A Modern Guideline Design for Remote Nurse Triage
TeleTriage Systems’ Design Advantage
The conceptual model developed by the 23-person Guideline Nurse Task Force has always been human-centered rather than purely algorithmic. That matters because future CCDSS are unlikely to function as rigid decision trees.
Instead, nurses will likely function as experts in assessing pattern recognition and patient contextual interpreters (Lephrohon & Patel, 1995), while operating within structured safety boundaries — much closer to the Wheeler/Guideline Task Force approach than to older deterministic protocol engines.
A SYSTEM: Structure-Process-Outcome (Donabedian, 1992) Our Expert Nurse Task Force approach and design contains concepts that resemble modern AI reasoning. Future upgrades will not require replacing the original framework, but will bolster it. 5-level, explicit acuity system (when, where, why, whether) is simplified for nurse, patient, family, co-workers, researchers and software developers to understand and implement, representing an important triage concept - safe outcomes --in concrete, practical terms..
TeleTriage Systems’ simple, elegant design is based on symptom pattern recognition and patient context, grounded in the Nursing Process (adapted for remote care), legal and nursing standards. It is a complete system, with integrated supportive components, with the goal of producing reliable, valid and safe patient outcomes.
Transparent, Explainable, Consistent, Familiar, User Friendly
Remote Nurse Triage Guideline & Protocol Resources
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Transparent, Explainable, Consistent, Familiar, User Friendly Remote Nurse Triage Guideline & Protocol Resources *
FAQ: How Can Remote Nurse Triage be Made More Safe?
The IOM report drew from disciplines (engineering, psychology and occupational health) and applied opportunities to improve patient safety to health care. Ms. Wheeler and a team of colleagues has adapted IOM’s common sense concepts and developed sample remote nurse triage clinical training and tools to facilitate safety.
1. “User-Centered Design” (IOM). Designed for the Nurse “End User”, TeleTriage System Nurse-driven and -designed triage system is unique and innovative. Focusing on making it easier “to do the right thing” (IOM, 2000; Atul Gawande, MD 2018)
2. “Avoid Reliance on Memory by Standardizing the Process” . Standardize and Simplify the Process. Three examples of how TeleTriage Systems’ protocols, guidelines and checklists enhance safety and avoid reliance on memory are the Nurse Triage Process Workflow, Triage QA Audit and the Universal Guideline Template. The QA Audit includes several checklists to standardize triage assessment. The Nursing Process is modified and integrated into Universal Triage Guideline Template.
3. “Attend to Work Safety” Developing and improving triage standards related to shift length, high volume systems, working conditions, equipment quality and distractions will impact patient safety. Examples include improved wireless headsets, quiet rooms set aside for triage, shorter Shifts to avoid decision fatigue, several or larger screens, User friendly technology.
4. “Train Concepts for Teams” The triage process typically involves Interdisciplinary teams. Training Triage Teams together (Physicians, Clerical staff, nurses, ED resource team members, as appropriate) fosters mutual trust in diverse teams’ competence and expertise, and may strengthen access, continuity and safety.
6. “Involve Patients in Their Care” Patient instructions about the Triage Service, and “how to prepare for televisits and to help the triage nurse to help them, can bolster patient and family health literacy. Patient Instructions are part of the User’s Guide..
7. “Anticipate the Unexpected“ By its very nature, the work of triage is uncertain and urgent. Some rules of thumb and policies are integrated into the Guidelines and Documentation, as well as the training manual. In addition, “technology introduces new error, even when its sole purpose is to prevent errors” (IOM). Check on Planned Error Feedback to correct error quickly.Awareness and Communication at regular triage staff meetings
8. “Assume that error will occur and plan for recovery” (IOM) Practicing tasks, processes by using previous case studies and actual encounters, is a feature of Planned Error Feedback. It will be a standard policy to learn from patient outcomes without endangering HIPAA patient privacy.
9. “Improve Access to Accurate, Timely Information” In the triage task, estimating patients’ risk level is critical for estimating urgency. Heuristics, planned error feedback and built-in Red Flags can help nurses to verify, update and correct patient context, recent medical Information to reduce risk, and lead to under triage and unsafe outcomes.
Foundational Standards Guide Safety Features
Medical diagnosis and estimating symptom acuity (triage) are not synonymous.
TELEPHONE TRIAGE requires clinicians to remotely assess and sort (triage) symptomatic patients according to their combined symptom and patient acuity to determine the need for additional on-site evaluation, testing or treatment. Telehealth nursing requires clinically-informed estimates and decisions about when, where, why and whether symptomatic patients require additional on-site evaluation and treatment.
Checklists – Five standardized checklists help to screen -- key symptoms to estimate symptom urgency and reduce undertriage (Gawande, 2009; Wachter 2015)5 –Level Triage Dispositions – insure patient informed consent and continuity, directing patients to where, when, why and whether they should be further evaluated on site. This approach consistently apprises callers of their estimated acuity in terms they understand, and fulfills clinicians’ “Duty to Warn” (Tennenhouse, 1993). Five clearly defined, standardized dispositions — with firm but flexible time frames, access sites and urgency rationale —promote consistent outcomes and support patient compliance.
This is the first “Uniform Remote Triage Scale”. Although it is not EBM-validated, it has been part of TeleTriage Systems’ guidelines, clinical training, standards and documentation system since 1995, explicitly describing and advising when, where, why and whether a given patient should be evaluated on-site. This feaure is essential to Informed Consent, the Duty to Warn, Safe Pass-Off and continuity of care.
All Hours/All Access Sites Dispositions apply 24/7/365; they are not limited to office- or after- hours. Access sites are flexible for all hour options. Expanded Office, Clinic and Urgent Care Clinic Hours are proliferating, enhancing patient access and helping to reduce Emergency Department overcrowding.Standards-Based System to reduce common errors: inadequate data collection, miscommunications, cognitive bias and inadequate informed consent and continuity (IOM, 2011, Donabedian, 2003, Patel, 1996, AAACN, 2012)
A Universal Guideline Adapts ACEP symptom acuity categories. Meets Manchester Triage Group triage system criteria. The Universal Guideline design has potential to support clinical triage in several useful ways, as a:
Template as a structure for designing a full set of guidelines
Contingency or “Fall Back” guide for cases where no specific guideline applies
Preemptive Guideline, or “Go To” Guide before selecting a more specific guideline
Training Tool or Introduction to remote nurse triage system, for newly hired nurses. As a review of practice and commonly presented symptoms (IOM, Joint Commission, 2011)
The Universal Guideline serves both as an “Uber Triage Check List” as well as a Guideline Template for 45 + Site-Based Chief Complaints. The unique remote triage design is transparent, explainable and consistent. The clinical approach supports pattern recognition, patient context and heuristics that nurses typically use (Lephrohon, Patel, 1995),
As an integrated system, the guideline design, clinical process and clinical training increase opportunities to make safe clinical decisions by:
adapting the nursing process to apply to remote nurse triage
describing emergent to non-acute conditions
listing broad categories of high-risk patients — Patient Contextual Patterns
integrating built-in safety prompts and standards intended to reduce recurrent error
requiring training for remote clinical decision making.
Updated Remote Nurse Triage References: Remote Nurse Triage 5-Level Flow Chart, Triage QA Audit, Clinical Training & Safety Research
Essential, Unique Features:
Evidence-Informed Standards are derived from Manchester Triage Group, Emergency Medicine, American College of Emergency Physicians, Institute of Medicine, Joint Commission, American Academy of Ambulatory Care Nurses
Comprehensive – Address the most common presenting symptoms, from rare, but predictable emergent to common non-acute symptoms –1,500 medical conditions addressed in 45 symptom-based guidelines.
Risk Management Used in several thousand sites since 1995 with no report of errors, omissions or malpractice.
User's Guide describes how to operate this reference (30 pages)
All Ages (Since 1995) Infant-Child (Birth - Six Years), School Age (6 -18 Years), Adult (18+ Years).
Cost-effective Paper-based guidelines are economical; electronic algorithms can be extremely costly.
TeleTriage Systems welcomes EBM research on safety and reliability of the Universal Guideline
CLINICIAN END-USERS MATTER
Nurse Designed & Developed Triage Guidelines/Protocols
Front-line remote triage nurses are intimately aware of the challenges of this fast-paced work. They well understand the need for a design that integrates the nursing process, is user-friendly, streamlined but thorough triage reference - a Universal Guideline Template.
In 1995, a Task Force of 23 expert-level nurses with three Physician-reviewers completed development of the first age-based, 5-Level Triage Acuity Decision-Support Guidelines for Pre-Hospital or Remote Triage. Ms. Wheeler serves as Editor- in- Chief. The process took two years. Published successively by Aspen and McGraw-Hill, last TeleTriage Systems updated the Adult and School Age versions in 2017. The complete age-based set are a basic resource for any remote triage setting. The Universal Guideline is multi-purpose, and can serve as a contingency (fall-back) or pre-emptive (first-pass) guideline, Template design or training tool for newly hired clinicians.
Ms. Wheeler’s unique triage design folows the nursing process which is modified for remote nurse triage. The first step of the nursing process — assessment, is crucial to the task of remote triage. To get a mental image, clinicians must elicit adequate information about symptoms — the chief complaint, and the patient context — past and recent medical history Both categories of information promote pattern recognition and context —essential to the task of estimating symptom and patient acuity.. Additional unique features include:
Unique 30-page Protocol Users Guide will orient new users to the guideline process, design and supporting system components (training, documentation form, process work flow, performance review). Both process and content are transparent and streamlined — easy to use- and new user confidence
Robust assessment tools standardized screening checklists Acronyms to capture Symptom and Patient Past and recent medical history, alerts and prompts
Explicit, flexible dispositions for 5-level triage support clinical decision making and inform patients when, where, why and whether they require further evaluation on-site. The guidelines enhance patient compliance by describing a time frame, a venue and an estimated risk level in concrete terms — constituting a plan going forward. Explicit instructions promote Patient Informed Consent, the Duty to Warn and staff communications for safe pass-off .
Essential patient instructions include first aid and/or or home treatment (5th to 8th grade literacy level) for patients to carry out. Follow up instructions include time frames for patients to call back for worsening or changing symptoms. Clinical training include mandatory follow up statement. First aid and home treatment instructions written in cookbook style expedite the process for nurses, and simplify it for patients to comprehend and carry out.
Unique and innovative, these guidelines help to streamline encounters and decision-making, reducing recurrent error, improving communications, promoting patient informed consent and enhancing continuity of care.
Aspen Publishers initially published in paper, the three-volume set of guidelines in a three-ring binder with tabs (now out of print). MrGraw-Hill published the bound version for a period of time. TeleTriage Systems now publishes the three paper volumes distributed through Amazon..
CLINICAL REMOTE TRIAGE STANDARDS
FOUNDATIONS: IOM, MTG, AAACN
Clinical Telehealth Guidelines We Can Trust
(Institute of Medicine, IOM, 2011)
TeleTriage Systems’ guidelines meet four of six IOM Criteria for Clinical Guidelines . We seek a partner to collaboratively develop the first EBM -proven CDSS with reliable and reproduceable outcomes.
In the era of AI-Augmented CDSS, Clinical Decision Support Systems (CDSS) should meet IOM criteria. The Guidelines are supported by a unique clinical training program on how to perform remote triage using the nursing process as applied to CDSS, EHR documentation and standards.
Explicit: clearly state the populations to which they apply - Age-Specific Infant-Child (Birth to Six Years), School Age (6 - 18 Years), Adult (18+Years)
Clarity: a user-friendly presentation, unambiguous language, using precisely defined acuity levels and terminology
Transparent & Understandable: Understandable process, heuristics includes exceptions.
User’s Guide: A Unique 30-page Users’ Guide, describes the process, assumptions and exceptions.
Reliable: designed to to consistently produce safe, timely outcomes using 5-Level Remote Triage
Reproducible Outcomes: Designed with the goal that different groups of clinicians are likely to choose the same safe dispositions, producing safe patient outcomes
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Our 5-Level Acuity Approach to
Remote Nurse Triage since 1995
A Task Force of expert-level nurses and nurse-practitioners (1995-2026) initially designed and developed TeleTriage Systems’ 5-level triage approach. This system is specifically designed for remote triage, and unique from all existing on-site triage systems. the systems’ explicit when, where, and why underlies the time-frame approach, and the appropriate venue specific to the acuity level. This approach supports Patient Informed Consent, Staff Communications and Hand-offs. Our triage system predated (1995) the Manchester Triage Group (MTG) 5-Tier Triage and meets MTG triage criteria for systems listed below:
Nomenclature. Basic terminology and descriptions of acuity.
Definitions of terminology. Five clearly defined and described ACEP - informed classification levels
Robust Triage methodology. Remote Nurse Triage methodology and workflow is adapted from the Nursing Process. Dispositions describe clear instructions on when, where. why and whether patient should be further evaluated.
Acuity classification. Clearly defined classification categories for Five-Level Remote Nurse Triage.
Clinical Training Program. A unique clinical training program for remote nurse triage, including audiolinks of 20 real life case studies with tutorials, 120+ page syllabus for training program: risk management, communications, high risk populations.
Audit (QA, QI). QA Triage Performance Review Audit
AAACN Standards Based & Informed
Telehealth Nursing Guidelines (AAACN, 2018)
Safe: TeleTriage Systems’ track record of safety has been spotless since first published (1995). No malpractice case has been associated using TeleTriage Systems’ remote nursing triage guidelines.
Multi-Purpose/Multi-Setting: Applicable and adaptable to a range of remote and on-site clinical settings: Virtual Telehealth Visits, Pre-hospital & Ambulatory Settings (Office, Clinic, Student Health Centers) to Face-to-Face Encounters, Emergency Department, Urgent Care.
Five-Level Triage: A unified method for assigning triage that is innovative and exclusively unique to this system (AAACN Telehealth Standard 2, 3). Includes consistent, defined clinical prioritization nomenclature: acuity classifications, descriptions, time frames and follow up sites.
Patient Centric & Age-Specific. Since 1995, the guidelines explicitly descibe the population to which they apply (IOM). Content in the three-volume set is customized to three unique age groups: Infant-Child (Birth to 6 Years), School Age (Age 6-18 Years)and Adult (Age 18 +years ) (AAACN Standard 1)
5-8th grade literacy level Patient instructions facilitate communication and call brevity Assessment questions and home treatment instructions will serve all literacy levels — college-level to low literacy, (AAACN Telehealth Standard 1, 5, 6)
All Economic Levels: Originally developed to serve low-income, high risk, multi-cultural populations at a large county Health Center, the home treatment and first aid advice is aimed at low-cost and easily accessible home treatment. Contact Information includes free self-help and support groups for chronic illness.
Access — Round -the -Clock Design supports 24/7/365 patient access policy — not just office hours. (AAACN Telehealth Standard 1)
Adapted from American Academy of Ambulatory Care Nurses Telehealth Standards, 2025
