal with telephone calls if staff are to accurately assess the situation and give appropriate responses. It would be better not to take calls at all than to take them in haste.

Taping is not a recommended policy. Taped information is difficult to store and retrieve safely and effectively. Information may get taped over. Information that should be routed to a patient's chart will not be. Once a lot of tapes are recorded, retrieval and identification are virtually impossible, and taped information is not as reliable as a written document as evidence in court.

Policies should be in place to ensure every call is documented and standard information gathered. Your standardized form of telephone log should record:7 the date and time of the call; the time the call ended; the name, address and phone number of the caller; the data provided by the caller; the advice or information given, including symptoms you have asked the patient to call back with; the referral and follow-up information given; and name and designation of person taking the call. These telephone logs should be retained along with other confidential medical records.

There should also be policies governing confidentiality. This is an issue because you cannot always be certain to whom you are speaking. These policies should address the need to protect the confidentiality of callers' or patients' health information from persons outside the agency such as family or police, who should not be contacted without callers' consent, provided they are adults. Policies should include reference to legislation that requires reporting alleged or suspected abuse of children or persons in need of protection, so that staff are clear on their legal obligations.

Risk management tips
Seek clarification if you do not understand the information given. Do not make assumptions when a person mispronounces something or does not know the appropriate terms. It is important to delve further if there is conflicting or ambiguous information given. "He can't breathe" could be anything from a stuffy nose to acute respiratory distress. Obtain callers' names and phone numbers first, in case they panic and hang up before completing their story or you need to call back. Let callers hang up first to avoid cutting off any delayed information or questions. Close by letting callers know what you will be doing, if anything. Tell them you will not call back; they need to call you again if the situation changes or they have further concerns.

Some Canadian professional nurses' associations have published guidelines on telephone advice. The Canadian Nurses Protective Society also has a telephone advice infoLAW bulletin available free of charge. For further information, call 1-800-267-3390.

References:

  1. Coroner's Explanation of the Verdict of the Jury at the Inquest into the Death of Clare Azzopardi, February 10-14, 1998, Ontario
  2. Quilter Wheeler, S. in Telephone Nursing Telezine, Ed. Kathi Webster.
  3. Jenkinson, S. Telephone Advice: Should You Be Giving It?, Telemedicine, 13 January, 1998
  4. Poole Estate v. Mills Memorial Hospital, [1994] B.C.J. No. 635, DRS 95-07912, Kamloops Registry No. 17664
  5. Quilter Wheeler, S., Windt, J. Telephone Triage Theory, Practice & Protocol Development, Delmar Publishers Inc., 1993
  6. Mass, H. Telephone Advice, Nursing BC, January-February 1998
  7. infoLAW, Vol. 6, No.1, September, 1997, Canadian Nurses Protective Society

Note: This article has been reprinted with permission from the Canadian Nurse, September 1998.

All articles appearing in this section are for information purposes only and should not be construed as legal advice. Readers should consult legal counsel for specific advice.

Addendum:

The Telephone Advice infoLAW bulletin was revised in 2009.

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