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", Ms. Wheeler was not reassured. Her new mission: finding solutions – ultimately enhancing patient safety and developing a remote nurse triage clinical subspecialty.

Initially, she suggested two books, to management, both written by physicians (Vickery, Fries and Pantell) for the lay audience.   Still in print, in 9th and 10th editions, these resources 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 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 Over a 40+ year period, Ms. Wheeler, other nurse-consultants, and a team of of 23 + Nurse-experts developed a complete remote nurse triage system.

Major influencers included two nurse legal experts —Barbara Siebelt, RN, MSN, and Laura Mahlmeister, RN, PhD. They emphasized the importance of the “duty of due care” represented by a "paper trail" — written evidence of a complete system.

Carolyn Smith Marker, RN, MS developed nursing standards, while Pat Benner, RN, PhD developed the concept of nursing expertise. Ms Wheeler adapted “From Novice to Expert” to the new practice of remote nurse triage.

Robert Smith, JD, advised that remote triage 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”, and working together.

Jeff Clawson, MD, pioneer of 911 - Emergency Medical Dispatch —served as Ms. Wheeler’s mentor, supporting her pioneering work, exemplified by his training manual, rules of thumb and devotion to patient safety.

Nurse Remote Triage Research

Researchers found that nurses used context, heuristics and pattern recognition — clinical decision-making strategies for triage, (Lephrohon, Patel, 1995). They theorized that medical diagnoses are unnecessary in remote nurse triage.

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

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 Master Guideline — serving as a template for all Guidelines. It later evolved into a Universal Guideline, a foundational Remote Nurse Triage structure, to be prospectively developed as AI-augmented co-pilot.

An Evolving Nursing Hybrid

Telehealth nursing is a pre-hospital, remote and rapidly expanding hybrid of techno-clinical nursing care.

Telehealth nursing is a broad category that includes telephone triage, nurse televisits, and virtual chronic care nursing. Widely practiced across a range of ambulatory settings (office, clinic, post-operative care), as well as in emerging emergency department call centers,k telehealth is unique and ubiquitous.

Telehealth nurses utilize the nursing process—modified for remote patient encounters and supported by various technologies—to assess symptom and patient acuity to make triage dispositions and/or to treat and monitor patients, medications or treatements virtually.

The primary goal is to avoid delays in care or diagnosis by estimating the combined urgency of symptoms and patient contextual risk. A secondary goal is to enhance cost-effectiveness for the institution offering this service to patients.

Telehealth nurses are sensorily deprived in remote environments, making the work inherently high risk. Nurses' "eyes and ears" consist of various technologies: telephone-only communication, video, biometric devices, and patient wearables.

Like other nursing specialties, telehealth nursing requires a support system consisting of specialized clinical training, nursing standards, clinical decision support systems (CDSS), and electronic health records (EHRs). These four components, along with required nursing experience qualifications are often underdeveloped.

As a rapidly evolving specialty, some telehealth system components—such as clinical training—may be inadequate or absent. Patient safety depends on system integrity. All components must be proven safe, valid, and reliable, including CDSS and EHRs.