Telephone triage skills
Basic skills for the process of telephone triage
Telephone triage skills
The term "triage" (trē-äzh', trē'äzh') is a French word that literally mean "to sift". It became associated with clinical processes before the first world war, when a French surgeon Dominique-Jean Larrey (1766-1842) developed triage stations on the battlefield to sift wounded soldiers. Since then this process has been inextricably linked to the prioritisation of medical treatment i.e. A process for sorting injured people into groups based on their need for, or likely benefit from, immediate medical treatment. The first recorded example of telephone triage was in First documented telephone consultation by a GP (1879).
However it is only relatively recently that telephone triage has been recognized as a specialist nursing area. Just as face-to-face patient assessment requires particular skills, patient assessment by telephone can be even more challenging.
Today, telephone triage has become an essential part of the delivery of health care in Australia. The remoteness of many communities and the lack of access to medical services, has led to other staff being increasingly called upon to prioritise patients and provide interim advice. This manual has been designed to assist nurses and other health care personnel to understand and help them to master the complexities, challenges and skills required in this area.
Telephone triage is based on the premise that staff can provide advice about the context and timing of care to callers based on presenting symptoms. Supported by evidence-based guidelines, experience, training and knowledge, they would then:
- Interpret symptoms and answers to carefully structured questions to determine the severity of the condition
- Recommend patients to an appropriate level of health care or self-management or other health professionals/levels of care
Many countries (including Australia and New Zealand) have national telephone triage systems, usually nurse-led. The largest of these is in the United Kingdom (NHS Direct), where a system of nurse triage call centres have been established to provide health advice based on symptoms and health information to callers 24 hours a day and is linked to general practice. There are also large centres in South Africa and North America. In Australia there are a number of types of services, from those based in rural Emergency Departments, to well resourced call centres set up especially for this function, to general practices using formal and informal guidelines to advise patients about their health care options. In Australia services are set up in most states and territories and vary in size, operational area and ability to tie in with local medical services. There are also areas in Australia where general practice triage has been formalised. The RACGP through it's Standards for General Practice set out various requirements for practices to have identifiable triage systems and training.
The Limitations of Telephone Triage
During face-to-face assessment of patients, you can formulate a provisional diagnosis simply on the way the patient looks or sounds. There is an old saying concerning patients which says, ‘If a patient looks crook they probably are crook’. When assessing patients by telephone, you can only hear and talk to the caller; who may, in fact, not be the patient. This is why telephone triage has been described as "patient assessment wearing a blindfold", which is in some ways a very accurate description of the process and its unique challenges.
Our ability to make decisions about a patient’s condition accurately when carrying out telephone triage and advice can be restricted by several factors:
- The lack of opportunity to directly observe the patient
- Communication and/or language barriers
- The inability of the caller to accurately describe the situation/primary complaint
- The caller’s emotional state
- The assessors skill in asking and processing the appropriate questions and listening to the answers
Therefore those providing telephone triage and advice must therefore have the necessary knowledge, special skills and judgement to assess the health urgency of the patient, in spite of these limitations.
Due to these limitations, telephone triage is not design to arrive at a diagnosis but rather the context and timing of care.
Summary of Differences: Face-to-face Triage vs Telephone Triage
FTF: Assessment can be rapid – if the patient looks ‘crook’ they probably are ‘crook’.
TT: Information without the advantage of sight and touch can take a little longer and relies on other senses to create a mental image of the patient and critical think to sort out which information is relevant.
FTF: Conventional triage criteria using appearance and physical assessment to determine urgency.
TT: Assessment relies almost entirely on responses to questions i.e. ‘triage with a blindfold on’.
FTF: The patient has arrived in the place where care can be provided so the caregiver and patient relationship is established.
TT: Rapport, trust and roles need to be established with verbal communication.
TFT: The triage decision usually only relates to the time frame in which the patient needs to be seen. After this the patient just waits.
TT: The triage decision involves not only a time frame in which to seek care but where is the most appropriate care and what to do in the interim.
FTF: The patient is in a medical facility is therefore in a safe location and is reassured that they are being dealt with.
TT: The patient has made contact because of anxiety about a medical problem, may feel isolated, alone or vulnerable. Hence triage decision may be driven more by anxiety level of patient or carer.
FTF: The patient can be monitored easily and reclassified.
TT: The opportunity for reassessment is more difficult and may not yield additional information.
FTF: Relies on good observation skills
TT: Relies on good listening skills
Good Telephone Technique
There are certain elements of good telephone techniques that we all expect when we talk to a representative of an organization. Using these elements will mean that a patient feels that their problems are important to you, that you care about them and thus they are more likely to come away with a positive feeling about the encounter and recommend the service to others.
- A good listener
- Admitting mistakes
- Recognises limitations
- Apologise when appropriate
Bad Telephone Technique
By using bad telephone techniques the patient is more likely to become frustrated, angry or upset. In addition to this they are likely to tell many others about their negative experiences.
- Not accepting responsibility
- Blaming the caller
- Complaining about equipment/business
- Refusing to apologise
- Not listening
- Pretending to know
- Asking the caller to repeat details already stated
- Keep the caller waiting
Who is good at Telephone Triage?
Ever since the field of telephone triage was introduced there has been much debate over who it is that makes the best telephone triagist. In nursing it has always been assumed that the best nursing staff for this role were those with experience in emergency departments in a patient triage role. However as the field has developed, this criteria in isolation has become less important against other essential requirements. Indeed some emergency department staff make excellent telephone triage operators, (some individuals are just naturals at communicating and assessment over the phone) but some cannot make the transition to a new skill-set. So what is the criteria for a good triagist?
- Prior experience and training in triage, but more specifically telephone triage. This happens more frequently in rural settings where nurses become an intermediary between the patient and doctor and the local ED.
- Life experience is always beneficial in any vocation that involves interacting with people.
- Broad work experience, so that the general knowledge-base and patient types is wider. Experiences involving challenging patient assessment roles in isolation are particularly valued
- Ability to relate to callers of all ages and levels of understanding is an essential aspect. Not everyone has such high-level communications skills.
- Critical thinking is one of the most highly-prized skills, it is also difficult to initially assess and very difficult to teach. Telephone triage requires the ability to listen, assimilate, collate and prioritise many pieces of information. It involves common sense mixed with the ability to think on your feet. This can be critical to the success of any prospective telephone triagist. The tendency in face-to-face triage is for your mind to race ahead to a quick determination (provisional diagnosis) about where the patient should be treated and when, but in telephone triage a structured set of information must be gathered before deciding on an outcome and disposition or vocalising any gut feelings to the patient. Early decisions can create expectations in the callers mind and may, when an outcome is finally decided upon, contradict the initial advice to the patient leading to confusion and possible non-compliance.
- Team player behaviour is important in any workplace. This is especially true in telephone triage where a team that may consist of varying roles and responsibilities exists.
- Problem solving ability is the hallmark of a good triagist. Patients' presenting problems, their circumstances, availability of support and ready access to transport and services can differ greatly from caller to caller. Each of these combinations of issues can present unique challenges for the triagist.
Types of Callers
One of the exciting things about telephone triage is that there is always a variety of callers and patient problems. Male, female, elderly and very young, those with English as a second language and the hearing impaired. One of the most important factors in the effectiveness of telephone triage consultations is who in fact you are talking to. Callers are classified by how close they are to the patient, and fall into three categories: first party, second party and third party callers.
Let’s now look at the definitions and some of the advantages and disadvantages of each caller classification.
Caller who is also the patient
Caller who is with or near the patient
Caller who is not with the patient
First Party Callers are the best type of callers because you are speaking directly to the patient themselves. This has several important benefits in triage:
- There is no privacy issues with the information discussed.
- The most accurate information will probably be available from the patient themselves e.g. the parent of a 15 year old girl with abdominal pain may not provide an accurate response to a question like, “Is there any chance that she is pregnant?”. In this example, the patient herself is more likely to admit that she is sexually active.
- There are no difficulties or misunderstandings created by the relaying of information between caller and patient.
Second Party Callers are only the ‘second best’ callers because:
- They are often not able to appreciate the extent of patient symptoms e.g. level of pain, distress or anxiety.
- They tend to interpret rather than relay information.
- The process of relaying information between parties unnecessarily prolongs and complicates the call.
Third Party Callers are our least favourite callers as they are very difficult, if not impossible to triage effectively as:
- The information can be considered ‘hear-say’.
- There is no way the caller can observe the patient’s condition, ask them questions or confer with them regarding their wishes.
The goal in talking to Third Party Callers is to try and convert them to Second Party Callers or better still First Party Callers. Any patient 15 years or older is usually quite capable of talking about their own health issues. Sometimes there is no choice but to triage Third Party Callers when there is no practical way to convert them into Second or First Party Callers. In these cases you can only offer the best advice based on the limited information you have. However, without the ability to get adequate detail, outcomes for these patients may be toward higher levels of care.
Active listening is a specific communication skill, based on the work of psychologist Carl Rogers, which involves giving free and undivided attention to the speaker. Dr Kathryn Robertson in an article in Australian Family Physician, December 2005, outlines the process of active listening in the following article.
“Active listening skills are an extension of generic communication skills and involve both verbal and non-verbal communication. In some ways, active listening is characterised more by what is not done, than what is done. This is because real active listening requires the listener to avoid common responses when listening, even internally, and these are very difficult habits to break. In other circumstances many of these responses may be entirely appropriate, but in active listening these are commonly called 'road blocks'.
Judging, which may include: • criticizing • name calling or labelling • diagnosing • ordering • threatening • moralising • excessive/inappropriate questioning
Carl Rogers stated that the natural tendency to evaluate from the listener's own frame of reference, and approve or disapprove of what another person is saying, is the major barrier to successful interpersonal communication. He felt this was particularly the case when the topic was linked to strong emotions.
(Restating the feeling and/or content with understanding and acceptance) • paraphrase (check periodically that you've understood) • Reflect back feelings and content • Summarise the major issues away from the habit of labelling people by their disease, e.g. to refer to 'a person with epilepsy' rather than 'an epileptic'.
A person will usually have been pondering their problem for some time before they ring with it. If a solution seems obvious to the listener after only a short time, the chances are it is obvious enough to have occurred to the person with the problem as well. To suggest otherwise is an insult to their intelligence. Therefore the issues then become: have they already tried the solution? Presumably it has already failed? What factors led to its failure? If they have not tried the obvious solution, why not? What are the other factors about the situation that means they have decided not to proceed with the obvious solution? More active listening is needed!
A sign that suggesting solutions at this particular point is not appropriate is when the speaker starts to block the suggestions. This can be frustrating to both parties, and distract them from teasing out all the thoughts and emotions about the problem. Alternatively, some people simply 'shut down', outwardly appearing passive and compliant, but inwardly disengaged and resigned to not getting the help they really need.
Another type of 'roadblock' is avoiding the other's concerns by:
• diverting •logical argument • reassuring.
These roadblocks deny the person the opportunity to talk about their problems, or worse still, try to convince them that there really aren't serious problems, and they are foolish to be worried about them.
Avoidance can be conscious or unconscious. Sometimes people simply don't hear the cues, the requests to be listened to. But sometimes avoidance is a conscious choice. Perhaps the topic is too challenging to the listener, perhaps they simply don't have the time or energy to expend at this particular time. Perhaps they wish to remain in control of the conversation, to keep it in areas in which they feel comfortable.”
Active listening therefore requires:
- Full concentration
- Listening to how something is said
- Absorbing and interpreting non-verbal clues
Nurse: ‘So [name] the problem you are concerned about today is that your ingrown toenail in causing you some pain, is that right?’
Patient: ‘Yes’ (you now know the line of questioning to pursue), or;
Patient: ‘No’ (you have to get some more information, you may have missed something)
Types of Questions
There are several basic kinds of questions that are used in telephone triage to get information from a caller. One of the skills in telephone triage is to know when to use each type of question and also the skill to avoid certain forms of questions that may give erroneous responses. The basic types of questions:
Closed Questions – These are questions that require, simply a ‘yes’ or ‘no’ response. These are usually the type of questions that will give you the most accurate responses, because the caller has limited choice in response. Most decision support guidelines or algorithms are written, based on a series of closed question.
E.g. have you taken any pain relief medication?
Closed Compound Questions – These types of question are ones that should be avoided. In these questions the operator asks multiple questions but expects one answer in reply e.g. ‘have you got any chest pain, shortness of breath, nausea or vomiting?’ If the patient answers ‘Yes’ or ‘No’ you are still not sure what they have answered accurately to. Do they mean yes to all or only to the first two, etc, etc. As people usually only remember the first or last things you say, this type of question is fraught with difficulties. If you are going to ask a question, it must be only one question i.e. Do you have any chest pain? Do you have any shortness of breath?
Open Ended Questions – Open ended questions are those where you are asking for a response of more than a few words. They can be about general things or more specific detail:
"What did you think caused this?"
"Could you describe the pain?"
Open ended questions usually start with "how, what, where, who, why, when, tell me about".
Probing Questions - These questions are when you ask the caller for more information about an answer. They can be used to follow up on both open ended and closed questions. They can be used to gather more facts, to build rapport, to keep the other party talking or to gather specific information:
"When you first became ill what did you feel?"
"Can you tell me more about the fall?"
"How many paracetamol tablets did you take today?"
Leading Questions - Leading questions strongly imply or encourage a specific answer. If you want straightforward, valid and reliable information from a caller, leading questions need to be avoided, the purpose of the leading question is to:
Suggest the type of answer you want e.g. “you are not really worried about that are you?”
Lead the caller into a particular area e.g. “your abdomen is feeling bloated, isn’t it?”
Narrow a very open-ended question e.g. “was the pain sharp or dull?” (this only gives the caller two options to choose from, when the actual description of the pain may be another option)
Impose your opinion on the caller e.g. “are there any other symptoms you have which are worthy of seeing a doctor about?”
Negative Questions – these questions are both the easiest to ask and the most confusing to patients and operators. Negative questions are really a form of leading question, where the caller is often presented with a confusing negative question or even a double negative. An example of this would be the question: “you don’t have any chest pain do you?’’ With this sort of question, regardless of whether the caller answers “yes” or “no”, you are never quite sure what they mean. Think of this example from everyday life: you come into a waiting room or function and there are a limited number of spare seats available. You approach a spare seat and out of courtesy ask the person sitting beside it, “You don’t mind if I sit here, do you?” In response to this question most people (unless they are minding the seat for someone who is yet to arrive) will be happy for you to sit in the spare seat. However the way they communicate this to you will differ. The grammatically correct answer to this negative question is ‘no’ i.e. they don’t mind if you sit there, but some people will answer ‘yes’ and smile encouragingly for you to sit down. You know by their facial expression that they don’t mind but their words are contradictory.
In the above example the person was presented with a positive and negative in the same question i.e. you don’t mind [negative] if I sit here do you [positive]. And so it is best to avoid this kind of question because the reply can be hard to read.
- Combine the question with the reason – ‘I need you to feel if your baby is hot to touch’ [question], ‘Then we can work out how best to help him/her’ [reason]. Adults respond better if they know why they are being asked something.
- Give advice with a positive tone - people are more likely to comply with advice or instructions if the speaker sounds confident that this is the correct advice.
- Use the caller name – this is a very basic and well-used way of gaining the trust of a caller. This technique has been used by used car salesmen for years to trick clients into buying a car they don’t really need. The psychology behind this taps into very basic human behaviours. The brain on hearing its name makes an automatic association with friends, loved ones and therefore trust. Thus a rapport can be built very quickly in the absence of any previous relationship. Callers can even be a little flattered when someone remembers their name throughout a conversation.
- Never be rude – using a request like, “Just calm down” doesn't work and may lead to an angry caller.
- Answer quickly - don’t put callers on hold too often or at all if this can be avoided, apologize for delays
- Identify yourself – use a script for greeting e.g. good morning/afternoon, this is (name of business), my name is _______, how can I help you?
The Story of the Horse
Years ago the only way to get a horse ready to be ridden was to ‘break’ it. This was a rather traumatic process for both the stockman and the horse. The process is still carried out today, however more and more, the technique of ‘horse whispering’ is being used as a quicker and gentler alternative. I remember watching this process demonstrated during a documentary about the subject and I was astounded by the speed at which a training handler could take a ‘wild’ horse that had never been ridden and have it ready to accept a saddle and rider within 1 hour! How does this happen so quickly and without the usual bucking and kicking and bruises? The answer lies in the horse whisperer discovering what motivates a horse. A horse if tied up and hit often enough will learn eventually that doing something that the stockman doesn't want will result in discomfort. However this process of learning, correcting negative behaviours is a very slow process. If discomfort and punishment aren't the best motivators for horses what are? It turns out that the worst thing that a horse can experience, which is far worse than the techniques used in ‘breaking’, is to be excluded from the herd. This fact is what makes the difference in ‘horse whispering’.
How does the whisperer use this knowledge; well, he starts in a yard with the horse, letting him move around freely and getting used to the trainer’s presence. The trainer is very careful to make eye contact with the horse. Very gently a piece of cloth on a stick is gradually introduced to the horse by the trainer, making contact between horse and cloth, so the horse can get used to its texture and smell. The horse of course is initially put off by this gesture and frequently tries to move away. In response to this, the ‘whisperer’ immediately averts his eyes from the horse and turns away from it. Horses, not being very smart, can’t count legs, so it perceives the ‘whisperer’ as just another strange looking horse. And the gesture made by the whisperer is interpreted by the horse as being excluded or shunned by the herd. In response to this, the horse seeks out the whisperer, hoping to be accepted back. The whisperer tries again to familiarize the horse with his smell and touch, the horse backs away and the same process is followed, with the identical response by the whisperer and horse. This continues on until by the time the 60 minutes is through, the horse has been saddled and will happily accept a rider without bucking and kicking!
The question you may be asking at this point is what does this have to do with telephone triage? Well except for some exceptions, people are more intelligent than horses. When speaking to people, whether it is face-to-face or over the phone, we tell them more in how we say something than the words we use to say it. Callers, like horses can tell what we really think about them by our tone and manner. They are quick to sense you are empathetic and just as quick to sense that you aren't feeling helpful.
When faced with an abusive caller, the best strategy is to adopt a strategy called a ‘detachment’. In this technique, you listen to the caller’s words without hearing or reacting to the insults. In other words you become detached from the caller’s emotion.
When using this technique, the important things to remember are:
- The caller doesn't know you, so the emotional attack directed at you is not personal.
- The caller’s behaviour would probably be similar regardless of who answered the phone and spoke to the caller.
- The caller has called to ask for help, so listen carefully for the message rather than the way in which it is delivered.
Remain calm and do not raise your voice as raising your voice attaches you to the call. Aggression leads to a rise in the pitch and volume of the voice. Therefore if your voice rises in pitch and/or volume in response this may be perceived by the caller as aggression also.
The caller’s social situation may have a bearing on their present demeanour. How long has it been since they slept? Have they tried ‘everything’ already? Is this call at the end of a long and frustrating process to get help and advice?
The greatest motivation for aggression is fear. Keeping this in mind may help you to deal with the aggression directed toward you.
The Mirror Principle
The “mirror principle” is a technique that can be used equally to defuse or escalate a tense or aggressive situation. When we join in with the aggressive person and raise the pitch and tone of our voice in response to theirs’, the tone, loudness and severity of our speech, will be reflected back to us by the person we are attempting to communicate with. Not only will it be reflected but may indeed be magnified by the person. This process of reflection and magnification can lead to an escalation in the situation.
However, this principle can also be used to our advantage if we reflect back a lower level of agitation, i.e. lowering the pitch and tone of our voice. This then can result in the agitated person decreasing their level of agitation or aggression.
If a caller becomes angry or upset, it is very easy to become emotionally involved. Anger expressed toward us is often taken personally and quickly invokes anger to build up inside us, which can affect the way we listen and how far we are prepared to go in helping the patient. A natural reaction when faced with an angry patient or caller is to reduce our level of help to what we are required to do, rather than going that extra mile. If you find yourself arguing with a patient, you have gone too far and you need to hand the patient to someone else.
- Don’t take aggression personally – patients are venting their frustration with anger, you just happen to be the ‘poor bunny’ that picked up the call. Reacting calmly takes practice but is the best way to diffuse a tense situation.
- Allow the patient time to vent – people just want their gripe heard and will run out of steam as they bring out all their ‘trump cards’. Of course, if the patient becomes personally abusive then the patient must be told immediately that this is unacceptable.
- Focus on the problem rather than the exchange – focusing on the problem is far more productive, it brings the patient back on track and enables you both to move on.
- Apologise when appropriate – apologies don’t necessarily mean you are admitting fault or weakness. You can apologise for the patient’s bad experience, or that they feel unhappy with the service, or that they have had to wait for so long to be answered.
- Recognise and acknowledge the patient’s feelings - the feelings that a patient has, well founded or not, are real to the patient e.g. ‘I understand that you must be feeling really tired’.
- Refer the patient on to someone else – if you are becoming upset or angry yourself, or the conversation is going nowhere, it is time refer the patient to someone else who can look at the patient dispassionately.
Practices to Avoid
- Stereotyping callers
- Stereotyping problems
- Lack of critical thinking
- Failure to identify the caller’s expectation or agenda
- Not allowing enough time
- Allowing too much time
- Ad-libbing questions
- Creating expectations
- Insufficient information or scrutiny
- Second guessing
- Taking caller anxiety or frustration personally
- Inadequate documentation of information and advice
- Failure to consult when required
Only a very small percentage of patients will actually complain about the service they have received. Some suggest that we never hear from 96% of our unhappy patients. For every complaint made, many other patients will have had the same problem. Patients have long memories of bad encounters. The average unhappy person may remember the incident for 23 years, whilst they will only talk about a pleasant experience for only 18 months. Therefore, it is really important that patients making complaints are not ignored or dismissed; their concerns are listened to, reported and acted upon.
What Do You Do When Someone Complains?
Here are my ten steps for handling a complaining patient:
Say "I'm sorry." These should be the first words out of your mouth. It costs nothing. It isn't admitting fault. You're just sorry they are feeling inconvenienced. These are the most powerful words you can speak to a complaining customer.
Honour their perspective. Even if their position is clearly off-base. Their perspective is their reality, and must be honoured.
Don't get defensive. This will only make things worse for you and for them. Resist the urge to protect yourself.
Don't make excuses or argue. Nobody ever won an argument with a customer. Even if you "win" and prove you are right, you lose.
Fully understand the problem. Ask questions and repeat back what you think you've heard. Make sure everything is crystal clear.
Tell them what you're going to do next. Seeing you take immediate and logical action will help them feel handled competently.
Tell them when you'll get back to them. Don't leave them hanging and stressed about the problem. If they know exactly when you'll be getting back to them, they will feel handled well.
Thank them for bringing the concern to your attention right away. You especially want to do this with the little things, so they'll keep bringing them up, rather than silently going to the competition.
Resolve the problem quickly. Studies indicate that the faster you resolve problems, the less damage is done. Don't let jackpots sit unresolved.
Follow through and follow up. Make sure all residual emotions have been cleaned up.
Bill Cates 1996
Dependant on the symptoms and the answers to the triage questions, there can be a wide range of outcomes from telephone triage. Outcomes may include:
Dial an ambulance on 000 immediately
Go directly to your nearest emergency department
See a doctor within 4 hours
See a doctor within 12 hours
Schedule an appointment with a doctor in 1-3 days
The result of the telephone triage process is that the patient is provided with:
- A definitive piece of advice about the medical care needed.
- A time frame for the recommended level of care to take place e.g. within the next 2 hours, immediately, within 24 hours.
- A disposition i.e. where and how the recommended level of care and time frame will be met. This will depend on where the patient is, the location of services and the availability of services at the time of the call e.g. a caller who rings at 11 pm on a Sunday night has less options available to be treated if required therefore although the recommended level of care may be suggested as within the next 4 hours, the only disposition available may be an emergency department. Alternatively if the patient rang on a weekday at 11 am there would be other ways to meet the recommended level of care, so the disposition may be different.
- A consideration as to the most appropriate transport method. Is it safe for the patient to drive themselves if they are suffering from dizzy spells or visual problems? This transport consideration may change the disposition.
- Advice on how to manage the problem at home or until medically assessed. These should be based on clinical best practice.
- Information about how to recognise that the condition is worsening and what to do if it does.
If unsure about the disposition, it is better to go with the higher disposition, or at least to get someone to look at the patient to assess the things that you cannot over the phone.
Australia is becoming an increasingly litigious society and as with any medical advice and consultation, telephone triage is subject to the same vulnerability as other medical services. Australia has not yet seen a significant amount of legal action in relation to telephone triage, despite the processing of hundreds of thousands of calls. There are some principles that should be followed to help protect from this sort of legal action:
- Control the call and listen carefully to the caller
- Use approved guidelines to maintain a standard of care
- Document the call and advice provided.
- Document any variations to the disposition
- Provide the caller with advice as to what action to follow if symptoms worsen
- Avoid medical jargon
- Talk directly to the person who is ill
If you would like further information about triage training in your facility, please contact Medics for Life
Copyright - Medics for Life 2016