| INTRODUCTION
Improper triage is a major factor in malpractice claims, making it critical for
any office staff member who answers the telephone, from the receptionist to
the optician, to be trained in recognizing possible emergencies and scheduling
patients appropriately. The importance of adequate training for this task cannot be stressed enough. Melvin Belli,
the notorious San Francisco plaintiff’s
attorney, once said, “In the eyes of
the law, the best doctor in the world
is only as good as his worst employee” (from Kasher, OMIC Claims
Manager. “Failure to Diagnose an
Eye Infection”, Digest, Winter,
1999).
Outside of the obvious legal implications, appropriate triage allows for
good patient care without creating a
“walk-in clinic” effect on the doctors schedule.
TRIAGE DEFINED
Triage is described as “a process in
which things are ranked in terms of
importance or priority.” There are
three categories of triage: emergency,
urgent and routine. If you think
about it, you “triage” everyday. For
example, picking up a suit at the
cleaners might be a routine stop on
the way home from work; but if you
plan to wear this particular suit to a
meeting tomorrow morning, getting to the cleaners would become urgent.
Now, let’s say the suit belongs to your boss and he plans to take it out of
town with him tomorrow. The trip to the cleaners has now become an
emergency.
In order to confidently choose the category in which the patient’s complaint fits, you must ask questions that relate to the following: onset, duration, severity and ocular/systemic history. Another factor that comes into
play is the perceived urgency of the patient. A complaint that normally
would be considered “routine” might be stepped up to “urgent” if the
patient is anxious or worried. Also, it should be standard procedure to give
emergency status to a post-operative patient with a real or perceived problem relating to the surgery.
| Questions Used to Determine
Appropriate Category |
| To determine: |
Ask: |
| Onset |
When did you first notice the
problem? |
| Duration |
How long has this problem existed? |
| Severity |
On a scale of 1 to 10, with 10 being
the worst, how severe are the
symptoms? |
| Ocular/Systemic History |
Do you have a history of past ocular surgery or trauma?
Do you have any current eye conditions, such as cataracts, glaucoma
or macular degeneration?
Do you have health problems, such
as diabetes, high blood pressure,
heart disease or migraine
headaches? |
| |
TRIAGE POLICIES AND PROCEDURES
Policies and procedures clearly instructing the office staff as to how the
doctor wants patients triaged should be in writing and reviewed with
every employee. Triage responsibilities of both staff and doctor should
be outlined.
| Staff and Doctor Responsibilities |
| Staff Responsibiites: |
Doctor Responsibilities: |
| Gather Information |
Establish written policies and procedures |
| Assign a category |
Provide adequate training to all staff members |
| Document the details of the call |
Encourage staff to come to him or her if there is any doubt as to when the patient should be seen |
| Follow office procedures in getting the information
to the doctor |
Review/sign off all triaged calls |
| |
In the same manner that retraining and recertification in CPR is required,
triage training should be a part of required continuing education in an
ophthalmic clinic.
Every new employee should review the office triage policies during the
first week of employment. New employees should never feel too intimidated to ask the doctor or a senior technician if they are unsure of how a
patient complaint should be categorized.
Staff must fully understand that only the doctor can diagnose and offer
treatment options. A staff member who suggests a diagnosis or treatment
is creating a liability risk and should be counseled. While it seems harmless to offer a patient a sample bottle of over-the-counter artificial tears,
staff must never give any eyedrops without a doctor’s order. In like manner, staff should never reassure a patient by saying, “you will not go
blind” or “the problem will improve.” Prognosis is always a doctor’s
responsibility.
Proper documentation of the telephone conversation with a patient is
as important as documenting the findings of an office examination. Recollections of what was discussed weeks and months later are unreliable
and open to dispute without notations in the patient’s record to back
them up. “Sticky notes” are not an acceptable method of documentation, as they can easily become separated from the chart. Documentation
should be accomplished in a manner, which makes the notes a part of
the patient record. A triage form, such as the sample provided in, is an
effective method of communicating and documenting the call. The form
can be printed on colored paper so it will stand out in the chart. If you
are using electronic medical records (EMR), there should be a method
of recording a triage call within the EMR program.
Communication can break down when a patient is concerned about a
potential eye problem. It is crucial for the staff member who is triaging the
call to have good communication skills. Listening to the complaint and
asking the appropriate questions help elicit cooperation with a patient who
may be very upset over his or her eye complaint. Repeating what the
patient tells you assures the patient that you heard the problem. Your tone
of voice should be confident, calm and reassuring.
The doctor may ask staff to phone in a prescription to a pharmacy. Documentation should include: medication name, strength, directions, amount
and number of refills allowed. In addition, it is helpful to document the
pharmacy name, phone number and the name of the person that took the
prescription order.
RED FLAGS
When discussing a patient complaint, you should be listening for “red flags”
that will help you in the triage process. The following discussion provides
information regarding the “red flags” of red eye and visual disturbance.
| |
Emergency
Required immediate attention |
Urgent
Schedule within
12 to 24 hours |
Routine
Schedule first available appointment |
| Red Eye |
Secondary to injury or if associated with severe pain; or if contact lens wearer with severe redness and pain |
Constant with additional complaints of itching, discharge or mild-modertate pain |
Intermittent, mild redness with no other symptoms |
| Visual Disturbance |
Sudden onset of painless decreased vision of vision loss associated with floaters,flashes, or “spider webs” |
Recent onset of double or distored vision; new development of floaters with or without flashes
and/or “spider webs” |
Gradual, progressive decrease in vision either at distance or near |
| Eyelid Complaints |
Blunt trauma causing swelling of lids |
Eyelid swelling with mild to moderate irritation |
Lid twitching/fluttering |
| Discomfort |
|
Acute light sensitivity; progressively worsening ocular pain; constant burning |
Intermittent, mild irritation, itching or burning |
| Tearing |
With severe pain and foreign body sensation |
With mild discomfort and foreign body sensation |
With no other symptoms |
| Broken or Lost Spectacles |
|
When refractive error is high and the patient does not own a backup pair of glasses |
Minimal refractive error or if patient has a backup pair of eyeglasses |
| |
Complaint: “My eye is red.”
Factors to consider: Onset, trauma, severity, presence of pain or foreign
body sensation, past ocular history and recent surgery
A complaint of redness resulting from trauma to the eye, such as a forceful blow with a fist or high-velocity object, a foreign body in the cornea or
the splashing of chemicals into the eye is an ophthalmic emergency. Eye
injury can be visually devastating; therefore, a patient with trauma must be
seen without delay. If the doctor is out of the office, arrangements should
be made for the patient to see the doctor on call or go to the nearest emergency room. A patient who calls the office to report a chemical in the eye
should be advised to irrigate the eye by holding it open under flowing
water for at least 15 to 20 minutes before coming to the office or an emergency facility.
Symptoms of a patient who claims to have “something in my eye”
include mild to severe pain, photophobia (light sensitivity), tearing and
increased irritation on blinking or moving the eye. The question, “What
were you doing when you first noticed the problem?” provides information as to the type and velocity of the foreign body. Knowing the speed at
which the foreign body entered the eye is very important
in determining the possibility of a ruptured globe or retinal damage. A patient with a metallic substance imbedded in the cornea could develop a rust ring if the metal
is not promptly removed.
Injuries are not the only cases of red eye emergencies.
A patient with a history of narrow angles (glaucoma)
should be brought into the office immediately if there are
complaints of red eye with pain. A patient complaining
of redness of the eye, orbital discomfort and swollen eyelids could have a potentially serious streptococci or
staphylococci infection called orbital cellulitis. Fever is
commonly present in cellulitis and the patient may have a
sinus infection.
Redness with deep-seated pain might be an ocular
inflammatory condition such as scleritis (inflammation of
the sclera) or iritis (inflammation of the iris). These conditions can be idiopathic (of no known cause), but are
commonly seen in patients with a history of connective
tissue disease. Scleritis is often bilateral and presents with
orbital pain, scleral edema and diffuse patches of redness.
Iritis, which is usually unilateral, is commonly described
as “stabbing pain” with severe photophobia. Redness in
the limbal area and a constricted pupil are common findings in iritis. Tearing may be present in both scleritis and
iritis. A patient with these complaints should be seen
within 12 to 24 hours.
The most common red eye condition with symptoms
of itching, tearing or discharge is conjunctivitis (inflammation of the conjunctiva), commonly referred to as “pink eye.” When
infected, the eye sometimes feels irritated and bright light may cause discomfort. The conjunctiva becomes pink from dilated blood vessels and a
discharge may appear in the eye. The discharge tends to be watery in viral
conjunctivitis and thicker white or yellow in bacterial infection, but this
distinction is not absolute. Often the discharge causes the person’s eyes to
stick shut, particularly overnight. The patient may complain of blurred
vision, which should clear upon washing away the discharge.
Allergic conjunctivitis is inflammation of the conjunctiva caused by an
allergic reaction. Patients with allergic conjunctivitis develop intense itching
and burning in both eyes. Although usually equal, occasionally, one eye
may be more affected than the other. The conjunctiva becomes red, and
sometimes swells, giving the surface of the eyeball a puffy appearance. A
patient with these complaints should be seen within 12 to 24 hours.
Red eyes in a wearer of contact lens could be as simple as mild irritation from dust under the lens or a
more severe condition, such as a corneal ulcer. It is very
important to advise the patient to remove the contacts
until the optometrist can evaluate the eyes. Any contact lens wearer with red eye complaints should be categorized as urgent.
It is not unusual for an upset patient to call the
office early in the morning with a complaint of “I
just looked in the mirror and saw blood on my eye.”
The best question to ask with this call is, “Does the
blood appear to be on the white part of your eye?”
A positive response to this question most likely indicates a subconjunctival hemorrhage (broken blood
vessel under the conjunctiva). A subconjunctival
hemorrhage of spontaneous onset is typically asymptomatic, however the patient may complain of a
“stinging” or “dry feeling” in the eye. There is no
recommended treatment for this condition; however
it is advisable to give the patient an appointment
within 12 to 24 hours to confirm the diagnosis.
An eye condition that has been present for several weeks or more is normally considered routine. Even though these conditions are not vision
threatening, the patient should be seen as soon as the schedule allows, usually within a few days or a week. Common routine complaints that involve
redness of the eyes include: red eye following prolonged reading or use of
computer and mild or intermittent redness associated with burning, stinging, itching or a “gritty” feeling.
Complaint: “I have blurred, distorted or double vision.”
Factors to consider: Duration, past ocular history, systemic history
A complaint of sudden, painless severe loss of vision is an emergency. In
many cases, the key to salvaging vision is early intervention; therefore it is
very important to bring the patient into the office immediately. This is
especially true in cases where
the patient reports floaters,” curtains” “spider-webs” or
flashing lights with loss of
vision.
A patient with changes in the
Amsler Grid or a complaint of
“straight lines look wavy” may
have developed macular
edema, which can be caused
by conditions such as macular
degeneration and diabetic
retinopathy.
Another condition that can cause lines to appear curved is central serous
retinopathy or CSR. CSR is more common in males between 25 to 50
years of age and seems to be associated with high degrees of stress. Whatever the cause of the complaint, the patient should be given an appointment for retinal evaluation within 24 hours.
A sudden onset of diplopia (double vision) can suggest a wide variety of
conditions ranging from myasthenia gravis (a condition that causes muscular weakness) to a dislocated intraocular implant. Many times a patient
who has blurred vision describes the problem as “double vision.” Questions should be asked to differentiate as to whether the vision is actually
double or only blurry. If it is determined the patient is experiencing double vision, an urgent appointment should be made.
An eye condition that has been present for several weeks or more is normally considered routine. Routine symptoms include: gradual onset of
decrease in vision at distance and/or near; blurred vision after prolonged
use of near vision; progressive “hazy” vision and/or problems with glare
in patients with cataracts.
SUMMARY
If there are doubts as to when the patient should be seen, the doctor
should be presented with all the facts and make the determination. It is
always best to err on the side of safety and general welfare of the patient.
In addition, if the patient is uncomfortable and/or extremely worried
about their condition, working them into the schedule promptly provides
for a good patient/doctor relationship. ■ |