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Emergency Department Telephone Triage

Lessons Learned from Unusual Calls to the ED

Written in 1989 by Sheila Wheeler, this article presents results of an early survey of ED nurses about types of calls managed in the ED.  The following eight anecdotes are taken from 140 reported in a survey of emergency nurses at a 1988 Scientific Assembly lecture. The 370 nurses who participated in the survey attended a seminar by the author on “Emergency Department Telephone Triage.” The anecdotes are taken verbatim from the written responses.

The survey was anonymous and voluntary. It was designed to assess the current state of the art of telephone triage in the emergency setting. Part I (True/False questions) of the questionnaire concerned call volume, acuity, standards, staffing, training, and protocol use.  Part II of the questionnaire requested brief descriptions of the most unusual calls (frightening, humorous, unexpected, and bizarre) received in telephone triage work. Obscene phone calls were excluded. The age and sex of caller, nurse’s response, and pertinent outcomes were requested. Demographic information was not collected. Several participants were from rural settings,  which, in the author’s opinion, partially explains the high level of acuity and lack of backup from other crisis intervention agencies (e.g., the 911 emergency call number and local suicide prevention agencies). Therefore it is also my opinion that the information presented herein does not represent a random sampling of emergency nurses and cannot be considered conclusive. However, the anecdotes do suggest an unmet need for training, improved practice, and perhaps increased staffing for this expanded role.

“Worst case scenarios” contain lessons for routine and crisis calls alike. The suggestions offered here are based the status of telephone triage in 1989 and as an expanded role of the emergency nurse. A scenario introduces each call, followed by a critique, new concepts, and suggestions for improved practice.

Lesson I: With all crisis levels, when possible, stay on the line with the caller while contacting 911.

I received a call from a young man (25 years old) who stated he “had a gun and was going to kill himself.” He was in the military and had just returned to the United States after a year of overseas duty. He caught his wife in bed with another man. I kept the man on the phone while the EMTs and sheriff were dispatched on another phone. When they arrived at the scene (less than 5 minutes from the hospital), the caller had shot himself, his wife, and her boyfriend (all fatally). The whole staff in the emergency department felt helpless. We could not prevent the suicide/homicide despite rapid appropriate procedures.

The nurse who fielded this nightmarish call followed her instincts to “keep the caller talking” and remained on the line. It is a cardinal rule of all crisis intervention agencies to stay with the caller to offer support and ensure sale, effective, and appropriate disposition of the problem} Medical dispatchers believe that telling the caller to redial can result in panic. Instead callers may just’ ‘load up the victim” and drive in, creating further hazard for themselves and other drivers. If the victim is alone, he or she might lose consciousness before redialing and become unreachable.

Considering the availability of other crisis lines, it is surprising that many callers still contact the emergency department. Inadvertently, the nurse is forced into the role of “first responder” to the crisis. Nurses can develop more sophisticated and refined techniques for handling homicidal and suicidal threats by working with other trained members of the crisis team. But, as with the preceding call, some crises cannot be anticipated. In such cases “debriefing sessions” for troubling or unsuccessful calls will help boost morale.

The crisis team consists of trained personnel from the emergency department and 911, suicide prevention, poison control, and rape crisis agencies. In addition to occasionally acting as first responder, the emergency nurse’s role is to expedite and coordinate calls between these team members. In a model ED telephone triage system, standards should include a crisis team interface: specific prioritized data to be documented (i.e., address, phone, age, complaint, cardiac and respiratory status), conference call capabilities, implementation of direct lines, and call tracing procedures. All team members, including nurses, have valuable information and “tricks of the trade” to share with each other. Joint meetings and information sharing in-services can troubleshoot areas of potential bureaucratic red tape. Nurses should be aware that community standards for medical dispatch vary widely. According to one expert, only 10% to 20% of all medical dispatchers are trained in a state-of-the-art program. (2)

In communities where the enhanced (E) 911 call Received a call from a family member. The 16-year-old son is not available, it is possible to locate callers who do not know their addresses by relaying the phone number to the dispatcher. Dispatchers often can use the phone number to find the address; however, it may be time consuming.

If the community has E 911 capability (dispatchers have a computer screen printout of the caller’s address), then this is the quickest way to locate the caller. If the caller is (1) a child, (2) severely confused, or (3) inebriated and cannot give his or her address, the nurse may be forced to hang up after first obtaining the phone number, landmarks, age, complaint, and directing the caller to dial 911. As a final safeguard, the nurse should ensure compliance by personally following up with an immediate call to 911.

Lesson II: Beware of caller noncompliance.

For unknown reasons three callers did not follow the nurse’s instructions to contact 911 or come in. If nurses stay on the line and contact 911 for the victim, they can help ensure an appropriate disposition. This was not the case in the following call:

Received a call from a family member. The 16 year-old son dove into the family pool, hit bottom, and was now complaining of neck pain and numbness and tingling to arms and legs. Family had pulled the patient out of the pool onto a lounge chair. I instructed them not to move the patient further and to call the EMS immediately to transport the patient to the emergency department- The patient arrived 3 hours later—upright in the back seal of the car. After neck and head were immobilized, he was transferred to ICU. Gardner-Wells tongs were inserted lor a 5-6 fracture. Fortunately, there was no long-term disability.

There are two instances when ensuring client compliance is critical. When the symptom(s) seems emergent (Table 3), the nurse should contact 911 directly while remaining with the caller. When the symptom(s) seems urgent, the nurse should make a verbal contract to ensure mutual understanding and commitment to an agreed-on course of action.

In the contract the nurse should tell the caller that he or she is notifying the emergency department of the caller’s impending arrival. Simply telling the client to “come to the emergency department” often is not directive enough. In addition, the nurse must formulate a “presumptive diagnosis”3 based on the severity or acuity- of the presenting symptom(s). She must then apprise the caller of the seriousness of the situation. Dan Tennenhouse, a California physician-attorney, calls this the “duty to warn or terrify.” This duty is based on liability from injury to the noncompliant pa tient who claims that his or her noncompliance was caused by inadequate understanding of the urgency of the situation.4

One way to clearly establish urgency and “warn” clients while using a presumptive diagnosis is to establish a time frame (Table 3) (i.e., “It is my recommendation that you come to emergency within the next hour because your symptoms sound urgent”). Disclaimers are appropriate only in cases where no urgency exists. They serve to place final responsibility for the disposition back on the client’s shoulders.

Lesson III: Develop crisis intervention “crash cards.”

Fourteen calls involved cardiac or respiratory arrest. In all of these calls, nurses were forced into the role of “first responder” to the crisis. Some possible explanations might be (1) 911 lines were busy, (2) local medical dispatchers were not trained to give pre- arrival instructions, or (3) in some rural settings, local emergency departments are the only places to call for help. Just as the “crash cart” is used for rare but inevitable cardiac arrests, emergency nurses can prepare for crisis calls with “crash cards.” Crash cards are treatment or action oriented protocols and differ from routine protocols, which are more diagnostic or analysis oriented. They are modeled after pre-arrival instructions used by medical dispatchers. A bare bones set of crash cards might include protocols for adult and child cardiac or respiratory arrest, choking, and childbirth.!

Woman caller stated that she “could not get her 18-year-old son off the floor.” He would not wake up and was not breathing. I helped the mother give CPR until the police arrived. The young man expired on arrival. I felt good about helping.

Woman in panic stating, “My baby isn’t breathing.” I got address, age of child, and had co-worker dispatch an ambulance. The mother stated that the child was getting blue. Mother dropped phone and went to give CPR until the ambulance arrived but the child eventually died. Diagnosis: sudden infant death syndrome.

Calls by parents wanting advice while “awaiting the ambulance.” I have fielded three choking and 20 pediatric ingestion calls.

Most nurses surveyed reported that cardiac/respiratory arrest victims did not survive. We have no way of knowing whether the outcome would have been more successful if a crash card for CPR or the Heim lich maneuver had been in place. However, statistics5’6 show that formal protocols produce more successful CPR coaching. A current myth suggests that nurses can successfully coach in CPR from memory. None of the nurses mentioned any sort of protocol or training for CPR coaching. Several expressed a desire for more formal training. A CPR crash card could be a lifesaver and morale booster.

Training programs for medical dispatchers working on 911 calls include CPR, Heimlich, childbirth, 30 different pre-arrival instructions, and psychologic techniques for coaching and calming callers. This coaching helps most callers to regain self-control and enables them to deliver effective pre-arrival care (first aid). Jeff Clawson, a Salt Lake City fire surgeon/medical director, developed a model program 10 years ago. He saw the medical dispatcher as the weak link in the sophisticated, multimillion dollar EMS sys tem. His training program has since become the national model for all emergency medical dispatcher training.1

Lesson IV: Develop protocols for a suicide in progress and suicidal threats.

Thirteen of the calls were overdoses or threatened suicide. One nurse’s courageous and candid self-disclosure demonstrates the incredible dilemma in which nurses are placed when understaffed.

I answered the phone and a female voice very calmly stated, “I have just taken a major overdose of pills and I want to know how long it will take me to die.”

Nurse: Miss, you need to be seen in the emergency depart ment. What kind of pills did you lake?

Caller: I want to die.

Nurse: Where do you live? What is your name?

Caller: I don’t want to tell you.

Nurse: I am trying to help you. Please tell me where you live or at least your name

Gsifer (very angrily): I want to die! You don’t care! All of you SOBs don’t care!

The caller hung up before I could answer. At the time our emergency department had two codes in progress and every room was full. Patients were angry because they weren’t being seen soon enough. I felt overwhelmed with this call. I don’t feel equipped to handle the caller who needs psychologic counseling, not to mention the medical emergency. In fact, I became angry with myself later because I was so busy in the emergency department that I was relieved when the caller hung up. In fact, I was so annoyed that she even called and when she hung up, I really didn‘t care.

Participants in this survey related that suicidal calls had the most demoralizing effect since many of the callers disconnected before help could be sent. Nurses said they felt “impotent,” “angry,” and “depressed.” This nurse was acutely aware of her need for and lack of psychologic and medical crisis intervention skills. With suicidal calls the nurse must differentiate quickly between low and high lethality- situations. Suicidal ideation requires psychologic sup port (suicide prevention); a suicide in progress is a medical emergency requiring 911 intervention. Additional training from suicide prevention agencies can help emergency nurses refine and enhance their psychologic and communication skills.7,8

Lesson V: In. crises, expect impaired judgment.

Rarely is a crisis simply a medical one. Conflicting emotions and irrational thoughts and impulses flood the minds of not only the callers and victims but also the nurses responding to the call. Clients in crisis revert to a regressive emotional state: they become helpless, hopeless, and childlike. They may be angry, panic-stricken, disoriented, or have impaired judgment, especially if they are the victim.

In such cases the antidote to fear is action—action supplied by first-aid coaching or simply turning on the porch lights and opening the door for the arriving paramedics. When callers realize there is something they can do to help the victim, their anxiety diminishes and their sense of control is restored. Likewise, when nurses have a protocol from which to coach, it will diminish their anxiety.

“Emotional overload” and distorted thinking also can contribute to client noncompliance. Parents of injured children may delay reporting accidents or ingestions because of embarrassment, guilt, denial, or simple ignorance. Family disgrace and legal implications may complicate a serious medical problem. Discovering “hidden agendas” can be extremely difficult. The following case shows how fear of parental reprisal led to a delay in medical care.

Boyfriend called several times reporting girlfriend’s symptoms (pelvic pain, increasing bleeding), 1 encouraged, treatment immediately. The 15-year-old patient finally came in 36 hours later in critical condition. Finally, the parents realized the problem. The boyfriend was 18 and the girl was a minor. There was fear of parental repercussions. The girl survived (uterine tear). The family was unaware of racial involvement.

Lesson VI: Believe the client when he or she says it is an emergency.

It is not up to the client to prove that the situation is a crisis. Nurses who fail to heed this rule are courting disaster.10 This nurse responded appropriately by taking the symptoms seriously, although her instincts originally told her this problem was not serious. A mother called saying her 23-year-old daughter was having severe chest pain. I advised the mother to bring the daughter to the emergency department. She said the daughter was too ill to bring by car. I further advised an ambulance. I didn’t doubt the severity of the call but “I knew” it wasn’t a myocardial infarct. The diagnosis was acute myocardial infarct. The patient recovered and was transferred to a nearby medical center for more studies.

Lesson VII: Get complete information.

The “routine” cases that seem least important may be the ones to come back and haunt a nurse.3 The following example illustrates how failure to collect baseline data (location of bee sting) and give appropriate follow-up instructions can lead to further complications.

A child was stung by a bee. After determining that there was no respiratory distress, the nurse advised ice and, if necessary, meat tenderizer. Two days later the mother brought the child into the emergency department with severe chemical conjunctivitis and possible blindness to the eye. The mother never told where the sting was (eyelid) and the nurse never asked.

The “true grit” of routine telephone triage is painstaking (and time-consuming) data collection (Table 4).5

Lesson VIII: Always err on the side of caution.

This nurse sensed the potential danger of the injury and followed her instincts to have the caller come in.

Mother called. Child (3 years) fell with a “stick” in mouth. No visible bleeding. They brought the child in and there was a 6 cm jagged laceration in back of throat about 1 cm away from carotid.

The Dilemma of Telephone Triage

In many ways telephone triage is still in an embryonic state. Its underdeveloped status is most obvious in glaring case histories such as the ones presented herein. So far the system has failed to recognize the need to formalize telephone triage into an expanded role. A “pro-active” stance (one that seeks to anticipate problems before they arise) can combat persistent anxiety about “nursing liability.”

Some nurses maintain that armed with only a telephone, it is unlikely that you can prevent child abuse, suicide, or murder. A pro-active approach argues that such an attitude is contrary to the experience of crisis team members and stress hotlines, all of which successfully avert crises (and occasionally save lives) by telephone every day.6”9 Should the standard for the emergency nurse be any different?

Nurses must continue to do the best they can with what they do know and do have. Unfortunately, in many institutions nurses perform telephone triage without proper documentation, training, standards, protocols, or adequate staff. This approach reduces telephone triage to a trial-and-error process—one de void of basic nursing principles. A pro-active approach seeks to further develop and define the practice of this expanded role.

Responsibility for deciding on a course of action (based on options provided by the nurse) belongs to the caller. Under ordinary (nonemergent) circum stances, this is true and disclaimers are especially appropriate for these calls. However, under crisis conditions, “The caller in crisis becomes our problem.”2

We are forbidden to give advice. Some maintain that emergency departments are advertised and hold themselves out to the community as a service providing emergency care. Therefore the nurse has a duty of care that extends to the client presenting by phone as well as one who presents in person.4 Accordingly, to give no advice and to give “generic instructions” to “come to the emergency department,” or simply to tell callers to dial 911 and hang up are flawed, unworkable, and dangerous approaches. Many callers need interim first-aid advice to prevent further injury or death. By quickly assessing and ascertaining how soon the client needs to be seen and giving interim first aid, the nurse can avert possible client abandonment and potentially save a life.

Such calls are so rare, why go to the length of developing protocols for them? It could be likewise argued that because cardiac arrests in the hospital setting are so rare, why bother to have crash carts? It is the nature of all professions to seek the highest standards in keeping with our ever-expanding technology and body of knowledge.

CONCLUSIONS Studies of ED telephone triage in 1980 and 1984 called for protocol development, training, and improved staffing.11’3 A recent study14 shows that little has changed. Clearly, the anecdotes presented herein are at the extreme end of the acuity continuum. However, such examples are needed to shock the health care industry into taking action. Carolyn Smith-Marker, MSN, pioneer of nursing standards and guality assurance, identifies the goal of all nursing as “safe, effective, and appropriate care.”Telephone triage should be no exception. These surprising and tragic tales point out the need to raise standards for all calls—routine and crisis. In closing, a final anecdote from this informal survey: just last week we coached a man through CPR on his wife. We had no protocols, but we did okay. Please send some “info” or publish them. Please!


1. Clawson JJ, Democoeur KB. Principles o( emergency dispatch. Enqlewood Clifis, New Jersey: Brady Books, 1968.
2. Clawson II. 60 minutes [interview]. CBS, 1988:Dec 25.
3. Politts EK. Medicolegal aspects of telephone triage. In: Wheeler SQ. The expanded role of telephone triage. San Anselmo. California: Wheeler and Associates, 1988.
4. Tennenhouse D. Legal aspects of telephone triage. In: Future trends in nursing Iseminarl. San Francisco: San Francisco General Hospital. 1988.
5. Wheeler SQ. The expanded role ol telephone triage. San Anselmo, California: Wheeler and Associates, 1988.
6. Eisenberg MS. Hallstrom AP. Carter WB, Cummins RO, Bergner L, Pierce I. Emergency CPR instruction via telephone. AmI Public Health 198S;75:47-50.
7. Eisenberg MS, Cummins RO, Litwtn P, Hallstrom AP, Hearne T. Dispatcher cardiopulmonary resuscitation instruction via telephone. Crit Care Med 1985; 13.-923-4.
8. Neville D, Sharon B. The suicidal phone call. J Psychosoc Nurs 1985;23:14-8.
9. Reubin R. Spotting and stopping the suicidal patient. Nursing 1979(Apr):83-5.
10. Turner SR. Golden rules for accurate triage. J Emerg Nurs 1981;7:153-5.
11. Shah CP, Egan TI. Bain HW. An expanded emergency service:role of telephone services in the emergency department. Ann Emerg Med 1980;12:617-23.
12. Levy IC, Strasser PH, Lamb GA, el al. Survey of telephone encounters in three pediatric practice sites. Public Health Rep1980;95:324-8.
13. Knowles PJ, Cummins RO. ED medical advice telephone calls: who calls and why? I EMERG NURS 1984;10:283-6.
14. Verdile V, Paris PM. Stewart R. Emergency department telephone advice. Ann Emerg Med 1989:18:279-82.
15. Smith-Marker CG. Setting standards for professional nursing the Marker model. Baltimore: CV Mosby. 1988

Used with Permission Journal of Emergency Nursing, Elsevier

Author’s note:  Policies for ED telephone triage have changed little since 1989, possibly contributing to a delay in care.


Written by Sheila Wheeler (15 Posts)

SHEILA WHEELER, RN, MS, is acknowledged as an international expert in the field of telephone triage. She has practiced nursing for over 30 years, primarily in critical care, emergency department and clinic settings. An accomplished writer, educator, researcher and consultant, Ms. Wheeler is currently President of TeleTriage Systems in San Anselmo, California.