Remote Nurse Triage Guideline & Protocol Resources

Remote Nurse Triage Guideline & Protocol Resources

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Remote Nurse Triage Guideline & Protocol Resources Remote Nurse Triage Guideline & Protocol Resources *

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 multi-purpose Universal Guideline serves as a reference for a Template design,

Ms. Wheeler’s unique triage design is grounded in the nursing process, 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 history — past and recent. Both categories of information promote pattern recognition and context —essential to the task of estimating symptom urgency. 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

  • Detailed, robust, flexible dispositions for 5-level triage support clinical decision making and inform patients when, where and why they require further evaluation on-site. Explicit instructions promote Informed consent and patient compliance by describing a time frame, a venue and an estimated risk level in concrete terms — constituting a plan going forward.

  • 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 the Amazon..

Clinical Guidelines We Can Trust

(Institute of Medicine (IOM, 2011)

TeleTriage Systems guidelines meet all but one IOM Criteria for Clinical Guidelines — that of qualifying as EBM Guidelines. TeleTriage Systems’ Guidelines have yet to meet EBM standards. However, unlike other Guidelines, we welcome EBM research on our guidelines and the overall system. Clinical Decision Support Systems (CDSS) should meet IOM criteria, especially in the era of AI-Augmented CCDSS.

  1.  Explicit:  clearly state the populations to which they apply - Infant-Child, School Age, Adult.

  2. Clarity: a user-friendly presentation, written in unambiguous language, using precisely defined terms

  3. Transparent and Understandable: Users can clearly understand the process, operational rules of thumb and exceptions to them.

  4. User’s Guide:  First paper-based guidelines with a Users’ Guide — 30 page with full operating instructions, describing assumptions and exceptions to recommendations.

  5. Reliable: designed to to consistently produce safe, timely outcomes. 5-Level Triage

  6. Reproducible Outcomes (EBM-verified): different groups of clinicians are likely to choose the same safe dispositions, producing safe patient outcomes

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Manchester Triage Group Informed Guidelines

(Manchester Triage Group, 2015)

The MANCHESTER TRIAGE GROUP (MTG) set forth requirements for on-site ED triage systems (2015). Although specific to ED triage, MTG triage system criteria are broad, thus valid and applicable to other triage settings. TeleTriage Systems Guidelines apply to nurse triage remote or ambulatory settings and meet six MTG category requirements. TeleTriage Systems’ five-level triage system is not intended to apply to on-site ED Triage — currently using ESI 5-Tier Triage.

  1. Nomenclature. Basic terminology and descriptions of acuity. 

  2. Definitions of terminology. Five clearly defined and described classification levels

  3. Robust Triage methodology.  Nursing triage process and workflow adapted from the Nursing Process. Dispostions describe clear instructions on when, where and why recommended, as appropriate

  4.  Acuity classification. Clearly defined classification categories for Five-Level Triage.

  5. Clinical Training Program. A unique clinical training program on “How to” perform nurse triage Unique audiolinks based on 20 real life case studies resulting in triage malpractice with tutorials, six clinical articles on risk management, the triage process, communications, high risk populations and 120+ page syllabus and more.

  6. Audit (QA, QI).  QA Triage Performance Review Audit

AAACN-Informed Standards-Based Triage Guidelines

(AAACN, 2018)

  • Safe:  TeleTriage Systems safety record since publication (1995) is spotless. There has never been a malpractice case related to the use of TeleTriage Systems’ 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. 

  • Uniquely Patient Centric & Age-Specific.  Explicitly state the population to which they apply (IOM). Content 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 Telehealth 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. Home treatment and first aid advice is aimed at low-cost, home treatment, commonly available in the home. Recommendations for chronic illness include free self-help and support groups.

  • 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 Nurses Telehealth Standards, 2018

Triage Protocol & Guideline Description

Medical diagnosis and nurse triage are not synonymous.  Diagnosis:  is defined as the identification of the nature (or cause) of an illness or other problem by on-site physical examination and testing.  Triage: requires the preliminary assessment of patients to determine the urgency of their need for treatment and the timing and nature of treatment required. Triage requires the  sorting of patients — in person —as in an emergency room, or remotely — pre-hospital, via telephone triage or telehealth. Clinicians sort patients with symptoms according to the urgency of their need or the need for additional evaluation or possible testing.

  • Updated Remote Triage References: Remote Triage 5-Level Flow Chart, Triage QA Audit, Clinical Training & Safety Research

    Checklists – Five standardized screening checklists help to rule out -- and to rule in -- key symptoms to estimate symptom urgency and reduce mistriage (Gawande, 2009; Wachter 2015)


  • 5 –Level Triage Dispositions – insure patient informed consent and continuity, directing patients to where, when and why they should be seen. Consistently apprises callers of the urgency of their symptoms in terms they understand to support patient compliance. Five clearly defined, standardized dispositions — with firm but flexible time frames, access sites and urgency rationale —promote consistent outcomes.


    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 beginning to proliferate, 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 criteria. The Universal Guideline design has potential to support clinical triage as a:

  • 1. template for design of a set of guidelines

  • 2 contingency or “fall back” guide for cases where no specific guideline applies

  • 3. preemptive guideline, or “go to” guide before selecting a more specific guideline

  • 4. training tool for new hires 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 triage design is transparent, explainable and consistent. The clinical approach supports pattern recognition and patient context that nurses typically use (Lephrohon, Patel, 1995), 

  • As an integrated system, the guideline design, clinical approach and clinical training increase clinical opportunities to make safe decisions by:

    •  adapting the nursing process to apply to nurse triage

    • describing broad patterns to identify high-risk symptoms (Four) plus broad patterns of emergent to non-acute conditions

    •  listing broad categories of high-risk patients (Six) — Contextual Patterns

    •  integrating built-in safety prompts and standards intended to reduce recurrent error

    • requiring training for clinical decision making.

  • Essential, Unique Features:

  • Evidence-Informed  Manchester Triage Group, Emergency Medicine, American College of Emergency Physicians, Institute of Medicine, Joint Commission, AAACN, etc.

  • 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)
    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

Telephone Triage Protocols or Guidelines Free Downloads

Telephone triage protocols
Telephone triage protocols birth to six
Book cover titled 'Adult Telephone Triage Guidelines, Age 18+ Years' with images of diverse smiling adults including seniors, middle-aged, and young adults.

TeleTriage Systems Copyright Statement

Copyright 1993 -2025 by Sheila Wheeler and TeleTriage Systems Publishers.  All Rights Reserved.  This book is protected by copyright.  No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means – electronic, mechanical, photocopy, recording or otherwise – without prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews. For Information and permissions, write to Sheila Wheeler 44 Madrone Ave, San Anselmo, CA 94960 or contact her by phone 415 453 8382