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, a remote, unique, ubiquitous form of nursing care, utilizes various technologies to care for patients. It includes telephone triage, nurse virtual televisits, and nurse virtual chronic care. 

Unlike other nursing specialties, telehealth nursing is sensorily deprived environment, technology dependence, and high risk. It requires remote decision-making skills and a support system — clinical training, standards, CDSS, and EMR. Due to its rapidly evolving nature and uneven development, some system components are inadequate or absent.

Beginning in the 1970’s, HMOs began using telephone triage --. the earliest form of remote nursing care--to reduce inappropriate ED and Office visits. Telephone assessment --limited to auditory cues – is risk-prone and time-sensitive.  Nurses  respond to patient-initiated calls about worrisome symptoms. Using the nursing process , they make clinical decisions to determine if the patients’ acuity level is life-threatening, urgent, or non-acute.

Nurse virtual televisits rapidly emerged in the Covid Pandemic -- pre-scheduled appointments, with nurses or Nurse Practitioner. RN and NP virtual assessment utilize auditory, visual, and/or biometric input. NPs can prescribe medications, order tests, refer patients, and remotely diagnose conditions like UTIs, pinkeye, sinus infections, and chronic diseases. However, chest pain, difficulty breathing, neurologic deficits, severe dehydration, or suspected sepsis must be evaluated in person.

Virtual Chronic Care Nurses use auditory, visual, and biometric input to monitor and remotely manage chronically ill patients or ongoing medication treatment. Experience in ambulatory care, case management, or specialty disease management experience is required.