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Telephone Triage Rules of Thumb

Clinical Decision Making in Telephone Triage

Experts (including clinicians) frequently use Rules of Thumb to make decisions.  These are rules that are generally correct but not scientifically proven.  Rules of Thumb can be useful in telephone triage, when estimating urgency quickly is more important than determining a diagnosis.  Here are several Rules of Thumb below from the Preceptor Workbook, an update to Telephone Triage: Theory, Practice and Protocol Development (1993), and exclusively available with select CE Courses.

Practice Rules

  • Two or more calls within hours or days should be seen urgently
  • Always speak directly with the patient
  • A Patient “too sick to talk” by phone should be seen urgently
  • Beware the “Recent or Previous Diagnosis” Corollary: MD’s occasionally misdiagnose problems
  • Beware of “Non-diagnostic Diagnoses” (Patient’s stereotyped self diagnosis)
  • Beware of “failure to improve” on current Rx, Pain Med, Home Treatment
  • Be mindful of possible atypical, silent or novel presentations
  • Make corrections for your own fallibility
  • The more vague the symptom, the greater the need for assessment.
  • Speed does not equal competence; avoid premature closure.
  • “Temperature extremes often trigger medical problems”. (Clawson, 1998).

Age-Based Rules

  • Kids get sicker quicker.
  • Assess all sick children and elderly for dehydration or sepsis
  • The older (younger) the patient, the greater the risk of hypo- or hyperthermia
  • All sudden confusion in frail elderly is considered emergent
  • Depressed teenagers are at risk for suicide

Symptom-Based Rules

  • All severe pain must be seen within 8 hours or less
  • Beware of pain that awakens patient or prevents sleep at night
  • Any pain between navel & nose is chest pain until proven differently
  • All first time seizures must be seen
  • The first symptom of an MI is denial
  • Beware of MI, Infection, sepsis masquerading as “flu” symptoms
  • “The Eight E’s” of Myocardial Infarct: Extremes of:
    • Emotion
    • Exertion
    • Extreme Age: >75
    • Eating (“Holiday Heart”)
    • Epigastric Distress
    • Early AM
    • Extremes of Weather/Temperature
    • Essential Hypertension

Trauma-Based Rules

  • Never remove impaled objects
  • Trauma + Suspicious History = Possible Domestic Abuse
  • Any face or jaw trauma: Always check for head injury
  • All chemical & electrical burns may be worse than they appear initially
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.