Literally overnight, the COVID pandemic fueled the explosive growth of remote nurse triage and telehealth. Pre-hospital triage was transformed into an essential, convenient and permanent clinical service. Current technological growth appears to outpace clinical safety and professional values but is lacking in regulation and EBM research to guarantee patient safety in this emerging subspecialty.
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. Are remote diagnosis and remote risk estimate 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)
* Nurse Triage Requires Repeated, Rapid, Safe Estimation of Symptom Urgency
* Nurse Triage Requires Repeated, Rapid, Safe Estimation of Symptom Urgency
TeleTriage Systems: Advancing Telephone Triage to Improve Patient Outcomes
Company Overview
TeleTriage Systems is a consulting company specializing in the development of telephone triage systems—also known as pre-hospital triage or remote triage—performed by registered nurses. Telephone Triage is one form of remote triage (telehealth, virtual triage, pre-hospital triage) and is similar to on-site triage encounters occurring in Emergency Departments or Urgent Care Clinics.
The company mission is to improve the safety, efficiency, and timeliness of nurse triage in any setting. When patients call, concerned by worrisome symptoms, nurses assess the symptoms and decide when, where, why, and whether patients might require further clinical evaluation on site — in the ED, Urgent Care, Office or Clinic.
Nurses use Clinical Decision Support Systems (CDSS) alongside Electronic Medical Records (EMR) to assess, document, estimate symptom acuity, and to advise a disposition. While it is widely believed that pre-hospital or telephone triage can reduce emergency department (ED) overcrowding and improve cost-effectiveness, there is limited peer-reviewed research to substantiate these claims.
Leadership
TeleTriage Systems was founded by Sheila Quilter Wheeler, RN, MS, a pioneer in pre-hospital telephone triage. Ms. Wheeler’s career spans over four decades and includes the design of nurse- developed and -driven triage systems, triage protocols and guidelines, clinical training programs, and national conferences. Her clients include government institutions such as the Hospital Authority of Hong Kong, military medical facilities, HMOs, private practices, and community clinics.
Ms. Wheeler authored the first training manual for telephone triage in 1993. Over a two-year period, she then led a task force of 23 expert-level nurses, nurse practitioners, and three physicians to develop the first age-specific, five-level pre-hospital triage protocols or guidelines. Expert nurses collaboratively designed and developed the guidelines while three physicians served as reviewers. Research on ED triage nurses’ reliance on pattern recognition and context for decision-making (Patel & Lephrohon, 1995), it is likely that nurses traditionally used triage to estimate urgency on-site and later remotely.
Evolution of the Field
Telephone triage predates telehealth, which surged during the COVID-19 pandemic to limit viral exposure for patient and clinician alike. Today, telehealth—defined as real-time virtual consultations between patient and clinician—has become a convenient - and essential - alternative to in-person visits. In the near future, telehealth will replace telephone triage, as wearable technologies and biotech tools become commonplace.
In the post-COVID landscape, virtual visits now serve not only for convenience but may also serve as pre-hospital triage virtual encounters. However, telephone triage remains distinct in that in telephone encounters clinicians cannot see patients. and decision making relies heavily on nurses’ clinical reasoning and judgment.
Current Challenges
The still-emerging subspecialty of nurse triage faces a “perfect storm” of urgent issues, professional, technological, and systems-based:
Professional Underdevelopment: Inadequate professional development of the nascent nurse triage subspecialty, to monitor patient safety of new technologies, as well as to support triage systems of excellence.
Inadequate Technology Regulation: IT, and AI development appears to be outpacing clinical standards, evidence based medicine, and regulatory oversight.
Inadequate Patient Access: Patient access is severely limited After Hours. Outdated Policies that limit patient access to Office hours (40 Hours M-F). are likely contributing to ED overcrowding . After Hours —from 5PM - 9AM M-F, and every Saturday Sunday and Holiday —the ED is transformed into the “venue of last resort” for patients with worrisome symptoms .
A growing trend is to expand patient access — and relieve ED overcrowding — through extended hours. UCLA’s innovative Immediate Care program is one such example.
Despite the ubiquity of pre-hospital triage — telephone encounters to ambulatory settings, clinics, student health centers, ambulatory surgery, clinical call centers and EDs —the field has no cohesive professional organization to call its own. Broadly speaking, nurse triage has grown unevenly, leaving gaps which require development.
Initially, the first paper triage protocols and guidelines were developed by physicians . Later, physician/IT teams developed Computerized ClinicaL Decision Support Systems (CDSS) with input from nurses — the primary users. Due to proprietary nature of these technologies, there are few rigorous outcome studies (EBM) on Patient outcomes and the validity and reliability of CDSS design, or of a given system’s overall completeness and integrity
Research seems to indicate that nurses’ appropriate referral rates are higher than physicians (Wheeler et al 1995). It is unclear if nurses use CDSS as intended or if their high safety outcomes are driven more by nurses’ clinical caution than tool effectiveness.
TeleTriage System’s Solution: A Return to Clinical Foundations, Nurse Informed Design
While the settings and approaches for remote and on-site triage differ, in general, the principles driving nurse triage remain the same:
The Nursing Process
The Duty of Due Care, Standards
Clinical Pattern Recognition, Patient Context, Heuristics
Evidence-Informed Triage Systems & Practice, Safe, Timely Patient Outcomes
Ms. Wheeler’s work is informed by established practice based on standards from analogous clinical specialties and safety experts, including Atul Gawande, MD; Avedis Donabedian, MD; Barbara Siebelt, RN, MS; and Laura Mahlmeister, RN, PhD. Ms. Wheeler has synthesized decades of safety research and standards from top agencies and specialty organizations such as the IOM, Joint Commission, NCQA, MTG, ACEP, ENA, and AAACN.
Looking Ahead: Integrating AI Thoughtfully
Artificial intelligence is poised to serve as an “AI co-pilot” to improve clinical decision-making. .
However, many existing CDSS platforms are not yet AI-ready.
The high volume of content alone, when combined with complex designs lacking a clear clinical process, and overwhelming number of disposition options, will make these systems difficult to revise, maintain or scale. Without thoughtful design, these tools risk becoming obsolete and unsustainable.
Vision
With proper validation through evidence-based medicine (EBM), Ms. Wheeler envisions a new industry standard — a system that includes an integrated CDSS that is EBM certified, transparent, easy to use, streamlined, and nursing process-based. The goal is to . improve patient outcomes, to reduce resource use, and even contribute to a lower carbon footprint.