Do Triage Nurses Require Familiar Processes & Decision-making Strategies?
Triage Safety Starts with a Nurse-Driven System ......
Triage Safety Starts with a Nurse-Driven System ......
Nursing Process
Pattern Recognition
Context
Heuristics…
“Making it Easy To Do the Right Thing” (IOM,2000)
.......TeleTriage Systems -- Devising Evidence-Based Strategies to Reduce Recurrent Triage Error
.......TeleTriage Systems -- Devising Evidence-Based Strategies to Reduce Recurrent Nurse Triage Error
.......TeleTriage Systems -- Devising Evidence-Based Strategies to Reduce Recurrent Triage Error .......TeleTriage Systems -- Devising Evidence-Based Strategies to Reduce Recurrent Nurse Triage Error
TeleTriage Systems: Advancing Nurse Triage for Safe, Timely Healthcare Access
Company Overview
TeleTriage Systems is a consulting company specializing in the development of nurse triage systems. The company mission is to improve the safety, efficiency, and timeliness of this critical service. When patients call, concerned by worrisome symptoms, nurses assess the symptoms and decide when, where and why 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 disposition decisions. While it is widely believed that telephone triage can reduce emergency department 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 nurse triage. Ms. Wheeler’s career spans over four decades and includes the development of nurse-driven triage systems, CDSS tools, clinical training programs, and a 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 nurse triage and led a task force of 23 expert-level nurses, nurse practitioners and three physicians in developing the first age-specific, five-level nurse triage guidelines. These guidelines are grounded in research on ED nurses’ reliance on heuristics, pattern recognition and context-based decision-making (Patel & Lephrohon, 1995).
Evolution of the Field
Nurse 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 patients and clinicians—has become a convenient alternative to in-person visits. Over time, telehealth will likely replace remote nurse triage, especially as wearable technologies and biotech tools continue to evolve.
In the post-COVID landscape, virtual office visits now serve not only as elective appointments — a convenience — but may soon evolve into pre-hospital nurse triage encounters for worrisome symptoms.
Current Challenges
The emerging subspecialty of nurse triage faces a “perfect storm” of urgent issues:
Inadequate regulation and standards for a rapidly-emerging clinical nursing subspecialty and technology
Competing forces: Patient safe, timely access vs. reducing system costs
ED overcrowding due to inadequate nurse triage policies, structure and process
Inadequate patient access after-hours. Few alternate sites to ED, likely due to outdated policies
Despite the ubiquity of calls to ambulatory settings, clinics, EDs, and call centers since the 1980s, nurse triage has grown unevenly. The rapid advancement of IT and AI has outpaced professional standards and regulatory oversight.
Moreover, many CDSS tools are designed by physician/IT teams without substantive, meaningful input from nurses—who are the primary users—and without rigorous outcome studies. It's unclear if these tools are used as intended or if nurses’ high safety outcomes are driven more by clinical caution than tool effectiveness.
Looking Ahead: Integrating AI Thoughtfully for Improved Outcomes for Patient, Nurse and Organization
Artificial intelligence is poised to transform nurse triage decision support tools. However, many existing CDSS platforms are not yet AI-ready. Confusing and overly complex designs, deficiencies in a clear clinical process and pathways, and an overwhelming number of disposition options make some systems difficult to operate, maintain, revise, scale or to test as a safe, efficient clinical decision support tool. Without thoughtful design, these tools risk becoming obsolete and unsustainable.
TeleTriage System’s Solution: A Return to Clinical Foundations
TeleTriage Systems draws on foundational work from healthcare quality and safety leaders, including Atul Gawande, MD; Avedis Donabedian, MD; Barbara Siebelt, RN, MS; and Laura Mahlmeister, RN, PhD. Ms. Wheeler has synthesized decades of research and standards from top agencies and specialty organizations such as the IOM, Joint Commission, NCQA, MTG, ACEP, ENA, and AAACN.
The company’s core approach is guided by:
The Duty of Due Care to answer the question: “what would the reasonable, prudent nurse (employer) do under the same or similar circumstances?”
The Nursing Process appears to apply to the nurse triage clinical decision support process
Clinical pattern recognition, context and heuristics are used by nurse to triage (Lephrohon and Patel, 1995) and are supported by TeleTriage Systems’ program.
TeleTriage Systems welcomes EBM research on the program
From this foundation, TeleTriage Systems has developed a prospective Universal Guideline, a single, robust CDSS template—essentially an “Uber Triage Checklist.” In her role as a consultant and expert witness in over 35 malpractice cases, Ms. Wheeler has identified several common recurring or unaddressed errors, both human and system related. These insights directly inform the design of a transparent, more reliable system.
Vision
With proper validation through evidence-based medicine (EBM), TeleTriage System’s prospective cloud-based AI-integrated CDSS-EMR could set a new industry standard—improving patient safety, enhancing care quality, reducing resource use, and even contributing to a lower carbon footprint.
This material was lightly revised with the assistance of ChatGPT, a language model developed by OpenAI.
.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions
.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions
-
About Sheila Quilter Wheeler, RN, MSN
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 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.
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 (still ongoing) 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. It is also the first nurse-driven system for nurse triage in a range of settings
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.
-
A Nurse-Driven Triage System Evolves
It Took a Village
Over a 40+ year period, Wheeler developed a complete system. Major influencers 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 the "paper trail" — evidence in the form of nurse triage call documentation, guidelines, clinical training materials, and practice standards. These components are the basis of Wheeler’s system
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” — like “an overcoat for safety”, but working together. TeleTriage systems components are complete and integrated.
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 for four decades..
From 1993-1995, Ms Wheeler led a Task Force of 25+ expert-level nurses, NP's and three MD-reviewers in developing a unique, innovative, five-level, age-specific set of nurse triage guidelines, based on research describing triage nurses’ existing decision-making strategies..
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.
Ms. Wheeler later discovered recurrent error (Atul Gawande, MD), in nurse triage while serving as an expert witness (1995-2023) on 30+ malpractice cases. Ms Wheeler began devising and integrating methods to avoid recurrent error. Stratgies include enhancing pattern recognition and context, prompts, rules of thumb and error feedback.
-
A Research-Based Triage Design
CERNO - I Perceive
Innovation and leadership guided the first and only Age- Based, 5-level triage guidelines with a Users’ Guide built for fast—paced nurse triage.
2025 Recurrent practice and system error will continue to threaten patient safety.
Without substantive research and a a professional platform - a National Association encompassing all of Nurse Triage — Pre-hospital, telephone-triage, clinical call centers and virtual settings — it is difficult to make significant progress.
There is still much work to do.