NURSE TRIAGE GUIDELINES & PROTOCOLS
In 1995, a Task Force of 23 expert-level nurses and three Physician-reviewers completed development of the first, 5-Level Triage, Age-Based, Decision-Support Guidelines for Pre-Hospital Triage. The process took two years. Please read below:
Nurse-Designed and Developed Guidelines & Protocols
Ms. Wheeler’s unique triage design is based on the nursing process, modified for nurse triage. The first step of the nursing process — assessment — is heavily emphasized to elicit chief complaint and patient past and current medical history. Both categories of information foster pattern recognition and context —essential to estimating symptom urgency. Additional unique features include:
First Protocol Users Guide orient new users to the protocol or guideline process, design and system components (training, documentation form, process work flow, performance review). Transparent, streamlined process and content support appropriate use and build new user confidence
Robust assessment tools and later, standardized screening checklists
Detailed, flexible disposition instructions for 5-level triage decision making and improved Informed Consent (when, where, why a patient might 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 follow-up patient instructions might include first aid and/or or home treatment (5th to 8th grade literacy level) if patients will not be evaluated soon. Follow up instructions about when patients should call back must be included for worsening or changing symptoms. All instructions are written in cookbook style to make it easy and fast for nurses to deliver, and easy for patients to comprehend and to carry out.
Unique and innovative, the guidelines will streamline encounters and decision-making, by working to reduce recurrent error, improving communications, promoting patient informed consent and enhancing continuity.
Aspen Publishers initially published the three-volume set in a three-ring binder with tabs in hard copy. TeleTriage Systems now publishes the three hard copy volumes through Amazon..
Telephone Triage Protocols or Guidelines Free Downloads
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
Triage Protocol & Guideline Description
Medical diagnosis and nurse triage are not synonymous. Diagnosis: the identification of the nature of an illness or other problem by on-site testing and physical examination. Triage: 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 — as in an emergency room, virtually or pre-hospital — according to the urgency of their need or additional evaluation.
Updated Protocol or Guideline Sections (available as free downloads here) include Telephone Triage 5-Level Triage Flow Chart, QA Audit, Standards Exemplars and 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. contingency or “fall back” guide for cases where no specific guideline applies)
2. preemptive guideline, or “go to” guide before selecting a more specific guideline
3. 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-Supported Manchester Triage Group, Emergency Medicine, American College of Emergency Physicians, Institute of Medicine, Joint Commission, AAACN, etc.
Comprehensive – Address the most common presenting symptoms, and rare, but predictable emergent 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
Clinical Guidelines We Can Trust
(Institute of Medicine (IOM), 2011)
Like other Telephone Triage Protocols and Guidelines, TeleTriage Systems’ paper-based Guidelines are not yet proven Evidence-based. However. they are designed to meet IOM Criteria for Clinical Guidelines in five of the following six IOM categories. Clinical Computerized Decision Support Systems (CCDSS) should also meet the same criteria, especially in the era of AI-Augmented CCDSS.
Explicit: clearly state the populations to which they apply
Clarity: a user-friendly presentation, written in unambiguous language, using precisely defined terms
Transparent: Users can clearly understand how they work
User’s Guide: Since 1993, the only paper-based guidelines with a Users’ Guide — 30 page with full operating instructions, describing assumptions and exceptions to recommendations.
Reliable: designed to result in safe, timely outcomes. 5-Level Triage
Reproducible Outcomes (EBM-verified): different groups of clinicians are likely to choose the same safe dispositions
Adapted from Clinical Practice Guidelines We Can Trust, IOM, 2011
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Standards-Based Triage Guidelines (AAACN, 2018)
Safe: TeleTriage Systems has had a spotless safety record since publication (1995). There has never been a malpractice case related to the use of TeleTriage Systems’ guidelines.
Multi-Purpose/Multi-Setting: Applicable to a range of clinical settings: Home Telehealth Visits to Face-to-Face Encounters, Emergency Department, Urgent Care, and Ambulatory Settings (Office, Clinic, Surgicenter and Student Health Settings).
Five-Level Triage: A unified method for assigning triage that is innovative and exclusively unique to this system (AAACN Telehealth Standard 2, 3). Includes defined clinical prioritization nomenclature: acuity classifications, descriptions, time frames and sites for follow up.
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 Assessment questions and home treatment Instructions facilitate communication and call brevity. Developed to serve all literacy levels, (AAACN Telehealth Standard 1, 5, 6)
All economic levels: Originally developed for a large facility serving low-income, high risk, multi-cultural populations. Advice for home treatment and first aid features low-cost, treatments commonly available in the home, plus recommendations for 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, 2015
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Triage Methodology Requirements
(Manchester Triage Group, 2015)
The MANCHESTER TRIAGE GROUP (MTG) set forth categories of requirements for on-site ED triage (2015). M delines meet these category requirements for nurse triage systems (remote or ambulatory on-site). This five-level triage system does not apply to ED Triage, currently using ESI 5-Tier Triage.
Nomenclature: Basic terminology and descriptions.
Definitions of terminology. Clearly defined and described classification levels
Robust Triage methodology. 5-Level Triage. clear instructions on when, where and why patients are to be further evaluated, as appropriate
Acuity classification. Five-Level Triage categories for remote or Ambulatory settings only
Clinical Training Program. Robust clinical training program
Audit (QA, QI). QA Audit
Adapted from Manchester Triage Group, 2015