Are We Asking the Right Question?
Is the question: What is the cause of these symptoms? or How urgent are these symptoms?”
EXPERTS HAVE WEIGHED IN
“Telephone triage represents a grey area between medicine and nursing where medical diagnoses are not essential in order to make a decision about the appropriate interventions, where the dimension of urgency becomes the primary focus of the reasoning process.” Lephrohon & Patel, J. Med Decisionmaking, 1995
”Triage (remote and face to face) is not an endpoint but a beginning”. Systems with a basic premise of attempting to make a tentative medical diagnosis at triage are doomed to fail.
.....triage, by definition, has limited time, history, and objective data. The only appropriate focus of triage is to identify key signs/symptoms so as to place patients in an appropriate level for their generic acuity or risk.” Manchester Triage Group in Zimmerman, 2001
System Error: If you fail to plan; plan to fail”
The Institute of Medicine defines medical (or system) error as the failure of a planned action to be completed as intended, or use of a wrong plan, or failure to use any plan. When negligence (as in a malpractice case) is alleged, the system will be used as evidence. Expert witnesses will request and examine the system components.
A Brief History of TeleTriage Systems
Founded in 1985 by Sheila Quilter Wheeler, RN, MS., TeleTriage Systems was among the first clinical consulting firms to the telehealth industry. Wheeler began pioneering the field — developing and teaching “The Fine Art of Telephone Triage” — a basic on-site clinical course.
In quick succession, Wheeler established a track record of innovation. Wheeler and Judith Windt, medical writer, authored the first training manual for Telephone Triage, published in 1993 by Delmar Thomson.
In 1994, Wheeler collaborated with Contemporary Forums to develop the first clinical telehealth conference for nurses. In 1995, Wheeler launched teletriage.com, one of the first telehealth websites. Google quickly ranked it as a website of quality in the top 10-20 of similar websites. Teletriage.com served as a clearinghouse of telephone triage information in the early days of the field.
In 1995, Wheeler consulted for Santa Clara Medical Center, a Medical Center serving a high-risk, low-literacy, multi cultural patient population of 1.2 million. Wheeler spearheaded a project to train nurses and develop telephone triage guidelines for this challenging population. She served as Editor-in-Chief to collaboratively lead a team of 23 expert nurses, nurse practitioners and physicians to develop the first 5-level triage, age-specific telephone triage guidelines.
From 1997 - 2020, Wheeler served as a Clinical Informaticist, collaboratively developing electronic software with LVM Systems for six VA hospitals in northern California and Hawaii. She consulted and presented seminars for a range of clients, from military facilities to international institutions. Wheeler developed a Telephone Triage course for physicians at Keck School of Medicine in Los Angeles, California.
For over 40 years, Wheeler has consistently worked to develop products that are “real world” — practical, user-friendly, transparent and as evidence-based as possible — built by experienced clinicians who practice telephone triage.
Inspired by the work of Atul Gawande, MD and informed by her experience as a legal nurse consultant on telephone triage malpractice cases, Wheeler’s mission has been to develop system components that reduce common teletriage errors.
Teletriage.com, a pioneering teletriage website — 1998 - 2023
Please come BROWSE TELETRIAGE.COM on the INTERNET ARCHIVE
Telehealth: An Evolving & Emerging Subspecialty
TELETRIAGE DERIVES DECISIONMAKING & PROFESSIONAL STANDARDS FROM TRIAGE
“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; & of trustworthiness. Aviators have a fourth expectation -- discipline”. (Gawande, 2010)
Human Error
In the ValuJet plane crash, “mechanics employed a “good old-fashioned pencil whipping”, resulting in the ValuJet plane crash. These “blizzards of small judgments” amount to a “widespread form of the ‘normalization of deviance’”. Langwiesche laments the failure of large systems that create an “entire pretend reality” that includes:
Unworkable chains of command
Unlearnable training programs
· Unlearnable training program
· Unreadable manuals
· a fiction of regulations, check and controls.
Langeweische (1978)
Face-to-Face Triage Standards Inform TeleTriage Standards
Emergency department triage: an ethical analysis
Triage is part of the healthcare continuum. It consists of a range of services — pre-hospital care [19], and onsite care. Teletriage is a form of pre-hospital care, when performed by clinicians. It is the first point of contact for patients. The levels described below apply to teletriage as well:
1. First, pre-hospital triage to determine if ambulance and pre-hospital care resources are required.
2. Second, triage by the first clinician attending the patient.
3. Third, triage on arrival at the hospital ED.
Teletriage conceivably meets the first two criteria. Even though remote, 1. initially, clinicians help determine if further evaluation on-site is required, and 2. first aid instructions may constitute attending to the patient.
It is an ethical requirement in triage to develop a system or plan, based on set of criteria to determine a treatment priority for each patient. It is safe to assume that teletriage — as pre-hospital care — also requires a system.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199257/ VBMC (2011) doi: 10.1186/1471-227X-11-16 PMID: 21982119
Access to Care, Delay in Care, Timely Care in Triage & Teletriage
“Standards for access to care are hotly debated for scheduled surgical procedures using delays of days, weeks, and months to determine what is acceptable or reasonable. No such time objectives exist in Emergency Departments (or for telephone triage) where delays of minutes or hours for unrecognized problems can be the difference between life and death. Without using a standard measure such as a national triage scale it will be difficult to measure acuity, perform case mix comparisons, or develop ED operational standards.” Adapted from American College of Emergency Physicians (1999)
https://www.acep.org/siteassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/administration/triagescaleip.pdf
Building Safer Tele-triage Systems — One Component at a Time
Mission - Vision - Standards
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![Patient Safety in Tele-triage]()
Mission
Patient Safety — Safe Practice — Safe Products
To devise and refine potential Solutions and Systems to reduce patterns of recurrent mistakes in tele-triage.
Develop evidence-based Structure and Process to enhance the safety and effectiveness of remote clinical tele-triage encounters
Improved Decisions and Patient Outcomes in Tele-triage.
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![Teletriage vision]()
Vision
An established professional clinical telehealth subspecialty
Complete, high Quality, Integrated System Components
Safe, Reproducible, Evidence-based Outcomes
User friendly Decision Support Tools
Substantive Clinical Teletriage Training
Decision Support Teletriage Systems supported by Artificial Intelligence and Evidence-based Research
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![Standards teletriage protocols]()
Standards
Wheeler’s products are guided by time-honored traditions of safe medical practice and clinical decision making derived from the tools of Patient History and Physical.
Wheeler relies on current recognized standards for Safety: National Academy of Medicine (NAM), Institute of Medicine (IOM) Joint Commission, American College of Emergency Physicians (ACEP), American Association of Ambulatory Care Nurses (AAACN), Manchester Triage Group (MTG), URAQ, AHRQ
