It’s Been A Journey

Sheila Quilter Wheeler had no intention of pioneering a new nursing subspecialty.   In the early 1980’s, while managing advice calls as an ED nurse, she requested guidelines to standardize the process and advice. The response -- she "was an ED nurse and knew what to do", Wheeler was not reassured. Her new mission: identifying a need, finding solutions – ultimately enhancing practice in a new clinical subspecialty.

Initially, she suggested two books, both written for the layman by physicians (Vickery, Fries and Pantell).   Currently, in 9th and 10th editions, they contain instructions for assessing, triaging and home treatment for common adult and pediatric symptoms.

Later, as a clinical call center advice nurse, Wheeler developed and taught an in-house telephone triage class. A participant thanked her for the class, adding that she "no longer felt like a stepchild of nursing".

At that time, telephone triage was an embryonic field, fraught with uncertainty.  Many nurses were "worried about their license" -- anxious to know safer methods to carry out the task.

In the mid-1980s, Wheeler taught “ The Fine Art of Telephone Triage”.  The training syllabus gradually evolved, and, four years later, became a book proposal. After nine rejections, Delmar Publishers agreed to publish it.

Due to the lack of pre-existing research, Wheeler extrapolated and applied existing findings from similar clinical subspecialties to the new field of telephone triage. 

Wheeler and medical writer, Judith Windt completed the training manual including real-life case-study audiotapes. “Telephone Triage: Theory, Practice and Protocol Development" published in 1993.

From 1993 to 1995, Ms. Wheeler served as Editor-in-Chief for the first age-based, five-level, patient centric telephone triage guidelines,  published by Aspen Publishers.

In 1994, she founded the first national Telephone Triage conference for nurses  In 1997, she launched her website to serve as an informational resource in a fledgling field.

It Takes a Village

Over a 40+ year period, Wheeler developed a complete system. Major influencers on Teletriage Systems 40+ year legacy included a legal nurse consultant, an attorney and a physician-mentor.

Barbara Siebelt, RN emphasized the importance of the “duty of due care” — written evidence — of a system, should malpractice occur. She stressed that expert witnesses request a "paper trail" — evidence in the form of documentation, protocols, clinical training materials, and practice standards. These components form Wheeler’s system, and support her guideline.

Robert Smith, JD, advised that these components be integrated. He cautioned against having " just bits and pieces", noting that each component served as layers of protection — an overcoat or safety, but working together..

Jeff Clawson, MD, pioneer of 911 - Emergency Medical Dispatch —served as Ms. Wheeler’s mentor and role model early on, deeply influencing Wheeler’s work. Clawson and Ms. Wheeler respectively pioneered their unique, innovative fields over the last 40 years.

From 1993-1995, Ms Wheeler led a Task Force of 25+ expert-level nurses, NP's and MD-reviewers. The group consensus resulted in a unique, innovative, five-level, age-specific set of telephone triage guidelines, based on a pattern recognition approach.

Pre-hospital triage research

In their early research on nurses’ decision-making strategies when performing telephone triage in an emergency department (ED) setting, researchers reasoned that nurses used context and pattern recognition as decision-making strategies. (Lephrohon, Patel, 1995)

Further, researchers believed that medical diagnoses are unnecessary in telephone triage. They found that heuristics -- a rapid problem-solving technique where precision is traded for speed -- achieved estimates based on understanding and responding to the urgency of the situation. This research specifically describes pattern recognition as nurses’ decision making process.

Ms. Wheeler reached two significant turning points, serving as an expert witness on 35 malpractice cases (1995-2023), and adapting the work of Atul Gawande, MD, on safety and the importance of checklists).

CERNO - I Perceive (Patent Pending)

Innovation and leadership guided the first and only Age- Based, 5-level triage guidelines with a Protocol Users’ Guide built for fast—paced triage in remote and on-site clinical settings.

Innovations The broadest, most inclusive content, accessible to the widest possible population - from low to high income and education levels, and multi-lingual and multi-ethnic populations. Home treatment instructions in 5th to 8th grade literacy level. low-cost easily available home treatments, free self-help & support group resources.

Turning Points: 1995 to 2020

1995 Wheeler's expert witness work on 35 telephone triage malpractice cases, witnessing the idiosyncratic evolution of telephone triage over 40 years made clear several risky trends. The telehealth industry at large, healthcare institutions, HIT and clinicians seemed unaware of long-standing system and recurrent human error.

2020 Pandemic: the Birth of Telehealth

In the midst of a world wide pandemic, telephone triage — a still-emerging low-tech field— suddenly gave birth to telehealth, now a permanent, essential, and extremely convenient service. Currently, hi-tech is outpacing clinical standards in both fields. The telehealth industry is starting to take note, as AI - the most powerful technology is surging ahead..

“To Err is Human, to Delay is Deadly” Delays in care and diagnoses contribute to patient injury and death, leading to medical malpractice.

After a 30+ year journey with an immaculate safety record, the Universal Guideline is a proof of concept for a Clinical Decision Support System (CDSS). It is

2025 A content expert with a proof of concept , Ms. Wheeler seeks to develop an AI-CCDSS to reduce "patterns of recurrent error" in the near future.

A Final Note Recurrent practice and system error will continue to threaten patient safety. Without a professional platform - a National Association of Triage Nurses (Pre-hospital, virtual, on-site) — it is difficult to make significant progress. There is still much work to do.