A Triage System Designed
to Improve Patient Outcomes
Explore a Nurse-Driven Triage System
Designed to “Make It Easier To Do the Right Thing”.
(Institute of Medicine, 2000)
TeleTriage Systems: Advancing Nurse Triage to Improve Patient Outcomes
Company Overview
TeleTriage Systems is a consulting company specializing in the development of telephone triage systems—also known as pre-hospital triage—performed by registered nurses. Telephone Triage is one form of remote triage (telehealth, virtual triage, pre-hospital triage) and is similar to on-site triage encounters occurring in Emergency Departments or Urgent Care Clinics.
The company mission is to improve the safety, efficiency, and timeliness of nurse triage in any setting. When patients call, concerned by worrisome symptoms, nurses assess the symptoms and decide when, where, why, and whether patients might require further clinical evaluation on site — in the ED, Urgent Care, Office or Clinic.
Nurses use Clinical Decision Support Systems (CDSS) alongside Electronic Medical Records (EMR) to assess, document, estimate symptom acuity, and to advise a disposition. While it is widely believed that pre-hospital or telephone triage can reduce emergency department (ED) overcrowding and improve cost-effectiveness, there is limited peer-reviewed research to substantiate these claims.
Leadership
TeleTriage Systems was founded by Sheila Quilter Wheeler, RN, MSN, a pioneer in pre-hospital telephone triage. Ms. Wheeler’s career spans over four decades and includes the design of nurse- developed and -driven triage systems, triage protocols and guidelines, clinical training programs, and national conferences. Her clients include government institutions such as the Hospital Authority of Hong Kong, military medical facilities, HMOs, private practices, and community clinics.
Ms. Wheeler authored the first training manual for telephone triage in 1993. Over a two-year period, she then led a task force of 23 expert-level nurses, nurse practitioners, and three physicians to develop the first age-specific, five-level pre-hospital triage protocols or guidelines. Expert nurses collaboratively designed and developed the guidelines while three physicians served as reviewers. Research on ED triage nurses’ reliance on pattern recognition and context for decision-making (Patel & Lephrohon, 1995), it is likely that nurses traditionally used triage to estimate urgency on-site and later remotely.
Evolution of the Field
Telephone triage predates telehealth, which surged during the COVID-19 pandemic to limit viral exposure for patient and clinician alike. Today, telehealth—defined as real-time virtual consultations between patient and clinician—has become a convenient - and essential - alternative to in-person visits. In the near future, telehealth will replace telephone triage, as wearable technologies and biotech tools become commonplace.
In the post-COVID landscape, virtual visits now serve not only for convenience but may also serve as pre-hospital triage virtual encounters. However, telephone triage remains distinct in that in telephone encounters clinicans cannot see patients. and decision making relies heavily on nurses’ clinical reasoning and judgment.
Current Challenges
The still-emerging subspecialty of nurse triage faces a “perfect storm” of urgent issues, professional, technological, and systems-based:
Professional Underdevelopment: Inadequate professional development of a nascent clinical nursing subspecialty to monitor new technologies for patient safety, as well as to support triage systems of excellence.
Technological Lack of Regulation: In the field of nurse triage, IT development is outpacing professional standards and regulatory oversight. AI is already being adapted, possibly without regulation or guardrails
System Error: Outdated Policies for patient access are likely contributing to ED overcrowding. For example, some offices, clinics and urgent careve begun to expand their weekday hours to 9AM - 10 PM, as well as expending weekend and holiday coverage.
Despite the ubiquity of pre-hospital triage — telephone encounters to ambulatory settings, clinics, student health centers, ambulatory surgery and EDs —the field has no cohesive professional organization to call its own. Broadly speaking, nurse triage grown unevenly, leaving gaps which require development.
Traditionally, physicians and some nurse experts developed hard copy triage protocols and guidelines. Later, physician/IT teams developed CDSS with input from nurses— the primary users. Due to proprietary nature there are few rigorous outcome studies (EBM) on protocol safety in either hard copy or electronic format(CDSS).
Research seems to indicate that nurses’ appropriate referral rates are higher than physicians. It is unclear if nurses use CDSS as intended or if their high safety outcomes are driven more by nurses’ clinical caution than tool effectiveness.
TeleTriage System’s Solution: A Return to Clinical Foundations, Nurse Informed Design
While settings for remote and on-site triage differ, in general, the principles driving nurse triage remain the same:
The Nursing Process
The Duty of Due Care, Standards
Clinical Pattern Recognition, Patient Context, Heuristics
Evidence-Based Systems and Practice, Safe, Timely Patient Outcomes
Ms. Wheeler’s work is grounded in established practice based on standards from analogous clinical specialties and safety experts, including Atul Gawande, MD; Avedis Donabedian, MD; Barbara Siebelt, RN, MS; and Laura Mahlmeister, RN, PhD. Ms. Wheeler has synthesized decades of safety research and standards from top agencies and specialty organizations such as the IOM, Joint Commission, NCQA, MTG, ACEP, ENA, and AAACN.
Looking Ahead: Integrating AI Thoughtfully
Artificial intelligence is poised to serve as an “AI co-pilot” to improve clinical decision-making. .
However, many existing CDSS platforms are not yet AI-ready.
The high volume of content alone, when combined with complex designs lacking a clear clinical process, and overwhelming number of disposition options, will make these systems difficult to revise, maintain or scale. Without thoughtful design, these tools risk becoming obsolete and unsustainable.
Vision
With proper validation through evidence-based medicine (EBM), Ms. Wheeler envisions a new industry standard — a system that includes an integrated CDSS that is EBM certified, transparent, easy to use, streamlined, and nursing process-based. The goal is to . improve patient outcomes, to reduce resource use, and even contribute to a lower carbon footprint.
.......TeleTriage Systems -- Making it Easier to Do the Right Thing
.......TeleTriage Systems -- Making it Easier to Do the Right Thing
FAQ About Nurse Triage
What is Nurse triage? Nurse Triage defined as the safe, timely clinical assessment and disposition of patient symptoms by registered nurses. It involves assessing, estimating and classifying patient symptoms according to acuity or urgency for additional on-site evaluation, testing and treatment. Nurse triage has been defined as clinical “decision making under conditions of uncertainty and urgency” (Patel, 1995). Nurse Triage is based on the nursing process, modified to apply to the triage process - that of estimating symptom and patient acuity. It is also an emerging nursing subspecialty and the first phase of the the the thecontinuitycontinuity of care - pre-hospital triage.
Where does nurse triage take place? Nurse Triage is ubiquitous. Nurse-patient encounters occur in a range of clinical settings - ambulatory and acute. For example patients calling Ambulatory settings, Medical Offices, Clinics, Student Health Centers, or clinical call centers to get advice on when, where and whether their symptoms require on-site evaluation. On-site, face to face or in-person triage encounters take place in acute settings like Emergency or Urgent Care departments, where nurses are able to perform more in-depth triage to determine the triage acuity level, when the patient might be seen by a physician and resources required.
What is remote or pre-hospital nurse triage? Remote triage can take place two ways: when patients or family members make a phone call to the triage nurse service, or use telehealth technology — a kind of “virtual visit” where the patient can be seen by the nurse.
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About Sheila Quilter Wheeler, RN, MS
It’s Been A Journey. Sheila Quilter Wheeler had no intention of pioneering a new nursing subspecialty. While managing advice calls as an ED nurse, she requested guidelines for the process. The response -- she "was an ED nurse and knew what to do", Wheeler was not reassured. Her new mission: finding solutions – ultimately enhancing patient safety and supporting nurse triage practice in a new clinical subspecialty.
Initially, she suggested two books, both written for the layperson 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.
In the early 1990’s, telephone triage was an embryonic field, fraught with uncertainty. Many nurses were "worried about their license" -- anxious to know safer practice methods.
As a clinical call center advice nurse, Wheeler developed and taught an in-house telephone triage class The training syllabus gradually evolved into a book proposal.
Wheeler and medical writer, Judith Windt completed the training manual, including real-life case-study audiotapes in 1993,
Due to the ongoing scarcity of pre-existing research, Wheeler extrapolated, applied and relied upon findings from foundational clinical subspecialties.
From 1993-1995, Ms. Wheeler served as Editor-in-Chief, directing a 23-member Nurse Task Force developing the first and only three volume, age-based, five-level triage guidelines..
From 1995 to 2023, Ms. Wheeler served as an expert witness on 35 malpractice cases, and later as founder of the first national Telephone Triage conference
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A Nurse-Driven Triage System Evolves
It Took a Village Over a 40+ year period, Wheeler developed a complete triage system.
Major influencers included nurses, an attorney and a physician-mentor. Barbara Siebelt, RN, and later, Laura Mahlmeister, RN, PhD, emphasized the importance of the “duty of due care” emphasizing that expert witnesses request the "paper trail" — written evidence of a system. Carolyn Smith Marker, RN, MS stressed the need for standards. Pat Benner, RN, PhD set forth the blueprint for nursing expertise with her ground breaking work - “From Novice to Expert”.
Robert Smith, JD, advised that systems be integrated, cautioning against having “just bits and pieces". He added that each component served as a “layer of protection” — “an overcoat for safety”, but working together.
Jeff Clawson, MD, pioneer of 911 - Emergency Medical Dispatch —served as Ms. Wheeler’s mentor deeply influencing her work.
Nurse Triage Research
Researchers discovered that nurses used context, heuristics and pattern recognition as decision-making strategies. (Lephrohon, Patel, 1995). Researchers also theorized that medical diagnoses are unnecessary in nurse 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.
While serving as an expert witness (1995-2023) on 35+ malpractice case, Ms. Wheeler discovered patterns of recurrent error (Atul Gawande, MD), in nurse triage. She began devising a Universal Guideline and improving and integrating methods to avoid recurrent error.
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The Future of Nurse Triage
Nurse Triage: An Under-Researched Subspecialty
Despite being practiced since the 1970s, nurse triage remains underdeveloped, partly due to a lack of timely and high-quality research. This research gap may be connected to external challenges, such as conflicting professional, regulatory, and marketplace needs and values. Additionally, the rapid evolution and complexity of nurse triage as a subspecialty, along with its controversial nature, have made systematic examination difficult.
Historically, nurse triage has been positioned at the intersection of competing priorities: cost containment versus ensuring patient safety and timely access to care (Wheeler, 2015). In addition, some researchers in this area commingle clinicians with non-clinicians performing to the task, creating confusion. Terminology is also commingled – telemedicine with nurse triage for example. Studies focus on patient perceptions and satisfaction, important, but not as essential as patient safety, outcomes, standards or guidelines. As a result, we have little substantive clinical evidence or consensus on standards necessary for safe patient outcomes.
Evolving Terminology in Triage
Terminology related to pre-hospital triage is still evolving. At present, “nurse triage” is considered the broadest and most inclusive term, encompassing both remote settings (such as telephone triage, clinical call centers, pre-hospital, virtual, and telehealth environments) and on-site settings (including emergency departments, urgent care centers, and others). Older terms like “advice nurse,” “telephone nurse,” and “telephone triage” are now seen as less helpful or relevant in describing the scope and complexity of modern nurse triage.