"Last week I received a call from a new father who was worried about his wife and two-week-old baby. Tearfully, his wife had confided to him that she didn't want to be alone-she was afraid that she might harm the infant," related Elaine Skleres, RN, MedStar telehealth nurse in Baltimore.

"In cases like this, initially your gut feeling tells you how to respond-I told him he definitely should not leave his wife alone, then assessed the situation according to protocol and provided crisis service telephone numbers," detailed Skleres.

MedStar Mission
At MedStar Health's (formerly Helix/Medlantic Health Group) 'Ask a Nurse,' Skleres and her RN colleagues routinely respond to questions like the troubled father's. In fact, on average, 1,000 callers contact the triage center during a 24-hour period, seven days a week. They seek medical advice, health care education and referrals for care, according to Sandra Dahl, MA, BSN, RN, program director.

"Ask a Nurse began at Helix when many similar programs were getting started across the country. There was a trend at the time," noted Dahl, who has successfully managed the service and guided its expansion since opening in 1990.

Staffed by 18-20 full time RNs, a similar number of part-time nurses and 15 non-nurses who provide administrative and marketing support, the nurse consultations are free to all consumers, not just those connected to the MedStar health care system.

Certain Temperament Required
"It takes a certain temperament to be a telehealth nurse. You have to be confident about your nursing skills and knowledge, have good verbal skills and like to teach. "Sometimes it takes ' hands-on nurses' a little longer to adapt," explained Dahl.

MedStar nurses, who all have three to five years of experience, come from varied clinical settings-medical-surgical, emergency, critical and ambulatory care and office nursing.

"Maybe it's a gift that we [telehealth nurses] have. What separates us [from other nurses] are the nursing skills that we use combined with our gut feelings and a keen sense of listening to the callers," said Skleres, whose previous experience includes coronary care, obstetrics and clinical research in vaccine studies.

"The pace can be very fast and stressful. Often we process a call in three to five minutes," noted Skleres, who explained that the nurses can view the number and nature of the calls on their computer screens. "The resource specialist takes the call first, codes it according to urgency and refers it to a nurse. The calls are matched with a nurse's area of expertise," she explained.

Responsive Listening
Although strict guidelines and medical protocols govern the nurses' actions, good assessment skills and nursing judgment are essential, explained Barbara Hamilton, RN, another MedStar telehealth nurse.

"You assess callers without seeing them, and you can't just depend on what they're telling you. You learn to listen for what they're not telling you. For example, I might ask a patient if he's short of breath and he might say 'no', but I can tell he is by listening to his prolonged responses to my questions," summarized Hamilton, an experienced coronary care, school nurse and home care administrator.

Standardized Procedures
"I've had a cough for five days. Should I see a doctor?" Typical of the calls received at 'Ask a Nurse' from those seeking medical advice, Hamilton explained that nurses follow protocols set up as decision trees to gain more information. One question leads to another prescribed question as the nurse assesses the caller.

The assessment completed and the caller's problem identified via a deductive process, the protocol outlines the appropriate action.

For example, an over-the-counter cough medicine may be the treatment of choice for the night until the caller can see his doctor in the morning. "I ask him [the caller] if he has allergies and if he's taking any other meds. If he's on a lot of meds, I would tell him to check with his doctor or the pharmacist," explained Hamilton.

Frequently, the caller is instructed to seek medical attention. If he doesn't have a physician, the nurses may refer him to an urgent care center or to a MedStar physician. 'Ask a Nurse' programs that function as triage services are credited with helping to decrease inappropriate emergency room admissions. However, if the nurse determines the caller's problem to be an emergency, she makes the 911 call.

Safety and Confidentiality
"The nurses' actions are based on organized, medical protocols and guidelines that are specific, direct, are nationally reviewed and modified frequently by our medical director. These guidelines protect the nurses," said Dahl addressing safe nursing practice in telehealth. Physician referrals, the computerized assessment record and documentation of the call further protect the nurses, according to the director.

'Ask a Nurse' calls are confidential, which the nurses must respect. They intervene and strongly encourage the individual to comply with the recommended action. However, if the person's situation may be potentially dangerous, the nurses use their judgment about making follow-up calls.

Ultimately it is the person's decision if he wishes to comply with the advice he receives. "You can only do so much," the three nurses echoed.

Educating Callers
The nurses have access to a vast library of health-related audiotapes that serve as a valuable resource for them and the callers who can be easily patched into a tape that they can listen to.

Assessing a caller's educational level and his learning needs is as essential for telehealth nurses as assessing physical and psychosocial needs, noted Hamilton.

"Recently, I instructed a person how to prepare saline nose drops as a comfort measure. It was someone who had minimal health care knowledge so I had to be very clear and spell it out carefully to make sure that he understood."

New Programs
In addition to the 'Ask a Nurse' program, four years ago the HelixCare Physican Network began offering an "after hours" call service to its patients. The telehealth nurses triage the calls and serve as a conduit between the patients and the physicians during the evening and on weekends. The network has been favorably accepted by patients.

"The patients and the doctors think this is a great service we can provide," said Dahl.

Recently MedStar initiated a telehealth service for mothers who deliver at any of the system's hospitals. Within one week post delivery, a nurse calls the mother to check how she and her baby are doing-offer assistance, answer questions, assess if there are any problems. This program, too, seems to be popular and provides a valuable service, according to the telehealth director.

"Through eight years in a rapidly changing health care system, our program has always provided a value-added customer service to both our internal and external customers," Dahl proudly summarized.*

Kay Bensing was a continuing education specialist and is a consultant to ADVANCE.

Telenursing Expanding Electronically and Through Certification

It's 9 a.m. and the 75-year-old woman with congestive heart failure (CHF), a Johns Hopkins Home Health Care patient gets ready for a nurse's visit. Chair-bound, the woman pushes a button on a television monitor a few feet away and instantly her nurse greets her from the screen. Welcome to the world of electronic health care!

Telenursing Expands
Until recently, telenursing usually meant nursing by telephone similar to the popular 'Ask a Nurse' programs. However, when health care systems and managed care companies realized the number of patients that could be reached with telephone check-ins, these programs mushroomed.

Today these same providers are experimenting with advanced technology to reach patients. For example, a patient's EKG, oxygen saturation, heart rate and physiologic parameters can be transmitted electronically from his home to a hospital or home care agency. Care via electronic transmission is still in its infancy, but its ability to reach patients in remote areas and to reduce costs will probably guarantee its expansion.

Doesn't Replace Nurse Visits
"Videoconferencing will not replace nurse visits," Amy Rader, BSN, RN, senior director of operations for Johns Hopkins Home Health service, in Baltimore, emphatically told ADVANCE.

An interactive nurse-based unit-equipped with 12 patient monitors-is being piloted on home care CHF patients, who have a high rate of recidivism, Rader explained.

Equipped with a blood pressure apparatus and stethoscope to monitor heart and lung sounds, the state-of-the-art system is connected to the telephone line in the patient's home. At the scheduled visit time, the patient activates the system.

Patients need to be taught the benefits of the system and to be assured that their confidentiality and privacy will be protected.

"They have a fear that we or big brother, can check in on them at any time," the director explained.

Tool in the Bag
Currently the Johns Hopkins distance care system, estimated to cost $150,000, has only two patients in the program. It has not been decided how frequently patients will be visited electronically. Pre- and post-hospital home care visits will not be replaced by this system, according to Rader.

"We know that there are applications for this technology and that it will improve patient outcomes. Currently we are trying to partner with interested companies to provide the service. There are two managed care companies that are interested.

"Right now it gives us a competitive edge. It's one more tool in our bag," the director candidly offered.

Endless Possibilities
"Once health care and related organizations understand the combined capabilities of nursing and telemedicine, the options are unlimited," wrote Loretta Schlachta, MSHP, RN, in Telemedicine '96 in the article "Telenursing Broadens Health Care Scope."

For the future, the author envisions monitoring systems set up at kiosks in malls, grocery stores, gyms and other public places. Individuals at risk for common health problems can be assessed and educational information disseminated to them at the site.

Regulating Telenursing
Telenursing is defined as the practice of nursing over distance using telecommunications technology, according to the National Council of State Boards of Nursing (NCSBN).

In its 1997 position paper on telenursing regulation, NCSBN made it clear that providing nursing by electronic transmission is nursing and thus should be regulated by the state boards of nursing. However, with managed care companies providing services to patients in multiple states, the question of regulation becomes more complicated. (See ADVANCE, Jan. 11, "Multistate Licensure Compact Proposes Protecting Practice Across State Lines.")

Credentialing for Telenurses
As telenursing expands and the number of nurses entering the specialty grows, there is a need for uniformity. Recently practice standards for telenursing have been published and are available through the American Academy of Ambulatory Care Nurses (AAACN).

To ensure competent practitioners, nurses are encouraged to become credentialed. In the near future, the American Nurses Credentialing Center will offer an exam in ambulatory care nursing. Telehealth nurses can qualify to take this exam, but it will include content that may be beyond the telenurse's practice domain.

A telenursing verification course, which includes an exam, is being developed and will be piloted this summer. Certification in telenursing practice is a future goal that those in the field would like to see.

-Kay Bensing, MA, RN