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 requested guidelines for the process. The response -- she "was an ED nurse and knew what to do", Wheeler was not reassured. Her new mission: finding solutions – ultimately enhancing patient safety and supporting nurse triage practice in a new clinical subspecialty.

Initially, she suggested two books, both written for the layperson by physicians (Vickery, Fries and Pantell).   Currently, in 9th and 10th editions, they contain instructions for assessing, triaging 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 license" -- anxious to know safer practice methods.

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.

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 findings from foundational clinical subspecialties.

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

From 1995 to 2023, Ms. Wheeler served as an expert witness on 35 malpractice cases, and later as founder of the first national Telephone Triage conference

It Took a Village Over a 40+ year period, Wheeler developed a complete triage system.

Major influencers included nurses, an attorney and a physician-mentor. Barbara Siebelt, RN, and later, Laura Mahlmeister, RN, PhD, emphasized the importance of the “duty of due care” emphasizing that expert witnesses request the "paper trail" — written evidence of a system. Carolyn Smith Marker, RN, MS stressed the need for standards. Pat Benner, RN, PhD set forth the blueprint for nursing expertise with her ground breaking work - “From Novice to Expert”.

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

Jeff Clawson, MD, pioneer of 911 - Emergency Medical Dispatch —served as Ms. Wheeler’s mentor deeply influencing her work.

Nurse Triage Research

Researchers discovered that nurses used context, heuristics and pattern recognition as decision-making strategies. (Lephrohon, Patel, 1995). Researchers also theorized that medical diagnoses are unnecessary in nurse triage.

They found that heuristics -- a rapid problem-solving technique where precision is traded for speed -- achieved estimates based on understanding and responding to the urgency of the situation.

While serving as an expert witness (1995-2023) on 35+ malpractice case, Ms. Wheeler discovered patterns of recurrent error (Atul Gawande, MD), in nurse triage. She began devising a Universal Guideline and improving and integrating methods to avoid recurrent error.

Telehealth Nursing  is a new, hybrid form of a remote, ubiquitous form of pre-hospital clinical care,  and the first contact on the continuum of care.  A techno-clinical form of nursing, whereby nurses utilize the nursing process—modified for remote patient encounters plus various technologies, to assess and triage patient and symptom acuity, and/or to treat and monitor symptoms and treatment virtually.

The goal is to avoid delay in care or diagnosis by making safe, timely dispositions and estimating the urgency of patient or symptoms.  A secondary goal is to enhance cost-effective Telehealth nursing is a broad category that includes telephone triage, nurse televisits, and nurse virtual chronic care.  Telehealth Nursing is ubiquitous – practiced in a wide range of ambulatory (office, clinic, post-operative) as well as emerging Emergency Department call centers.

As a pre-hospital care, telehealth nursing  requires clinical decision-making and care, uniquely harnessed with a growing number of technologies. Nurses are sensorily deprived, making the work very high risk. Nurses’ eyes and ears are range of technologies -- telephone only, or video, biometrics and/or patient wearables.

Like other nursing specialties , telehealth nursing is supported by a system — specialized clinical training, nursing standards, CDSS, and EHR – albeit one that is developing unevenly. A rapidly evolving specialty, some telehealth nursing system components – like clinical training – can be inadequate or absent.  Patient safety depends on safe, valid, reliable systems, including CDSS and EHR.