RULES OF THUMB FOR NURSE TRIAGE

In All Settings

A Rule of Thumb is defined as a “principle with broad application that is not intended to be strictly accurate”. An easily applied educated guess, intuitive judgment, or common sense. Rules of thumb may be used to guide decisions and to reduce error.  Using cardinal rules may reduce errors of assessment, communication and/or continuity.  Rules of Thumb apply to Triage in a range of clinical settings.

In a study ofnurse triage (without guidelines), researchers found that triage nurses taking calls in the Emergency Department employ three strategies to estimate symptom urgency and to make decisions: context, pattern recognition and Rules of Thumb as a decision support tool (Lephrohon & Patel, 1995). Most Rules of Thumb described here are common sense. Several rules demonstrate clinical failures recurrent error resulting in malpractice cases (see Cardinal Rules #1 and #2), also common sense. Many Rules of Thumb were suggested by class participants - front-line Triage Nurses.   Several Rules are attributable to Jeff Clawson, MD, Pioneer and Founder of Emergency Medical Dispatch (911).  The following Rules of Thumb may apply to most clinical settings where triage encounters take place

 Cardinal Rules of Thumb

• ·     Always speak directly to the patient.  Patients who are “too sick to talk” may require an urgent or emergent on-site evaluation. Failure to speak directly to the patient is a frequent source of recurrent error in malpractice cases related to remote or virtual nurse triage. (Wheeler, 2025)

• ·    Always ask patients if they (or family members) have repeatedly called or been seen in person or via telehealth in the recent past. This is a potential Red Flag situation, and requires that the patient be seen on-site urgently. Failure to ask patients about recent repeat calls and/or visits is a frequent source of recurrent error in malpractice cases involving remote nurse triage. (Wheeler, 2025)

Triage Rules of Thumb

• ·      Time is tissue, Time is muscle.

• ·      When in doubt, always err on the side of caution, and bring the patient in sooner rather than later.

• ·      “When in doubt, send ‘em out”.  (Clawson, 1998).

• ·      “If symptoms are new, unusual and worrisome, the patient should be evaluated on site.

• ·      Beware of “failure to improve” on current Rx or Home Treatment

• ·      Speed does not equal competence; avoid premature closure.

• ·      Beware the middle-of-the-night call or contact

• ·      Never abandon the caller in crisis. (Clawson)

• ·      Beware the Previous Diagnosis (Any previous Medical Diagnosis)

• ·      Beware the “Non-Diagnostic Diagnosis” (patient interpretation or explanation of symptoms)

• Remain alert for presentations that are atypical, silent or novel                          

• ·      The more vague the symptoms, the greater need for good data collection.

• ·      Make corrections for own fallibility (Underreacting, Fatigue, Overreacting,)

• ·      Initiate a “Welfare check” on patients who are alone and frail, mentally ill or not functioning well.

• Care delayed is care denied.

• To Err is Human, to Delay is Deadly

TRAUMA-RELATED Rules of Thumb

• ·      Trauma + Suspicious History: Consider Possible Abuse

• ·      Always consider head/neck injury if there is face or jaw trauma

• ·      All snakes are considered poisonous until proven otherwise.

• ·      All chemical and electrical burns have the potential for progressive injury

• ·      Never remove impaled objects

AGE-BASED Rules of Thumb

• ·      Assess all sick children (and elderly) for possible dehydration and sepsis

• ·      The older (or younger) the patient, the greater the risk for hypo- or hyperthermia.

  PEDIATRIC Rules of Thumb

• ·      “Kids get sicker quicker.”

• ·      Always err on the side of caution, especially with infants and toddlers.

• ·      < 4 Yrs: Symptoms tend to be very generalized.

• ·      > 4 Yrs: Symptoms tend to be more specific

• ·      Infants < 3 Months: Fever of 38ºC or 100.4ºF® – see immediately.

• ·      Always elicit immunization history. Delayed immunizations or inadequate immunizations place child and community-at-large at risk.

ELDERLY Rules of Thumb

• ·      Elderly may present symptoms in silent, atypical or novel ways

• ·      Elderly are at higher risk for suicide, Highest Completed Suicide: White male, > 65, widower/divorced, retired/jobless.

• ·      Incontinence in elderly may be related to UTI

• ·      Developmentally Disabled populations typically age prematurely

TEENAGER Rules of Thumb

• ·      Teen (College Age, Young Adult) is at > risk for suicide or violence when stressed or depressed due to impulsivity

• ·      Teens:  Overwhelming immune response (Swine flu epidemic, Other)

CHILDBEARING AGE Rules of Thumb

• ·      Once an ectopic, always ectopic

• ·      Any bleeding in pregnancy is an ectopic until proven otherwise

• ·      Beware all “flu-like” symptoms that can “mask” MI, Infection or sepsis.

• ·      Pregnancy and breast feeding may be risk factors for domestic violence  

SYMPTOM-BASED Rules of Thumb

• ·      All severe pain is considered an emergency (ACEP)

• ·      Beware of any pain that awakens patient or prevents sleep at night

• ·      Headache: “First, Worst, Cursed, Burst or 51st ” = Emergent

• ·      “Temperature extremes often trigger medical problems”. (Clawson, 1998)

• ·      All first-time seizures must be seen.

• ·      All rashes are contagious until proven otherwise

• ·      All new or worsening confusion in the elderly is considered emergent.

• ·      Any teenager who is depressed may be at risk for suicide

• ·      All new or worsening confusion in the elderly is considered emergent

• ·      All High-Risk Patients (see list) with moderate to severe symptoms of any kind should be upgraded

 Chest Pain Rules of Thumb

• ·      The first symptom of an MI is often denial

• ·      Smokers who have chest pain are more likely to die and die suddenly (within the hour) of MI.

• ·      Time is muscle. Patients treated within the first hour have a substantially improved outcome

• ·      A little chest pain may be as bad as a lot (Clawson)

• ·      All pain between nose and navel should be regarded as chest pain until proven differently. (Bartlett)

• ·      “Epigastric pain in males > 35 years and females > 45 years, is considered an MI until proven otherwise”.  (Clawson, 1998).

• ·      Treat any chest pain in high-risk caller as myocardial infarction until proven otherwise.

• ·      Beware atypical or novel presentations 

• ·      Acute symptoms in women, diabetics and elderly may present as vague, silent or atypical.

• ·      Age > 70 yrs. Patients over 70 might not experience chest pain.

• ·      callers may fail to recognize acute symptoms, report fewer symptoms, or attribute them to other causes (non-diagnostic diagnosis).

• ·      Beware of any pain that awakens patient or keeps them awake at night.

• ·      Trauma: all chest trauma is considered urgent until proven differently.

ACRONYM: Eight E’s” of MI Rules of Thumb

·       Extremes of:

o   Emotion

o   Extremes of Weather/Temperature

o   Exertion

o   Extreme Age:  >75

o   Eating (“Holiday Heart”?)

o   Epigastric Distress

o   Essential Hypertension

o   Early AM

• References:

• Fast and Frugal Heuristics (2018)

  https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0-S1755599X18300600/first-page-pdf

  Emergency Medicine (EM) is defined by timely and accurate decision-making ….. Many theories have emerged within the literature about clinical decision making from the perspective of analysis of the human thought processes [3]. Within this paper the authors discuss a form of heuristics called Fast and Frugal heuristics [4]. The authors then use a case study to illustrate an example of how fast and frugal heuristics can be applied on a daily basis within the emergency setting.

   

• Rules of thumb — An educational tool in teaching clinical communication to medical students (2017)

• https://www.sciencedirect.com/science/article/abs/pii/S0738399117303592

  A hundred years ago, doctors used rules of thumb to make up for a lack of facts. Modern day’s rule of thumbing is a way of surviving in an overabundance of facts. In a way, you may say that a rule of thumb turns the information the student already has into information the student needs in a particular clinical situation. However, although a rule of thumb may be appropriate in many situations, it is not appropriate in all.

• HeurIstic decision making in medicine (2012)

• s://pmc.ncbi.nlm.nih.gov/articles/PMC3341653/#:~:text=Speed,treatment%20was%20not%20as%20urgent.

   Heuristics are simple decision strategies that ignore part of the available information, basing decisions on only a few relevant predictors.

  
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