TELEPHONE TRIAGE GUIDELINES — DEVELOPED BY NURSES FOR NURSES
From the very Beginning….
For over 40 years, I have worked, consulted and pioneered the field of nurse telephone triage. In the early 1990’s I wrote the first training manual for telephone triage and learned about Duty of Due Care. I learned about this legal principle— intended to reduce medical malpractice and negligence — from Barbara Seibelt, RN, legal consultant.
In 1995, I began consulting on telephone triage malpractice cases. Lessons learned from thirty-five malpractice cases, plus the Duty of Due Care both inform and support the design of my system and guidelines. They also inform my philosophy of telephone triage — safety.
From 1993-1995, Sheila Quilter Wheeler trained, consulted with and guided the Telephone Triage Guideline Task Force —25 expert level nurses, nurse practitioners and later three physician reviewers. While developing the guidelines, the task force always kept the end user in mind — nurses, and even patients.
The end goal for nurses was “real world” guidelines and that made it “easy to do the right thing” (Institute of Medicine). The goal for patients: communications and home treatment instructions that were accessible, inclusive and low cost. Making the language level (5th to 8th grade literacy level), writing site-based symptom descriptions (the way patients often describe them), suggestions for home treatment that were low-cost, easily accessible.
Originally composed of 23 expert level nurses, nurse-practitioners and three physician reviewers in 1994, and later, bi-annualy, additional expert clinicians joined in. They developed telephone triage guidelines with end-user clinicians in mind. The goal was to create guidelines that were safe, effective, “real world” and that made it “easy to do the right thing” (Institute of Medicine/National Academy of Medicine). Free Telephone Triage Guidelines
We adapted telephone triage standards and guideline criteria from three key organizations: American Academy of Ambulatory Care Nursing (AAACN) for nursing practice standards, and the Institute of Medicine (2001) (now known as the National Academy of Medicine), and the Manchester Triage Group (MTG) for triage guideline and medical decision making standards and criteria.
Standards-Based Telephone Triage (AAACN, 2018)
Safe: TeleTriage Systems has a spotless safety record since publication (1995). There are no malpractice cases related to the use of TeleTriage Systems’ guidelines.
Multi-Purpose/Multi-Setting: Applicable to a range of clinical settings: Home Telehealth Visits to Face-to-Face Encounters, Emergency Department, Urgent care, and Ambulatory Settings (Office, Clinic, Surgicenter and Student Health Settings).
Five-Level Triage: A unified method for assigning triage that is innovative and exclusively unique to this system (AAACN Telehealth Standard 2, 3). Includes defined clinical prioritization nomenclature: acuity classifications, descriptions, time frames and sites for follow up.
Uniquely Patient Centric & Age-Specific. Explicitly state the population to which they apply (IOM). Content is customized to three unique age groups: Infant-Child (Birth to 6 Years), School Age (Age 6-18 Years)and Adult (Age 18 +years ) (AAACN Telehealth Standard 1)
5-8th grade literacy level Assessment questions and home treatment Instructions facilitate communication and call brevity. Developed to serve all literacy levels, (AAACN Telehealth Standard 1, 5, 6)
All economic levels: Originally developed for a large facility serving low-income, high risk, multi-cultural populations. Advice for home treatment and first aid features low-cost, treatments commonly available in the home, plus recommendations for free self-help and support groups.
ACCESS — Round -the -Clock Design supports 24/7/365 patient access policy — not just office hours. (AAACN Telehealth Standard 1)
Adapted from American Academy of Ambulatory Nurses Telehealth Standards, 2015
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Standards-Based Five-Level Telephone Triage (Manchester Triage Group, 2015)
In 2015, the Manchester Triage Group set forth requirements for on-site triage. MTG Triage requirements also apply to remote triage systems. Teletriage Systems guidelines meet MTG triage requirements.
Nomenclature: Basic terminology and descriptions.
Definitions of terminology. Clearly defined classification levels
Robust Triage methodology. 5-Level Triage with clear instructions on when, where and why patients are to be further evaluated as appropriate
Acuity classification. Based on Five-Level Triage (Emergency Severity Index or ESI) i.e. Life threatening, Emergent, Urgent, Acute, Non-acute.
Clinical Training Program. Robust clinical training program
Audit (QA, QI). QA Audit
Adapted from Manchester Triage Group, 2015
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Standards-Based Criteria for Guidelines (Institute of Medicine (IOM), 2011)
Like other Telephone Triage Protocols and Guidelines, teleTriage Systems Paper-based Guidelines have yet to be Evidence-BAsed. However, the Guidelines Achievable meet the IOM Criteria for Clinical Guidelines in the first five of six categories below. Clinical Computerized Decision Support Systems (CCDSS) should also adhere to the same criteria especially in the era of AI-Augmented Clinical Computerized Decision Support in healthcare.
Explicit: clearly state the populations to which they apply
Clarity: a user-friendly presentation, written in unambiguous language, using precisely defined terms
Transparent: Users can clearly understand how they work
User’s Guide: Since 1993, the only paper-based guidelines with a Users’ Guide — 30 page with full operating instructions, describing assumptions and exceptions to recommendations.
Reliable: designed to result in safe, timely outcomes. 5-Level Triage
Reproducible Outcomes (EBM-verified): different groups of clinicians are likely to choose the same safe dispositions
Adapted from Clinical Practice Guidelines We Can Trust, IOM, 2011
Telephone Triage Guidelines Free Downloads
TeleTriage Systems Copyright Statement
Copyright 1993 -2025 by Sheila Wheeler and TeleTriage Systems Publishers. All Rights Reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means – electronic, mechanical, photocopy, recording or otherwise – without prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews. For Information and permissions, write to Sheila Wheeler 44 Madrone Ave, San Anselmo, CA 94960 or contact her by phone 415 453 8382