1. College Health Nursing – Pearls of Triage, Treatment and Stats
Chris Rooney BSN, RN BC
Health Services
Millersville University of Pennsylvania
Welcome
Handouts – sign 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 students ?
10000 to 20000
5, ?
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

2. 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

3. 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 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?

4. Baseline considerations
State Board of Nursing Law
Standard of Care
National Council of State Boards of Nursing.
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

5. 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 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 Purtill Triage tool - should be simple, easy to use, easily taught and high level of sensitivity and specificity The tool sensitivity and 99.5 specificity
International Journal of Clinical Nursing April 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

6. 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

7. Other sources of Algorithms
Institute for Clinical Systems Improvement
Flow charts and algorithms for triage
Rapid Assessment A Flowchart Guide to Evaluating Signs and Symptoms Lippincott $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
(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.

8. 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 mandates from Dept of Health and Human Services Office of Minority Health

9. 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.

10. 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.

11. 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 UFL colleague (Kat Lindsey) informal EHR Benchmarking study % 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

12. 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