Triage —
— Pre-hospital, Virtual & On-site —
requires real-time, rapid, repeated, safe
clinical decision making…
Triage need not be so
uncertain and risky.
Safety Starts with a System.
.......TeleTriage Systems -- Devising Solutions & Strategies to Reduce Recurrent Triage Error
.......TeleTriage Systems -- Devising Solutions & Strategies to Reduce Recurrent Triage Error
TeleTriage Systems: Advancing Telephone Triage for Safer, Smarter Healthcare
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. 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, 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 disposition decisions. While it is widely believed that 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 development of nurse-driven triage systems, CDSS tools, 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 and led a task force of 23 expert-level nurses, nurse practitioners and three physicians in developing the first age-specific, five-level pre-hospital triage guidelines. These guidelines are grounded in research on ED nurses’ reliance on pattern recognition and context-based decision-making (Patel & Lephrohon, 1995), applying a heuristic approach to clinical decision-making.
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 patients and clinicians—has become a convenient alternative to in-person visits. Over time, telehealth will likely replace traditional telephone triage, especially as wearable technologies and biotech tools continue to evolve.
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 field of telephone triage faces a “perfect storm” of urgent issues:
Inadequate regulation and standards for a still-emerging clinical subspecialty
Patient safe, timely access vs. reducing system costs
ED overcrowding due to inadequate pre-hospital triage structure and processes
Insufficient patient access after-hours to alternate sites other than the ED, often due to outdated policies
Despite the ubiquity of triage calls to ambulatory settings, clinics, EDs, and call centers since the 1980s, the field has grown unevenly. The rapid advancement of IT 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
Artificial intelligence is poised to transform decision support tools. However, many existing CDSS platforms are not yet AI-ready. Overly complex designs, lack of a clear clinical process and pathways, and an overwhelming number of disposition options make these systems difficult to maintain, revise, or scale. 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
The Nursing Process
Clinical pattern recognition and context
Evidence-based clinical guidelines
Safe, Timely Patient Outcomes
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 recurring error, both human and system related. These insights directly inform the design of safer, more reliable tools.
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.
Triage Nursing – Subspecialty or Skill?
The distinction is drawn between a subspecialty, which is a focused area of nursing practice , advanced knowledge and skills in a specific patient population, disease, or care setting (e.g., Cardiology). Requirements include a specific body of knowledge, education, training, and experience. A skill, defines how care is delivered.
So, is triage nursing— conducted on-site, virtually, or via phone— a clinical subspecialty or simply a set of skills? Arguments supporting triage as a challenging nursing subspecialty:
Care Settings Triage is ubiquitous. Pre-hospital triage involves patients calling remotely about worrisome symptoms, and typically originate from home. These calls are received in diverse settings — Ambulatory and Emergency Departments to clinics, student health centers, clinical call centers and urgent care units.
Triage practice may require working 8 -12 hour shifts, making repeated, rapid (within 3-15 minutes), complicated clinical decisions, under conditions of uncertainty (unknown, unseen or even virtual patients). This volume and intensity of triage to identify or rule out high risk -patients, --symptoms and/or situations is a high risk for decision fatigue.
Triage populations are broad patient groups uniquely calling about worrisome symptoms, (possibly life-threatening to non-acute). Disposition choices range from venues and time frames of descending acuity, with diverse clinical resources, specialized tests and technologies.
Clinical training identifying high risk patients, situations and/or symptoms, using symptom pattern recognition and patient context (age, chronic illness, literacy level, etc)
As a subspecialty, triage involves utilizing a modified nursing process (in italics):
Assessment – Elicit symptoms, Use pattern recognition and context to identify urgent symptoms.
Diagnosis – Estimate symptom risk by applying CDSS
Planning/Implementation – Formulate a Disposition, confirm patient informed consent.
Evaluation – Review patient outcomes and clinician triage decisions for Improved System Function.
.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions
.......TeleTriage Systems -- Asking the Hard Questions....and Providing Workable Solutions
-
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.
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.
-
A Pre-Hospital 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 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. She served as an expert witness on 35 malpractice cases (1995-2023) and follower of Atul Gawande, MD, applying his concepts to pre-=hospital triage to reduce recurrent error.
-
A Triage Universal Guideline
CERNO - I Perceive
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.