Rules of Thumb for Triage Clinical Decisionmaking

Research in clinical decision-making has identified heuristics (rules of thumb) as shortcuts. Rules of Thumb used for clinical decisionmaking for triage may apply to remote triage as well as face-to-face triage.

·       When in doubt, always err on the side of caution, and bring the patient in sooner rather than later.

·       “When in doubt, send ‘em out”.  (Clawson, 1998).

·       Always speak directly with patients; A patient “too sick to talk” is a “Red Flag” and should be evaluated on site

·       Beware of the middle-of-the-night call

·       Beware the “Recent or Previous Diagnosis”

·       Remain alert for atypical, silent or novel presentations.

·       Beware of “failure to improve” on current Rx or Home Treatment.

·       “Never abandon the caller in crisis” (Clawson, 1998).                                          

·       The vaguer the symptoms, the greater need for good data collection.

·       Speed does not equal competence; avoid premature closure or jumping to conclusions.

·       Beware the “Non-Diagnostic Diagnosis” (patient interpretation of symptoms)

·       Beware the “Out of Protocol” experience.

·       Two or more calls within hours or days should be seen urgently (1-4 hours)

·       Patients described as “too sick to talk on the phone” may require an urgent appointment

·       All severe symptoms must be seen in 1-8 hours or less.

Age-Based Rules of Thumb

·       Assess all sick children and  elderly for possible dehydration and sepsis

·       All new or worsening confusion in children or elderly is considered emergent.

·       Elderly and pediatric patients may present in silent, atypical or novel ways

·       Elderly and pediatric populations are at greater the risk of hypo- or hyperthermia during weather extremes.  

·       All Teens (including College Student/Young Adult)  are at increased risk for suicide/violence when stressed or depressed due to impulsivity

·       Elderly are at higher risk for completed suicide, especially males over 65 years. who are white, widowed, retired and unemployed.

Trauma-Based Rules of Thumb

·       Trauma + Suspicious History: Consider Possible Domestic Abuse

·       Always consider head and neck injury when there is face or jaw trauma

·       All snakes are considered poisonous until proven otherwise.

·       All chemical and electrical burns have the potential for progressive injury

·       Never remove impaled objects.

Symptom-Based Rules of Thumb

·       All severe pain must be seen within 8 hours or less.

·       Beware of any pain that awakens patient or prevents sleep at night

·       Headaches described as: “First, Worst, Burst, Cursed (other accompanying symptoms), or 51st (age over 50 years)” = Emergent

·       “Temperature extremes often trigger medical problems”. (Clawson, 1998)

·        “Epigastric pain in males > 35 and females > 45, is considered an MI until proven otherwise”.  (Clawson, 1998).

·       Any pain between the navel and nose is chest pain until proven otherwise

·       The first symptom of an MI may be denial.

·       Once an ectopic, always an ectopic

·       Any bleeding in pregnancy is an ectopic until proven otherwise

·       All first-time seizures must be evaluated .

·       All rashes are contagious until proven otherwise

·       Beware of any atypical, silent or novel presentations.

·       Beware all  “flu” symptoms that can “mask” MI, Infection  or sepsis.

·       Pregnancy and breast feeding may be risk factors for domestic violence

• All High-Risk Patients with moderate symptoms of any kind may require higher triage acuity.

Rule of Thumb for Myocardial Infarct Risks: “The Eight E’s”

Extremes of:

• Emotion

• Extremes of Weather/Temperature

• Exertion

• Extreme Age:  >75

• Eating (“Holiday Heart” ?)

• Epigastric Distress

• Essential Hypertension

• Early AM

© Sheila Quilter Wheeler, 2025

References for Rules of Thumb  

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