It’s Been A Journey. Sheila Quilter Wheeler had no intention of pioneering a new nursing subspecialty.   While managing advice calls as an ED nurse, she suggested guidelines for the process, her new mission — find solutions by developing this remote nurse triage clinical practice.

Initially, she suggested two books by physician-authors Vickery, Fries and Pantell to management, for the lay audience.   Still in print, these resources contain instructions for assessing, triaging, first aid and home treatment for common adult and pediatric symptoms.

In the early 1990’s, telephone triage was an embryonic field, fraught with uncertainty.  Many nurses were worried about their licenses -- anxious to know how to practice remote triage safely.

As a clinical call center advice nurse, Wheeler developed and taught an in-house telephone triage class. The training syllabus gradually evolved into a book proposal. The proposal was subsequently accepted by Delmar Publishers after nine publisher rejections.

Wheeler and medical writer, Judith Windt completed the training manual, including real-life case-study audiotapes in 1993,

Due to the ongoing scarcity of pre-existing research, Wheeler extrapolated, applied and relied upon research from foundational clinical subspecialties.

From 1993-1995, Ms. Wheeler served as Editor-in-Chief, directing a 23-member expert Nurse Task Force developing the first and only three volume, specific age-based, five-level triage guidelines. Ms. Wheeler served as founder of the first national Telephone Triage conference.

From 1995-2003 she served as an expert witness on 35 malpractice cases, gradually noticing patterns of recurrent error (Atul Gawande, MD). She began devising solutions —safety prompts — integrated into clinical training, the guidelines and new rules of thumb.

It Took a Village Ms. Wheeler, colleagues, nurse-consultants, and a team of of 23 + Nurse-experts and three physician-reviewers developed a complete remote nurse triage system.

Two nurse legal experts —Barbara Siebelt, RN, MSN, and Laura Mahlmeister, RN, PhD. emphasized the importance of having a "paper trail" should malpractice arise — written evidence of a complete system to bring to court — representing the effort to fulfill the “duty of due care”.

In “From Novice to Expert” Pat Benner, RN, PhD developed the concept of nursing expertise. Ms. Wheeler adapted the concept to the emerging practice. Carolyn Smith Marker, RN, MS, nursing standards expert, recommended specialized standards.

Robert Smith, JD, advised that remote triage system components be integrated, cautioning against having “just bits and pieces". He added that each component served as a “layer of protection” — “an overcoat for safety”, working together.

Jeff Clawson, MD, Pioneer of 911 - Emergency Medical Dispatch, served as Ms. Wheeler’s mentor, paving a path with his training manual, rules of thumb and devotion to patient safety. Ms. Wheeler followed suit with training manual, training, standards and triage tools

Remote Triage Research

Researchers discovered that nurses relied on symptom pattern recognition, patient context, heuristics as clinical decision-making strategies for triage, (Lephrohon, Patel, 1995). They theorized that medical diagnoses are unnecessary in remote nurse triage.

Nurse-Driven Guidelines

‍ For two years, Ms. Wheeler. and a team of 23+ expert nurses developed the first 5-level, 3-volume, Age-based Guidelines. They also developed the first Universal Guideline — serving as both a Guideline template and then evolving into a semi-working prototype suitable as an AI-augmented co-pilot.

Modern Telehealth Nursing Systems Rapidly evolving and expanding, remote nurse care is unique and ubiquitous. Nurses practice in range of ambulatory and acute care settings (office, clinic, ED, post-operative care).

Ambulatory care is predicted to expand rapidly in the future; bringing with it remote nurse triage and the technologies rquired to perform telephone triage, nurse televisits, and virtual chronic care monitoring.

Various technologies: telephone-only , video, biometric devices, and patient wearables will enhance nurses’ ability to perform this challenging task.

Remote encounters will include patients calling about worrisome symptoms to pre-scheduled virtual visits for non-acute consultations.

Grounded in the nursing process, care will include triage— referrals to ED, Urgent Care or Office visit — or virtually prescribing, treating, referring and monitoring patients, medications or treatments. A secondary goal is to enhance cost-effectiveness by reducing inappropriate ED, Urgent Care and Office visits for institutions offering this.

All forms of telehealth nursing will require the process of triage, if only for the limitations of access, remote encounters, incomplete information that will require avoiding potential delays in care or diagnosis that must always be considered in remote clinical encounters.

A high risk task and work environment, nurses experience stressors: sensory deprivation, rapid clinical decision-making, remote enounters.

Like other nursing specialties, remote nurse care is based on the nursing process, and requires a support system — specialized components: clinical training, nursing standards, clinical decision support systems (CDSS), and electronic health records (EHRs).

Finally, nurses must have a substantial amount of clinical experience. Patient safety depends on system integrity. All components must be proven safe, valid, and reliable, including CDSS and EHRs.