Nurse Triage: Pre-Hospital, Call Center & Virtual Settings

Nurse Triage Requires Repeated Clinical Decision Making

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Nurse Triage Requires Repeated Clinical Decision Making *

Literally overnight, the COVID pandemic fueled telehealth’s explosive growth. Pre-hospital triage was transformed into an essential, convenient and permanent clinical service. However, technological growth has outpaced clinical safety and professional values. Technological growth alone does not guarantee patient safety in this emerging subspecialty. 

Nurse Triage – Subspecialty or Skill?

A subspecialty is a focused area of nursing practice , advanced knowledge and skills in a specific patient population, disease, or care setting (e.g., Cardiology). Requirements include a specific body of knowledge, education, training, and experience. A skill, defines how care is delivered.

So, is nurse triage — conducted virtually, via phone and on-site— a clinical subspecialty or simply a set of skills? Nurse triage has many of the hallmarks of a challenging nursing subspecialty:

  • Care Settings Unlike most nursing subspecialties, Nurse Triage is ubiquitous. Patient calls typically originate from home, but are received in diverse settings — from a range of acute hospital and ambulatory care settings to medical offices, clinics, student health centers to clinical call centers, urgent care units and Emergency Departments.

  • In clinical call centers, triage nursing may require working 6 -8 hour shifts, making repeated, rapid (within 3-15 minutes), complex clinical decisions, under conditions of uncertainty. Patients (unknown, unseen or virtual encounters) contacting clinicians about worrisome symptoms — possibly life-threatening to non-acute. The volume and intensity of triage to identify or rule out high risk -patients, --symptoms and/or situations is a high risk for decision fatigue. Nurse triage in some ambulatory settings may be sporadic and informal.

  • Patient populations can be challenging and diverse in Age, language, culture and educational level, Disposition choices range from five acuity time frames in 4-5 venues, each with diverse clinical resources, specialized tests or other diagnostic technologies.

  • Clinical training for assessment using symptom pattern recognition, patient context and rules of thumb to identify and triage high risk patients, symptoms, and/or situations

As a subspecialty, triage involves utilizing a modified nursing process (in italics):

  1. Assessment – Elicit symptoms, Use pattern recognition, context and heuristics to estimate symptom urgency.

  2. Diagnosis – Consult the clinical decision support system (CDSS) to determine the appropriate, timely disposition

  3. Planning/Implementation – confirm patient agreement to the disposition and elicit informed consent

  4. Evaluation – Review the patient outcome to evaluate nurse triage decisions, and CDSS validity and reliability.