Telephone triage
- - remote, real-time clinical decision making --
need not be so uncertain and risky.
Safety starts with a system.
.......TeleTriage Systems -- Devising Solutions & Strategies to Reduce Recurrent Telephone Triage Error
.......TeleTriage Systems -- Devising Solutions & Strategies to Reduce Recurrent Telephone Triage Error
TELEHEALTH AND SYSTEM ERROR
From 1995-2018, Ms. Wheeler served as an expert witness on 35 malpractice cases involving telephone triage - a turning point in her career. Recurrent error was often involved. For 40+ years Ms Wheeler has worked diligently on solutions to avoid recurrent error. TeleTriage Systems represents the legacy of Ms Wheeler and other experts to make telephone triage safer. Many recurrent errors are still unaddressed. Clinician error may be related to corporate (system) error.
FAILURE TO ASSESS or TO ELICIT ADEQUATE INFORMATION: Incurious, passive clinicians, placing the burden to provide all essential information on a lay-person -- patient or family.
FAILURE TO DOCUMENT & TO COMMUNICATE with patients, family, healthcare providers, Failure to obtain Patient Informed Consent
IIGNORING RED FLAGS: In addition to extremes of age and chronic illness, Failure to identify high risk symptoms frequent calls over hours or days are signs of patient anxiety Failure to factor in recent environmental events -- Heat/Cold extremes, occupation or
GUIDELINE ERROR: Failure to use any guideline, selecting the wrong guideline, using a guideline incorrectly.
COGNITIVE ERROR: Stereotyping symptoms or patients, jumping to conclusions, confirmation bias, attribution error and others
RED HERRINGS (Distractors): Relying on the previous misdiagnoses and/or ED visit outcome, or relying on patient misperceptions of symptoms
System or Corporate Error: Failure to provide adequate After Hours patient access to care (alternative venues for further evaluation). Inadequate follow -up Error Feedback to clinicians about their triage decisions - appropriate or inappropriate. Excessive Call volume or Inadequate Staffing. Inappropriate Staffing non-clinicians. Failure to provide Standards or Clinical Training, Inadequate Guidelines, Technology, EMR and CDSS.
TWO HISTORIC SYSTEM ERRORS: CLINICIANS WORKING IN A VACUUM & WORSENING LACK OF PATIENT ACCESS AFTER HOURS RESULTING IN DELAY IN CARE (see below)
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About Sheila Wheeler
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.
Her first solution was two books, both written for the layman by physicians (Vickery, Fries and Pantell). They were the first telephone triage guidelines in that ED. 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, remote assessment 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, as a consultant, Wheeler taught a clinical course -- “ The Fine Art of Telephone Triage”. The training syllabus gradually evolved, and, four years later, became a book proposal. Nine publishers rejected the proposal, but she persevered. In 1993, Wheeler and medical writer, Judith Windt, completed training manual including real-life case-study audiotapes, and “Telephone Triage: Theory, Practice and Protocol Development" was published by Delmar Publishers.
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.
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A Telephone Triage System Evolves
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 stressed the importance of written evidence of the duty of due care — 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, founder of 911, served as mentor and role model as both he and Ms. Wheeler respectively pioneered their unique, innovative fields over the last 40 years.
Early telephone triage research was sparse, confusing and often flawed. Some researchers treated the task of clinical decision-making as “appointment making”. Some studies commingled non-clinicians with clinical decision maker.
Experts compared hard-copy (paper) Telephone Triage Protocols to “standing orders” — like having a physician-advisor at one’s elbow while on the phone.
In 1993, Ms Wheeler led a Task Force of 25+ expert-level nurses, NP's and MD-reviewers to develop a unique, innovative five-level, age-specific telephone triage guidelines.
With a foundation of real-world experience, Wheeler scoured the research extrapolating standards and tools from authoritative sources -- ACEP, Joint Commission, AHRQ, MTG to build a robust, complete system.
Ms. Wheeler reached two more significant turning points, serving as an expert witness on 35 malpractice cases and following the work of Atul Gawande, MD.
Currently, recurrent practice and system error still threaten patient safety. Without a professional platform - a National Association of Triage Nurses (remote, telehealth and on-site) — it is difficult to make significant progress. There is still much work to do.
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A Telephone Triage Universal Guideline
From Universal Guideline to AI-CCDSS (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 for remote and on-site triage environments.
Innovations included broadening the content, to increase accessibility to the widest possible population. Home treatment instructions include low-cost home treatments, self-help and support group lists and 5th to 8th grade literacy level —for multi-lingual and multi-ethnic populations.
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: Common errors and even system error was being ignored. .
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 service. Hi-tech is outpacing clinical standards in both fields. This is a new risky development, of which the telehealth industry has made little note.
“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 AI-ready proof of concept for Computerized Clinical Decision Support System (CCDSS).
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 .
.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions
.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions
DOES SYSTEM ERROR IMPAIR TELEPHONE TRIAGE EFFECTIVENESS?
WORKING IN A VACUUM & INADEQUATE AFTER HOURS ACCESS TELEPHONE TRIAGE NURSES TYPICALLY WORK IN A VACUUM - A PERSISTENT ERROR FOR OVER 40 YEARS Remote triage is uncertain and urgent at best. Clinicians performing this task typically work in a vacuum, rarely receiving daily feedback on their decisions. If AI can be trained to learn from its mistakes and successes, then why not clinicians?
Technology can be developed so that HIPPA regulations will both protect patient privacy and insure correction of desicionmaking error. HIPPA rgulations can and must be managed to allow for Planned Error Recovery.
INADEQUATE AFTER HOURS ACCESS A SYSTEM ERROR? Would that patients only got ill between the hours of (9-5, M-F)! In healthcare, office hours seems like a throwback from the 1950's. Patients often become ill during the After Hours period -- 5PM-9AM and 24 hours on weekends and holidays. For decades, repeated research studies on ED overcrowding point to inadequate patient access to care. The healthcare system is stressed, and low-income patients and others cannot afford to take time off work to keep appointments during office hour, it seems reasonable to expand access.
A SOLUTION TO PATIENT ACCESS AFTER HOURS A "venue of last resort" is defined as “a place or institution used as the final option when all other possibilities are unavailable”. Currently, the ED is often the “venue of last resort” for patients requiring medical evaluation after hours. Given the clinician stress (and increased error) related to overcrowding, as well as the expense, doen’t it make good sense to improve patient access by expanding Urgent Care hours? A reasonable and prudent policy (both legally and economically). Urgent Care -- daily from 5PM-11PM, and 7AM-11PM on weekends and holidays?
RESEARCH: AI & Telephone Triage
NEW relevant, Innovative research: Machine learning models predict under triage in telephone triage, Inokuchi et al., Annals of Medicine.
To Err is Human, to delay is deadly New research describes the role of AI in reducing under triage (and delay in care) in pre-hospital telephone triage by nurses. Unlike any current studies - typically focused on in-person triage of emergent symptoms — this research focuses on how AI might help reduce undertriage of ostensibly non-urgent symptoms in remote triage — a more difficult task. Questions and suggestions follow;
· The amount of symptom data collected (and relied upon) is not clear and four risk categories seemed sparce (patient age, sex, chief complaint category, comorbidities).
· Were “Fire and Disaster Management Agency Protocols” medically developed or EBM? A sample protocol and previous protocol outcome results would be helpful for comparison.
· How are nurses trained to use these protocols -- as decision-making or decision support tools? If used for decision support, then what clinical training for telephone triage did they have? Will nurses be required to use AI-supported protocols as decision-making tools?
· In telephone triage, proficiency is linked to safe outcomes, not speed (Perrin & Goodman, NEJM,1978)
Telephone Triage -- remote clinical risk assessment and decisionmaking “under conditions of uncertainty and urgency” (Lephrohon & Patel, 1995) – requires pattern recognition (with or without AI). Pattern recognition requires adequate detail. If telephone triage is plausibly analogous to a virtual history and physical, then the duty of due care (the standard), requires that nurse elicit information and identify red flags (risk factors) to rule out urgent symptoms.
Generally speaking, eliciting symptom history, functional status, and medical history are all essential. Is it a high risk patient, with high risk symptoms? Both? Or none? In addition to the Patient Medical History checklist described, rule out questions might include: immunodeficiency, immunosuppressive disease, Implant, Invasive events: Post-Op; Post-Partum; Post-Procedure; Trauma; Large Burn, Recent injury or International Travel.
Protocols, EMR, clinical training, experienced clinicians and professional standards are all part of a complete telephone triage system. Hopefully, as Computerized Decision Support Systems improve, AI will serve as a Clinical Co-pilot – suggesting reasonable, prudent triage levels, with the nurse as the final decision maker.
Perrin EC, Goodman HC. Telephone management of acute pediatric illnesses. The New England Journal of Medicine 1978;298(3):130-5.
Leprohon J, Patel V. Decision-making Strategies for Telephone Triage in Emergency Medical Services. Medical Decision Making. 1995;15:240-53.
RESEARCH: AI & ED TRIAGE
A recent JAMA Commentary provides an analysis of ED triage research and the application of AI and Large Language Models (LLM) to ED Triage on-site. Friedmans’s analysis suggests it may be too early to know AI’s effect on ED triage. He suggests a human-machine hybrid — AI as a clinical-co-pilot to clinical decision makers. Williams asks “Is just being able to do something the bar for using AI, or is it being able to do something well, for all types of patients?”
Since the 1980s, ED overcrowding has continued to increase. Are patients (perhaps low-income groups, lacking adequate access) increasingly self-triaging to the ED, thereby compounding overcrowding? Recent studies point out negative consequences: reduced patient safety, increased staff stress level, increased error, and delays in care.
One wonders if increasing research studies on how AI can reduce ED overcrowding is on the right track? Increasingly crowded EDs are a major systemic problem that likely needs to be solved first. Is overcrowding solved by enlisting AI to support ED staff to triage new arriving patients more rapidly? Given ESI triage mismatch, how can the ESI tool meaningfully apply to self-triaged patients, inappropriately now on-site?
ED overcrowding is likely a long-standing symptom of inadequate patient access to less emergent venues – open for expanded hours, not just office hours. Inadequate access also can also sabotage the effectiveness of telephone triage, its original purpose — to reduce inappropriate ED visits. It was also intended to make health systems overall more cost-effective. Without expanded access and improved pre-hospital triage systems, ED overcrowding will likely continue to worsen.