Safety of clinical and non-clinical decision makers in telephone triage: a narrative review

Patient safety is a persistent problem in telephone triage research; however, studies have not differentiated between clinicians' and non-clinicians' respective safety. Currently, four groups of decision makers perform aspects of telephone triage: clinicians (physicians, nurses), and non-clinicians (emergency medical dispatchers (EMD) and clerical staff). Using studies published between 2002-2012, we applied Donabedian's structure-process-outcome model to examine groups' systems for evidence of system completeness (a minimum measure of structure and quality). We defined system completeness as the presence of a decision maker and four additional components: guidelines, documentation, training, and standards. Defining safety as appropriate referrals (AR) - (right time, right place with the right person), we measured each groups' corresponding AR rate percentages (outcomes). We analyzed each group's respective decision-making process as a safe match to the telephone triage task, based on each group's system structure completeness, process and AR rates (outcome). Studies uniformly noted system component presence: nurses (2-4), physicians (1), EMDs (2), clerical staff (1). Nurses had the highest average appropriate referral (AR) rates (91%), physicians' AR (82% average). Clerical staff had no system and did not perform telephone triage by standard definitions; EMDs may represent the use of the wrong system. Telephone triage appears least safe after hours when decision makers with the least complete systems (physicians, clerical staff) typically manage calls. At minimum, telephone triage decision makers should be clinicians; however, clinicians' safety calls for improvement. With improved training, standards and CDSS quality, the 24/7 clinical call center has potential to represent the national standard.

Nursing responsibilities in preventing, preparing for, and managing epidural emergencies

An increasing number of women receive epidurals during labor and birth. Although the incidence of adverse reactions remains very low, the potential for life-threatening complications still exists. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) states that the safety of women undergoing procedures, such as the administration of epidural analgesia/anesthesia, depends significantly on the competence, attentiveness, and experience of those responsible for their care. The purpose of this article is to review the significant complications related to obstetric epidural. Recommendations are presented to aid the nurse in preparing for and managing epidural emergencies. Specific responsibilities of nurse managers and educators in competency training, evaluation, and guidance of nurses are also discussed.

Legal implications of fetal heart assessment

The standard of care requires perinatal nurses to perform fetal heart (FH) assessment competently and safely. Failure to adhere to established guidelines and standards for FH assessment may result in negative outcomes for the fetus or newborn and contributes to claims of nursing negligence. The perinatal nurse must be fully cognizant of professional guidelines and standards for FH assessment and comply with agency policies and procedures when conducting assessment of the fetal heart. Guidelines for FH assessment during the antepartum and intrapartum period are discussed within the context of restructured health care settings and today's medicolegal climate.

The process of triage in perinatal settings: clinical and legal issues

The process of triage in perinatal settings often has been considered the sole function of the labor and delivery nurse. In fact, all nurses have a legal and professional duty to engage in the systematic identification of patient-client problems, prioritization of needs, and prompt deployment of personnel and equipment to meet those needs. In-person and telephone triage occur in all obstetric ambulatory and acute care settings. The organized steps in triage should be identical regardless of the location or size of the perinatal service. The redesign of women's and neonatal services, the reduction of professional nursing staff, and predictions of a growing nursing shortage require perinatal nurses to develop highly refined triage skills.

Professional accountability and legal liability for the team leader and charge nurse

The rapid evolution in health care systems has significantly altered the roles and responsibilities of team leaders and charge nurses. Charge nurses and team leaders are responsible for promoting safe and effective patient care and maintaining high clinical standards in all settings. The Nursing Practice Act, state board of nursing administrative rules and regulations, and resources from professional organizations guide team leaders and charge nurses in these functions. Case law in recent medical malpractice actions also has affirmed the central role that team leaders and charge nurses play in preventing negative patient outcomes. The professional accountability and legal liability of team leaders and charge nurses in perinatal settings are examined. Effective strategies for reducing legal risk also are presented.

Consent and informed consent in perinatal and neonatal settings

It is commonly accepted in American law that an adult of sound mind has the right of self-determination, that is, the right to say what is to be done to his or her own body. This includes the right to accept and refuse treatment for most medical problems or disorders. During the perinatal period, the woman may be asked to submit to procedures and medications for herself and her fetus/ neonate. Nurses must be sure that patients or parents have given valid consent to any type of touching done in the course of nursing care. Furthermore, nurses must be certain that women have given informed consent to the certified nurse-midwife, nurse practitioner, or physician for any treatments or procedures that have inherent risks. The article defines and describes the concepts of consent and informed consent and examines the roles and responsibilities of perinatal nurses in these processes.

The perinatal nurse's role in obstetric emergencies: legal issues and practice issues in the era of health care redesign

The perinatal nurse is charged with providing safe and effective care in both routine and emergency situations. This duty arises from the states' nurse practice acts and American Nurses Association's Code for Nurses, and it has been affirmed by a growing body of case law. Current changes in health care systems have created new challenges for the perinatal nurse. In some instances, the transformations occurring in health care may actually hinder the nurse's ability to provide care when faced with an obstetric emergency. These changes do not, however, alter the nurse's affirmative duty to take some positive action when complications arise. The article elaborates essential nursing actions required when an obstetric emergency occurs within the context of redesigned maternity settings.

Perinatal group B streptococcal infections: the nurse's role in identification and prophylaxis

Group B Streptococcus (GBS) is a major cause of perinatal infectious morbidity and mortality in the United States. An estimated 50,000 women and 7,600 neonates experience GBS disease, and as many as 310 infants die each year. In 1992, the American Academy of Pediatrics published recommendations for identification and treatment of pregnant women colonized with GBS. In 1996, the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists developed more comprehensive guidelines. The article describes the central role of perinatal nurses in the identification of pregnant women colonized with GBS, patient education about GBS disease, and successful implementation of intrapartum GBS prophylaxis.

When cost-saving strategies are unacceptable

With health care redesign, nurses in every setting are challenged to provide more cost-effective care. While quality models for health care have been developed, nurses are at times asked to implement unsafe practices in the name of cost reduction or profit building. Both legal and ethical dilemmas arise when an emphasis on economic considerations supersedes patient well-being. Nurses must recognize their primary duty as patient advocates, and work to modify unsafe plans. The ANA's Code for Nurses and Guidelines for Reporting Incompetent, Unethical or Illegal Practices, and the Nursing Practice Act are primary resources in this effort.