28.4 Triage, Urgency-Based Scheduling, Patient Flow & Telephone Management

Triage by symptom

The blueprint names "schedule appointments based on degree of urgency." Urgency is determined by symptoms, not by how upset the caller sounds or how insistent they are.

See now — same day, immediately:

• Chemical splash — irrigate at home or at the nearest tap immediately and come straight in
• Suspected penetrating injury or high-velocity trauma — shield, nothing in the eye, come now
• Sudden painless loss of vision in one eye
• A curtain, shadow or shower of new floaters, especially with flashes
• Severe eye pain with nausea, vomiting and haloes around lights
• Post-operative or post-injection increasing pain with decreasing vision
• Headache with jaw claudication or scalp tenderness in a patient over 50
• Proptosis with fever, restricted eye movement or reduced vision
• New double vision with a droopy lid and a large pupil, or with other neurological symptoms
• Hyperacute copious purulent discharge, or any conjunctivitis in a neonate

See today or tomorrow:

• Corneal foreign body or abrasion
• Contact-lens-related red painful eye (always urgent — assume microbial keratitis)
• Acute red painful eye with photophobia
• New diplopia without other neurological features
• Sudden onset of floaters without a curtain
• Lid swelling without proptosis or motility restriction
• Blood in the front of the eye after trauma

See within a week or two:

• Gradual blur, gradual change in glasses
• Chronic red eye, dry eye symptoms
• Long-standing floaters unchanged
• Lid lump without change
• Routine post-operative review

Routine:

• Screening examinations, routine glaucoma and diabetic reviews, spectacle updates

The triage questions

A short, fixed set of questions establishes urgency in under two minutes:

1. What is the problem, in your own words?
2. One eye or both? (Ask them to cover each eye and check.)
3. When did it start, and is it getting worse?
4. Is there pain? How severe?
5. Any injury or chemical exposure?
6. Any flashes, new floaters, or a curtain or shadow?
7. Any loss or change in vision?
8. Any headache, nausea, weakness, numbness or difficulty speaking?
9. Do you wear contact lenses? (A red painful eye in a lens wearer is urgent until proved otherwise.)
10. Any recent eye surgery or injection?

The two questions that change the most outcomes are the contact lens question and the curtain question, because both identify sight-threatening conditions that patients frequently downplay.

Telephone management

Telephone triage is high-risk because you cannot see the eye.

Rules:

1. Identify yourself and your role. "This is Sam, one of the ophthalmic technicians."
2. Verify the caller's identity and their relationship to the patient before disclosing anything. Confidentiality applies on the telephone exactly as in person.
3. Gather symptoms systematically using the triage questions.
4. Do not diagnose. "That sounds like conjunctivitis, just use some drops" is outside scope and has missed angle closure and microbial keratitis.
5. Do not give prognosis or interpret results over the phone.
6. When in doubt, bring the patient in. The cost of an unnecessary visit is far lower than the cost of a missed detachment.
7. Give clear, specific instructions — where to come, when, what to bring, whether to arrange transport because they may be dilated.
8. Confirm understanding before ending the call.
9. Document immediately.

Documentation of a call must record: date and time, who called and their relationship, the symptoms reported, the advice given, the urgency assigned, the appointment offered, whether the patient accepted, and the name of the person taking the call. A call where the patient declines the advice must record the advice, the refusal and the fact that the risk was explained.

Escalation: any call where the symptoms meet the see-now criteria, where the caller is distressed and you are uncertain, or where the patient is deteriorating despite treatment, goes to the clinician — not into a callback queue.

Prescriptions and messages to pharmacies

Delivering patient prescriptions to a pharmacy by phone, fax or electronically is a named task. Read back the drug, strength, form, eye, frequency and quantity to the pharmacy and have them confirm. Spell drug names that sound alike. Record who you spoke to, the pharmacy, the time and the exact content. Never transmit a prescription that you have not been explicitly directed to send, and never alter one.

Coordinating patient flow

A well-run clinic is largely a scheduling problem, and the technologist's decisions determine whether the clinic runs.

Sequencing rules that prevent rework:

Practical flow measures: instil dilating drops early so the pupil is ready when the clinician is; run the tests that do not need dilation during the 20-minute wait; batch patients who need the same instrument; tell patients how long each stage will take and update them when it changes; and flag the patient who has been waiting longest before they have to ask.

Keep the clinician informed. If a patient arrives with a symptom that has changed since booking — a routine glaucoma review who now describes a curtain — the appointment type changes, and that must be communicated before the patient reaches the front of the queue.

Documentation of flow events: arrival time, drops instilled and when, tests completed, and any delay explained to the patient. When a complaint about waiting arises later, that record is what shows the patient was kept informed.