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Telehealth: Essentials for Expert Clinical Practice (2022)

Structure, Process, Outcomes for

5-Level Telephone Triage 

Essentials for Expert Clinical  Practice is a revision of The Fine Art of Telephone Triage (1993) the original “how to” course in telephone triage.

Structure – Process – Outcome = Quality and Safety

This comprehensive Training Program combines two (training and Standards) of four System Components (Documentation Form, Guidelines, Standards and Training). It demonstrates a Process — Standard Operating Procedure — Nursing Process — including Nursing Risk Diagnoses, assessment tools, communication techniques and a 5-Level triage approach. The materials update the Role, the Risks, Rules of Thumb, Red Flags, Red Herrings for a  “real world” approach that supports clinicians in getting patients to the right place, at the right time, for the right reason.  Contents include the  following:

  •  the nursing process and nursing risk assessment
  •  sample system components:   job descriptions and standards,  documentation form, QA Audit Form, Universal Guideline, Work Flow Process, patient brochure, phone tree, unique telephone triage policies
  • 5-level triage outcomes representative of improved assessments, communications, continuity and informed consen
  • Identify 5 root causes of error related to telephone triage
  • Select and apply 5 key assessment methods
  • Improve clinical decision-making and triage dispositions
  • Improve assessments and communications, in both written and verbal formats

Table of Contents

  • Chapter 1.  Overview
  • Chapter 2:  Rules of Thumb
  • Chapter 3:  Prioritization: Red Flag Symptoms and Populations
  • Chapter 4:  Process:  Clinical Decision Making
  • Chapter 5:  Communications: Written and Verbal
  • Chaper 6:   Right Level of Care: 5-Level Triage
  • Chapter 7:  Avoiding Human Error
  • Appendix: Telehealth Standards



 Questioning Our Assumptions:

Expectations, Error and Evidence-Based Policies

Although telehealth is a uniquely high-tech field, it is still evolving professionally.  And because it lacks full professional development, it is reasonable to question our current assumptions.

 For example, is it our task to perform a differential diagnosis? Does Information technology inherently make the work safer?  Historically, developers have given short shrift to the nursing process and its clinical application to the task of telephone triage. Do medically developed algorithms take the place of critical thinking and clinical training in telephone triage?

Finally, has technology made our professional lives easier? Is our work less stressful or safer?  New research finds that user-unfriendly software creates more work for some physicians, who now work 11-hour days (Gawande,  2018).  Can telephone triage nurses be far behind?  Some software may exacerbate decision fatigue – a predictable human condition that degrades decision-making after 6 hours (Linder, 2019).


To quote Donald Rumsfeld “there are known knowns — things we know we know…..there are known unknowns; things we know we do not know….there are also unknown unknowns—the ones we don’t know we don’t know”.  (Wikipedia)

It is safe to assume that telehealth

  •  is a form of clinical care
  • is designed to facilitate safe, timely (early or on time) access
  • is a form of pre-arrival care (takes place prior to arrival on site )
  • requires clinical decision-making under conditions of uncertainty and urgency


Is it the task of telehealth to perform a differential diagnoses or to estimate symptom urgency?  No research has definitively determined which task is actually feasible  — differential diagnosis or nursing diagnosis.

Realistically, even seeing a patient on a screen, or hearing their voice on the phone is extremely  limited.  Even a differential diagnosis  requires face-to-face  encounters, tests or vital signs at minimum.  It is reasonable to expect that we can only  estimate symptom urgency.

Triage 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.  Diagnosis-based triage scales could actually be dangerous because 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)

Triage requires critical thinking and traditional skills of gathering and recording data about the chief complaint and patient history.  By using the nursing process, performing a thorough symptom and patient history, and estimating the symptom urgency, one can formulate a nursing diagnosis (part Problem Focused, part Risk-Focused Nursing Diagnosis), while identifying risk factors that contribute to increased vulnerability — information available in the EHR.

Error:  Unintended Consequences of IT

Are our expectation of our electronic/paper guidelines and EHR reasonable?  Has evidence shown them to be reliable and valid?  Or are we being lulled into outsourcing our -medical traditions? -documentation? – critical thinking?

Robert Watcher, MD, an internationally known expert in patient safety, quality, and information technology, is alsochair of the Department of Medicine at the University of California, San Francisco. In his book “The Digital Doctor”, he describes the profound effects of IT on medical staff, their work, relationships with each other and their patients. (Wachter, 2017)

For example, Watcher describes the “faceless note” a way of charting whereby notes are fragmented, repetitious statements and rendered nearly generic, whereby all traces of the individual are missing.  He encourages clinicians to perform “uber assessments”,  be more expansive, expressive – to tell a story – the medical narrative.

Jeff Brown, MD, an early pioneer in pediatric telephone triage – also laments the lost art of writing a brief general description of the patient, much to the patient’s deficit.   (Brown, 2017)  There is no reason why this cannot be accomplished in telephone triage.

In a New Yorker article “Why doctors hate their computers” (2018),  Atul Gawande, MD, surgeon, writer and safety expert, describes how inadequacies in technology are leading to an epidemic of physician burnout.

“We’ve learned that automation does not eliminate errors. Rather, it changes the nature of the errors that are made, and it makes possible new kinds of errors. The bottom line is this: Systems that integrate the best of human abilities and technology are the safest for all concerned”.                        Captain Sully Sullenberger, Pilot, “Miracle on the Hudson”

Evidence-based Policy?

I recently heard a story of a 74-year-old female patient suffering from severe post-operative pain.  She called the advice nurse on a Saturday morning, requesting that she be seen. The response (in two different calls with two different clinicians) was that “it is our policy to not give advice to post operative patients.  Call back on Monday morning when the Surgery Department is open”.

What type of evidence could possibly support this misguided and dangerous policy?  Is it not abundantly clear that the purpose of telephone triage is to facilitate safe, timely access?  Is it not true that symptoms like post operative pain may be time sensitive, and that care delayed may be viewed as care denied?

Although studies of patient self-referrals have existed for several decades (North, 2010), perhaps we need to implement a policy that encourages patients to be proactive. Patients experiencing urgent symptoms should be given priority.  In fact, for decades many patients have bypassed the advice nurse (or physician) altogether, taking matters into their own hands, and self-presented to the nearest ED, thereby achieving safer outcomes.

New research describes what might be a policy for safer, more timely dispositions than described in the case study above. Researchers found that callers who self-referred by “jumping the queue” were more severely ill than callers who did not bypass the queue (Ebert, 2019).  The study utilized an “Emergency Access Button”, whereby patients were allowed to jump the line, if they felt that their symptoms were urgent.

Systems ErrorA recent article in the New York Times entitled “How Corporate Medicine Exploits Doctors and Nurses” (Ofri, 2019) highlights a worrisome trend.  Danielle Ofri, MD — a physican at Bellevue Hospital –notes that corporate medicine has milked all the “efficiency” it can out the the system.

In recent decades, the workload on medical and nursing staff has increased by 30%.  Nurses and doctors are burning out and even becoming suicidal (and at higher rates than nearly any other profession), likely from the stress of trying to manage the increased workload while still adhering to professional standards and ethics.

Not surprisingly, higher levels of burnout are associated with medical error.  Ofri concludes that “healthcare is by no means perfect, but what good exists is because of individuals who strive to do the right thing” (Ofri, 2019). Such observations have particular relevance to the current practice of telephone triage, where staff sometimes find themselves “between a rock and a hard place”.

Human Error:  Decision FatigueAs a full-time or even 8-hour task, telephone triage requires continuous, unrelenting clinical decision-making – a repetitious, arduous, exhausting and mentally draining task. After 6 hours, this type of mental work results in decision fatigue.

A recent New York Times article described research on physicians’ decision fatigue, advising patients to visit their doctor early in the day (Linder, 2019).   So too, clinicians working full time in high volume clinical call centers (or exclusively on the phone for 8-hour shifts) are likely to suffer decision fatigue, raising questions about safe shift length for this type of work.

Pre-Hospital Calls and Sepsis  Having served as an expert witness on approximately 35 malpractice cases in telephone triage, the author discovered that approximately 30-40% of malpractice cases (most of whom died) were later diagnosed as sepsis.

Evidence Based Medicine According to Wikipedia, “evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. “

 Little or no research on Early Sepsis Recognition in telephone triage exists.  However, recent research on sepsis finds that 85% of sepsis cases arrive with sepsis (Health Catalyst, 2018) Furthermore, mortality rates approach 50%when delays occur. Using current EBM, would it make sense to create guidelines, training and policies for pre-Hospital early sepsis recognition?


Based on the above research, it seems reasonable and prudent to promote a Culture of Safety in telephone triage grounded in EBM polices.

  • Formally recognize and legitimize Telehealth as Pre-hospital care— the first contact and initial phase of the Continuum of Care,
  • Enable patients with self-identified urgent symptoms to jump the line
  • Implement Sepsis Early Recognition Guideline especially for children and elderly
  • Integrate the Nursing Process more formally into training materials and guidelines
  • Institute 4-6 Hour shiftsin all High Call Volume clinical call centers or 8-hour dedicated positions.


The work of telephone triage is nothing if not uncertain, and humans intensely dislike uncertainty.  However, it is prudent to acknowledge the limitations of this work, and to question our assumptions about it.  Safe assumptions (based on evidence)  can be the foundation for safe policies.

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