TRANSPARENCY BUILDS TRUST
History of a Nursing-Based Guideline Template
A Remote Nurse Triage Template
FAQ: What is Nurses’ Approach to remote triage Guidelines? If yes, how is it different?
Developed by experienced, practicing front-line telehealth nurses, nurse pracitioners and nurse-specialists (and reviewed by three physicians with remote triage expertise). A Universal Guideline or Triage Template basic remote template for nurses, by including:
Supports natural problem solving process: Nurses use pattern recognition, patient context, heuristics. Patel & Lephrohon, 1995).
Non-deterministic, built specifically for remote triage.
Provides More Opportunities to anticipate/correct Common Error (Proactive Error Reduction)
Enhances, incorporates, legitimizes Nurses’ Professional Caution and increases “Opportunities to be Right”
Patients’ Own Degree of Worry Score (DOW)
Built-In Prompts; Red Flags & Rules of Thumb (Heuristics)
Facilitates data collection Patient Context to inform EMR score
Ease of Use: Workflow based on Acuity Assessment: Pattern Recognition, Patient Context and Nursing Process - a familiar, time-tested pattern recognition, patient context - nurses’ historic clinical approach to remote triage.
Transparent, Understandable, Natural Decision-making Flow
A Robust Template for a Remote Clinical Decision Support System (CDSS). Some remote triage CDSS are confusing, complicated and impractical. In clinical use and development for three decades (1993-2026), this remote Nurse Triage Template - adheres to the nursing process, a five-level triage process with clear dispositions (when, where and why there is need for further evaluation).
Improved Remote Nurse Triage Pass Off Explicit Informed Consent instructions sets the stage for clinicians’ collaborative “pass off”. Anticipated resources — equipment, medication, lab work, x-rays and/or procedures — upon arrival at the ultimate venue where a patient will be evaluated. on-site.
Research-Friendly Difficult designs interfere with proving safe patient outcomes, or that a given CDSS is reliable and valid or evidence-based medicine (EBM).. Inadequately tested CDSS might actually interfere with the decision making process (Wachter, 2017).
Prospectively: Online, Cost-Effective to Built, Test & Maintain
CDSS designs for Telehealth Nursing (Remote Nurse Triage) Remote care is more difficult and risky, making user-friendly tools— elegant, transparent and seamless. Standards or guard rails are essential for the next generation of AI-assisted CDSS. Meaningful research on how to safely incorporate AI/PA into current CDSS is essential.
All-Purpose Remote Triage CDSS:
Telephone Triage, Telehealth or ED Triage
Generative AI, predictive analytics, advanced EMRs and biotechnology will be standard components of a suppost system for prospective CDSS. These powerful technologies, require a reliable system within which to operate — clinical guardrails.
Typically, clinical specialties require systems: clinical training, clinical practice standards, safe CDSS, EMR and experienced clinicians trained in remote clinical decision making. In other words, clinical systems must meet the Duty of Due Care — a legal principle underlying established nursing specialties, and one underlying the Duty to Communicate, Warn and Document - each built into the framework and process.
A Universal Guideline with nursings’ historical structure and process — serves as a “virtual visit”. A modified and abbreviated History — past and recent medical history or “back story” - provide contextual information about the patient’s risk level. Essential assessment questions elicit more information about the chief complaint - a virtual
Early on, protocols were likened having a physician at one’s side while making difficult clinical decisions— supporting, reminding and prompting with additional questions. AI and predictive analytics may supplant the expert physician advisor, supporting pattern recognition, suggesting an acuity level and triage disposition — however, AI should act only as a co-pilot.
“Improved Systems improve safety” Giesen et al., (2011), Annals of Medicine
“If you fail to plan; plan to fail” (IOM)
“Triage (on site) is not an endpoint but a beginning.” The American College of Emergency Physicians, 1999. Uniform Triage Scale in Emergency Medicine,
"Physician expertise and professionalism alone could not prevent common error.” Killip, MD (2007),
Does your organization have a formal remote nurse triage system?
Or is it just “bits and pieces”?
Or is it a “black box inside another “black box” i.e. EBM untested, unproven CDSS and AI?
System error: “the failure to use a plan; using the wrong plan; or failure of planned action to be completed as intended”. Institute of Medicine, 2000. [PubMed]
FAQ: How did this Design Evolve?
1993 “Master Template” A skeletal Guideline Template format as a basis for a set of Guidelines (minimal disposition details, acuity levels).
1993 Duty of Due Care adapted to remote nurse triage (Barbara Siebelt, RN, MS, Founder of Critical Care Nurses), the first standards for Guidelines.
1995 Vimla Patel & Lephrohon ResearchResearch describes the “Real World” nurses’ approach to remote triage
1993-1995 Nurse Task Force Develops Unique Telephone Triage Protocols (Age -Based, 4-5 Acuity Level). It included a Guideline Template:
1995 A “Fall-Back” or first Contingency Protocol (No Protocol Found (NPF) when no Protocol seems to apply.
1998 A “Pre-Emptive”, “Go-To or“All Purpose” Protocol for a first pass — prior to selecting a specific guideline
2000 “Master or Generic Guideline” A well -developed Framework and consistent Template
2002 “Universal Guideline” More robust and developed with broad Key Questions to rule out common emergent to non-acute symptoms,
2002 Universal Guideline as Training Adjunct to introduce broad principles and policies to train new staff or novice triage nurses.
2005 Optional Face-to-face triage Guidelines for ambulatory settings: on-site — ED/Urgent Care or any ambulatory or pre-hospital setting: Office, Clinic, College Student Health, etc..
2020-2025 Universal Guideline Proof of Concept- with Reminders, QA qestions, Built-in Nursing Process, Error Feedback, EBM ready — As-Is and later — AI-ready.
Is this Prototype/Proof of concept prospectively AI-Augmented CDSS Ready? Yes, provided EBM -based research is performed on a CDSS prior to indroduction of AI features
We don’t look for patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point”(Gawande, MD 2010).
AI Safety
CDSS that employs AI without a governing framework and EBM testing - can produce unsafe outcomes. Some might compare it to “a Black Box inside of another Black Box”. Errors of Assessment, Communication, Continuity, Informed Consent and Human Error.(Joint Commission) are Root Causes of unsafe outcomes in all remote nurse triage (telehealth nursing).
Malpractice cases in teletriage are typically related to these predictable and preventable errors. Human and system error can be addressed by improving systems —structure and process — a group of related parts that work together for common goals — patient safety, practitioner safety, system effectiveness.
Meets System Requirements of Manchester Triage Group
1. Practice Management:
a. Clinical Training - Five plus Clinical courses
b. Risk Management - Clinical training, Error Feedback
c. Clinical Standards: AAACN Practice & Call Center
d. Prospectively Research and AI-ready
2. Clinical Trends/Health care Technology: CDSS, EMR
3. Financial Performance: Tracking & Trending Capabilities
4. Patient Experience:
a. Patient Brochure on how to use Telehealth Nurse Service
b. Patient Instructions (5th-8th Gr. Literacy) for Home treatment of Symptoms
Developer Standards for POC AI-CDSS
Prospectively: If EBM-tested and demonstrably safe, valid and reliable without AI:
Prospectively AI/PA-Ready
A Robust Template Framework to streamline development for remaining Guidelines
Adaptable to Key Age: Birth to Frail Elderly
Template for rapid integration, updating, modifying & testing
Multi-Purpose, Multi-Setting
Remote nurse triage requires clinical tools & technologies that meaningfully support remote decision-making using the Nursing Process.
CERNO…..I Perceive -
Discern – Distinguish – Sift – Separate - Bear in Mind – Reckon – Determine – Resolve – Contend - Decide
CERNO: I Perceive– Distinguish – Sift – Separate - Notice -Detect -Recognize -Differentiate -Distinguish -Bear in Mind – Reckon -Determine - Establish – -Weigh - Contend - Decide
REMOTE NURSE TRIAGE — A BRAVE NEW WORLD
Enhanced Pattern Recognition & Patient Context Predictive Analytics
AI-AUGMENTED TELEHEALTH NURSING
The work of teletriage is nothing if not uncertain, and humans intensely dislike uncertainty. However, it is reasonable and prudent to bear in mind the uncertainty and urgency of remote nurse triage and care, and to question our assumptions. Safer practice and evidence-based tools can reduce uncertainty and improve outcomes.
“Triage (on site) is not an endpoint but a beginning.”
The American College of Emergency Physicians, 1999. Uniform Triage Scale in Emergency Medicine
"Physician expertise and professionalism alone could not prevent common error.” Killip, MD (2007),
“All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. They all have at least three common elements: expectation of selflessness; of skill; and of trustworthiness. Aviators have a fourth expectation -- discipline”. (Gawande, 2010)
“Any mistake or failure in the diagnostic process can lead to a diagnosis that is wrong, missed or delayed. More diagnostic errors occur in ambulatory settings, but inpatient diagnostic errors tend to be more lethal”. Groszkruger, 2014.
We don’t look for patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point”(Gawande, MD 2010).