*** FAQ Frequently Asked Questions

*** FAQ Frequently Asked Questions

Students sitting in a classroom, listening and smiling.

FAQ: How Can Telephone Triage be Made More Safe?

Patient Safety in Telephone Triage

The IOM report drew from disciplines (engineering, psychology and occupational health) and applied opportunities to improve patient safety to health care.  Ms. Wheeler has adapted IOM’s basic concepts and included exemplars from both remote and on-site triage tools.

1. “User-Centered Design” (IOM). Designed for the Nurse “End User”, TeleTriage System Nurse-driven and -designed triage system is unique and innovative.   Focusing on making it easier “to do the right thing” (IOM, 2000, Atul Gawande, MD 2018)

2. “Avoid Reliance on Memory by Standardizing the Process” . Standardize and Simplify the Process. Three examples of how TeleTriage Systems’ protocols, guidelines and checklists enhance safety and avoid reliance on memory are the Nurse Triage Process Workflow, Triage QA Audit and the Universal Guideline Template. The QA Audit includes several checklists to standardize triage assessment. The Nursing Process is modified and integrated into Universal Triage Guideline Template.

3. “Attend to Work Safety” Developing and improving triage standards related to shift length, high volume systems, working conditions, equipment quality and distractions will impact patient safety. Examples include improved wireless headsets, quiet rooms set aside for triage, shorter Shifts to avoid decision fatigue, several or larger screens, User friendly technology.

4. “Train Concepts for Teams” The triage process typically involves Interdisciplinary teams.  Training Triage Teams together (Physicians, Clerical staff, nurses, ED resource team members, as appropriate) fosters mutual trust in diverse teams’ competence and expertise, and may strengthen access, continuity and safety.

6. “Involve Patients in Their Care” Patient and Family Health Literacy can be bolstered through patient instructions abut the Triage Service, and “how to prepare for the encounter and to help the triage nurse to help them”.  A Patient Instruction kexample is part of the User’s Guide in all Guideline volumes.

7. “Anticipate the Unexpected“ By its very nature, he work of triage is uncertain and urgent. Some rules of thumb and policies are integrated into the Guidelines and Documentation, as well as the training manual.  In addition, “technology introduces new error, even when its sole purpose is to prevent errors” (IOM). Check on Planned Error Feedback to correct error quickly.Awareness and Communication at regular triage staff meetings

8. Design for Recovery. “Assume that error will occur and plan for recovery” (IOM) Triage role playing by practicing tasks, processes based on previous case studies and actual encounters. In the future, a feature of Planned Error Feedback, will be a standard policy that supports learning patient outcomes without endangering HIPAA patient privacy.

9. “Improve Access to Accurate, Timely Information”  In the triage task, estimating patients’ risk level is critical for estimating urgency. The EMR plays a major role here,. by providing a summary of essential patient contextual information (past and recent medical history, allergies, medications, pregnancy status). Remember to “Trust but Verify) (always update and correct the patient history).

 Built-in written or electronic prompts in the EMR can help nurses to verify, update and correct these summaries. EMR Prompts should also include Lab, and recent on-site visits, telephone or telehealth encounters. Neglecting to include this recent  medical  Information can increase risk, and  lead to under triage and unsafe outcomes. 

Telehealth Nursing: An Evolving Specialty

Are We Asking the Right Question?

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.com was an internet presence to telehealth industry beginning in 1989. 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

Mission - Vision - Standards

  • 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.

  • 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

  • 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

Advancing Telephone 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 or remote 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, MS, 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 clinicians 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 the nascent nurse triage subspecialty, to monitor patient safety of new technologies, as well as to support triage systems of excellence.

  • Inadequate Technology Regulation: IT, and AI development appears to be outpacing clinical standards, evidence based medicine, and regulatory oversight.

  • Inadequate Patient Access: Patient access is severely limited After Hours. Outdated Policies that limit patient access to Office hours (40 Hours M-F). are likely contributing to ED overcrowding . After Hours —from 5PM - 9AM M-F, and every Saturday Sunday and Holiday —the ED is transformed into the “venue of last resort” for patients with worrisome symptoms .

  • A growing trend is to expand patient access — and relieve ED overcrowding — through extended hours. UCLA’s innovative Immediate Care program is one such example.

Despite the ubiquity of pre-hospital triage — telephone encounters to ambulatory settings, clinics, student health centers, ambulatory surgery, clinical call centers and EDs —the field has no cohesive professional organization to call its own. Broadly speaking, nurse triage has grown unevenly, leaving gaps which require development.

Initially, the first paper triage protocols and guidelines were developed by physicians . Later, physician/IT teams developed Computerized ClinicaL Decision Support Systems (CDSS) with input from nurses — the primary users. Due to proprietary nature of these technologies, there are few rigorous outcome studies (EBM) on Patient outcomes and the validity and reliability of CDSS design, or of a given system’s overall completeness and integrity

Research indicates that nurses’ appropriate referral rates are higher than physicians (Wheeler et al 1995). The reasons for this are not clear. Do nurses use CDSS as intended? Are nurses utilizing a different methodology? Are nurses more clinically cautious?

TeleTriage System’s Solution: Research, Clinical Foundations, Nurse-Informed Design

While the settings and approaches 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

  • Pattern Recognition, Patient Context, Heuristics

  • Clinical Training in Remote Care

  • Evidence-Informed Triage Systems & Practice, Safe, Timely Patient Outcomes

Ms. Wheeler’s work is informed by 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.