Protocol & Guideline Description

The first and only 5-Level Triage, three volume, Age-Specific Guidelines for Infant-Child, School Age and Adult Populations with a Users’ Guide.

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 in order 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 for care. The Guidelines featured here are based on nurse triage.

Updated Sections (available as free downloads here) include Telephone Triage 5-Level Triage Flow Chart, QA Audit, Standards and safety research

Evidence-Based Design

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 to help insure timely compliance. Five clearly defined, standardized dispositions (with firm but flexible time frames, access sites and urgency rationale), promote reliable, consistent outcomes and explicit directives for follow up.

The goal of these guidelines is “to get patients to the right place, at the right time for the right reason”. Users are spared frustrating, confusing and time-consuming decision-making related to algorithm formats (ENA/ACEP, 2010)

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 treduce Emergency Department overcrowding.

Standards-Based System to reduce common errors: inadequate data collection, miscommunications, cognitive bias (jumping to conclusions or stereotyping) and inadequacies in informed consent and continuity (IOM, 2011, Donabedian, 2003, Patel, 1996, AAACN, 2012)

A Universal Guideline A triage format adapting ACEP symptom acuity categories and 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)

In addition, 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 a transparent, explainable and consistent triage tool. The clinical approach supports the task of contextual and pattern recognition that research shows that nurses typically use (Lephrohon and Patel, 1995), 

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

1.  adapting the nursing process to apply to nurse triage

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

3.  listing broad categories of high-risk patients (Six) Contextual Patterns

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

5. requiring clinical training that includes Heuristics, or Rules of Thumb, commonly used by clinicians for decision making.

Essential, Unique Features:

Nurse-Driven 23+ member Task Force: Expert Nurse and Nurse-Practitioner, Nurse-User contributors, Structured by the Nursing Process.  Nurse-developed, physician-reviewed.

Authoritative Collaboratively developed over a two-year period by expert clinicians

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
Risk Management Used in several thousand sites since 1995 without any 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

 by  Ms. Sheila Quilter Wheeler  (Author)

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