CHAPTER 3: RULES OF THUMB FOR TRIAGE

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A Rule of Thumb is defined as a “principle with broad application that is not intended to

be strictly accurate”. It is an easily applied procedure for approximation, an educated

guess, intuitive judgment, or common sense. Rules of thumb may be used to guide

decisions and to reduce error. Cardinal rules may help avoid root causes of errors of

assessment, communication and/or continuity. These rules generally apply to Prehospital, Virtual (telehealth) and on-site (ED) Triage settings.

Several Rules of Thumb below are attributable to Jeff Clawson, MD, Pioneer and Founder of Emergency Medical Dispatch (911).

• Cardinal Rules of Thumb for Triage

  • Time is tissue, Time is muscle.

  • Care delayed is care denied.

  • To Err is Human, to delay is deadly

  • Pre-Hospital: frequent calls within hours or days should be seen urgentlySpeed does not equal competence; avoid premature closure.

  • Beware all “flu-like” symptoms that can “mask” MI, Infection or sepsis.

  • Whether in person or pre-hospital: Patient “too sick to talk” is a “Red Flag” and may require an urgent or emergent on-site evaluation.

• Trauma-Related Rules

  • All chemical and electrical burns have the potential for progressive injury

  • Never remove impaled objects

• AGE-BASED RULES (All ages)

  • Assess all sick children (and elderly) for possible dehydration and sepsis

  • The older (or younger) the patient, the greater the risk for hypo- or hyperthermia.

• Pediatrics

  • “Kids get sicker quicker.”

  • Infants < 3 Months: Fever of 38ºC or 100.4ºF® – see immediately.

• Elderly

  • Elderly may present symptoms in silent, atypical or novel ways

  • Elderly at highest risk for competed suicide: White male, > 65, widower/divorced,

  retired/jobless.

• Teenagers

  • Impulsivity may mean teen, college or Young Adult is > risk for suicide/violence

  when stressed/depressed

• Childbearing Age

  • Once an ectopic, always ectopic

  • Any bleeding in pregnancy is an ectopic until proven otherwise

• Symptom-Based Rules

  • All severe pain is considered an emergency (ACEP)

  • Beware of any pain that awakens patient or prevents sleep at night

  • Headache: “First, Worst, Cursed, Burst or 51st” = Emergent

  • In women, diabetics and elderly MI may present as vague, silent or atypical.

  Excerpted with Permission from CE course: “ Telephone Triage: Essentials for Expert Practic”e by Sheila Quilter Wheeler, RN, MS, President, TeleTriage Systems

  Copyright 2025-2026. Sheila Quilter Wheeler, TeleTriage Systems

References for Rules of Thumb  

1.     John Saunders, The practice of clinical medicine as an art and as a science West J Med. 2001 Feb;174(2):137–141 1

2.     Malin André 1, L Borgquist, M Foldevi, S Mölstad  Asking for 'rules of thumb': a way to discover tacit knowledge in general practice. Fam Pract. 2002 Dec;19(6):617-22. doi: 10.1093/fampra/19.6.617.

 3.     Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: Theory and implications. Acad Med 1990; 65: 611–621

4.     Gigerenzer G, Todd P and the ABC group. Simple heuristics that make us smart. Oxford: Oxford University Press, 1999: 3–34.

5.     O’Neill E. Heuristic reasoning in diagnostic judgement. J Prof Nurs 1995; 11: 239–245.

 6.     Essex Ben. Doctors, dilemmas decisions. London: BMJ Publishing Group, 1994.

7.     Morgan D, Kreuger R. The Focus Group Kit, Vol 1. London: Sage Publications, 1998: 9–15.

8.     Morgan D, Kreuger R. The Focus Group Kit, Vol 2. London: Sage Publications, 1998: 55–71.

9.     Crabtree B, Miller W. Doing qualitative research. Newbury Park: Sage Publications, 1992: 13–21.

10.  McWhinney I. A textbook of family medicine. Oxford: Oxford University Press, 1997: 123–155.

13.  Malterud K. The issue of validity regarding the contents of consultations. Scand J Prim Health Care 1993; 11 Suppl. 2: 64–67.

 14.  van Leeuwen YD, Mol SSL, Pollemans MC, Drop MJ, Grol R, van der Vleuten CP. Change in knowledge of general practitioners during their professional careers. Fam Pract 1995; 12: 313–317.

15.  Westin S. Problem solving styles of general practitioners in simulated clinical situations. Fam Pract 1984; 1: 92–99.

16.  Greer AL. The state of the art versus the state of the science. I J Tech Ass Health Care 1988; 4: 5–26.

17.  Soumerai S, Avorn J. Principles of educational outreach (‘Academic detailing’) to improve clinical decision making. JAMA 1990; 263: 549–556