FAQ About Remote Nurse Triage

• What is Nurse triage? Nurse Triage defined as the safe, timely clinical assessment and disposition of patient symptoms by registered nurses. Three types of nurse-patient encounter are: 1. by phone (remote), 2. via telehealth (a “virtual visit”) or 3. in person (Emergency Department or Urgent care).

• Are diagnosis and triage synonymous? No

• What is the most difficult type of triage to perform? The most challenging method of triage is remote triage (known as telephone triage or pre-hospital triage) because clinicians cannot see, physically examine or take vital signs of the patient. Because of these limitations, nurses may relay on professional caution in addition to protocols or guidelines. Under such circumstances, the rule of thumb “err on the side of caution” allows for a margin of error. This rule is an example of the “duty of due care” - doing what the reasonable, prudent nurse would do under the same or similar circumstances.

• How do nurses perform triage? Nurse Triage is based on the nursing process, modified to apply to the triage process - that of estimating symptom and patient acuity. The task requires assessing, estimating and classifying patient symptoms according to urgency, including the patient past and recent history - to establish patient risk.. The goal of triage is on-site evaluation, testing and treatment. Nurse triage has been defined as clinical “decision making under conditions of uncertainty and urgency” (Patel, 1995). . It is also an emerging nursing subspecialty and the first phase of the the the thecontinuitycontinuity of care - pre-hospital triage.

• What are typical settings for nurse triage? Nurse Triage is ubiquitous, often occurring at all hours of the day. Nurse-patient encounters occur in a range of clinical settings - ambulatory and acute. For example patients calling Ambulatory settings, Medical Offices, Clinics, Student Health Centers, or clinical call centers to get advice on when, where and whether their symptoms require on-site evaluation. On-site, face to face or in-person triage encounters take place in acute settings like Emergency or Urgent Care departments, where nurses are able to perform more in-depth triage to determine the triage acuity level, when the patient might be seen by a physician and resources required.

• How did nurse triage begin? In the 1970’s, pediatricians recruited nurses to relieve physicians of this task. Pediatricians saw children as potentially high risk and were the first group of physicians to develop pediatric guideline (Schmitt (1980, 2023), Brown (1994), Katz (2001), Pantell & Fries (2002, 2015)). Protocols and guidelines served as “standing orders”. Nurses were required to use protocols or guidelines when taking calls.

• Nurses were chosen because they could safely perform the task, following guidelines. Nurses were also less costly than physicians. Initially, nurses answered patient calls during Office Hours, and later covered the After Hours period and all age groups - including adult and geriatric populations.

• Does the Continuum of Care apply to Triage? It is likely that remote triage (pre hospital, telephone or virtual television) qualifies as a form of care and the first contact on the continuum of care.. Patientscall to have symptoms assessed, classified and then be advised on next steps to take.

• What are Standards for Triage Acuity Levels? Standards for access to care are hotly debated for scheduled surgical procedures using delays of days, weeks, and months to determine what is acceptable or reasonable. No such time objectives exist in Emergency Departments (or for telephone triage)  where delays of minutes or hours for unrecognized problems can be the difference between life and death. Without using a standard measure such as a national triage scale it will be difficult to measure acuity, perform case mix comparisons, or develop ED operational standards.” Adapted from American College of Emergency Physicians (1999)

• All learned occupations have a definition of professionalism, a code of conduct.  It is where they spell out their ideals and duties.  They all have at least three common elements:  expectation of selflessness; of skill; & of trustworthiness.  Aviators have a fourth expectation -- discipline”.  (Atul Gawande,MD 2010)                                                                                                                              

• Human Error. In the ValuJet plane crash, “mechanics employed a “good old-fashioned pencil whipping”, resulting in the ValuJet plane crash. These “blizzards of small  judgments” amount to a “widespread form of the ‘normalization of deviance’”.  Langwiesche laments the failure of large systems that create an “entire pretend reality” that includes:

• Unworkable chains of command

• Unlearnable training programs

• Unlearnable training program

• Unreadable manuals

• A fiction of regulations, checks and controls. Langeweische (1978)