Telephone Triage Nursing: Roles, Tools and Rules



This course will expire or be updated on or before May 1, 2014.

You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.


Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.

Secure online transactions guaranteed by GlobalSign. Click for details.

Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.

Telephone Triage Nursing: Roles, Tools, and Rules

By Sheila Wheeler, MSN, RN

Sheila Wheeler is a pioneer in the field of telephone triage as a trainer, writer, researcher, and consultant. She has written Telephone Triage: Theory, Practice, and Protocol Development and Telephone Triage Protocols for Adult and Pediatric Populations. Ms. Wheeler consults as an expert witness for legal cases, and in training program development, clinical engineering, new product and QA development, risk management, and research. She received her MS in Community Health Nursing from the University of California, San Francisco in 1993, and currently practices telephone triage at a call center for Contra Costa Health Plan in Martinez, CA.

COURSE OBJECTIVE:  The purpose of this course is to provide RNs and other healthcare professionals with a broad overview of telephone triage nursing as an emerging subspecialty and its most essential components.


Upon completion of this course, you will be able to:

  • Define telephone triage and describe its settings and participants.
  • Explain how the telephone triage process is related to the nursing process.
  • Summarize the essential aspects of good communication.
  • Identify red flags, rules of thumb, red herrings, and common pitfalls in telephone triage.
  • Describe three mnemonic tools for assessing patients or symptoms.


Telephone triage is commonly defined as the safe, effective, and appropriate disposition of health-related problems via telephone by experienced, trained RNs using physician-approved guidelines or protocols (Wheeler, 2009). Telephone triage interactions may require assessment, patient education, and crisis intervention.

As a new subspecialty, there is still controversy about terminology. For example, some nurses refer to telephone triage as "telephone advice” and consider themselves advice nurses, whereas other nurses use the words telepractice or telehealth.

For the purposes of this course, telephone triage is considered to be the interaction between patient and nurse that takes place exclusively by telephone. This course will not address such topics as telemedicine or telehealth.

The Focus of Telephone Triage

The focus of telephone triage is on the assessment and disposition of symptom-based calls rather than message taking. While message taking is a current practice in some settings, most state boards of nursing support using a professional nurse as a medical decision maker. The message-taking role is more appropriately relegated to unlicensed assistive personnel.

Telephone triage does not involve making diagnoses—nursing or medical—by phone. Telenurses do not diagnose but rather collect sufficient data related to the presenting problem and medical histories, recognize and match symptom patterns to those in the protocol, and assign acuity. Telenurses provide for the safe, timely disposition of health-related problems. Telephone triage aids in getting the patient to the right level of care with the right provider in the right place at the right time (AAACN, 2007).

Telephone encounters, if handled sensitively, can reduce inappropriate appointments, reduce anxiety, educate clients, and increase client satisfaction levels in addition to reducing risk when there are medical complications. Patients value the care that they receive. In fact, one study showed that reassurance was more important than the relief of symptoms (Wheeler, 2009). Clearly, reassurance and thoughtful attention to client concerns—whether medical, informational, or even administrative—often meet patients’ needs and satisfy them.

Practice Settings

Currently, formal telephone triage is practiced in three major settings: health maintenance organizations (HMOs), office and group practices and emergency departments (EDs), and crisis lines. Occasionally, telenurses encounter crisis-level calls, such as ingestions, domestic abuse, rape, cardiopulmonary resuscitation (CPR) coaching, or threatened suicide. In many communities, nonmedical personnel with specialized training staff crisis hotlines such as poison prevention, rape crisis, and suicide prevention, and customarily manage such calls. Finally, 911 medical dispatchers perform high-level telephone triage and coach callers in first-aid treatment, CPR, and the Heimlich maneuver until paramedics arrive.


In the 1970s, HMOs recognized telephone triage as a separate subspecialty. Since then protocols, training, and standards have typically kept pace with technological advances. When high standards are maintained, telephone triage in the HMO setting is a successful, highly appreciated, and integral part of the larger system.

HMO call volume can be extremely high, making the work stressful. Telenurses usually have electronic protocols and access to patient demographic information via an electronic medical record (EMR) on which to rely. Typically, demographic information includes previous medications, medical history, and dates of recent visits. The EMR software program creates a paper trail; enables managers to track and trend calls; and creates statistics on call volume, types of calls, and individual staff workflow and dispositions.

Generally, HMO call centers are larger and better organized than most small offices, group practices, and ED systems. In HMOs, electronic protocols are provided, as are formal training programs and standards.


Office and ED practices can vary widely in standards and protocol availability. Most offices use paper protocols and pen-and-paper documentation. Training may be on-the-job.

Even when taking calls about high-acuity problems, the traditional sphere of ED activity, the average ED lacks standards and training programs. While emergency nurses openly acknowledge telephone triage as an expanded role, there has been resistance on the part of administrators to formalize the practice, perhaps due to fear of liability. However, when surveyed informally, many ED nurses admit to performing telephone triage even in the face of administration directives forbidding it. Most ED nurses are torn between providing by phone what they consider reasonable and prudent care despite the legal consequences and not providing care at all.


Obvious examples of crisis intervention lines are poison prevention, suicide prevention, rape crisis, and 911. Emergency medical dispatchers (EMDs) are nonmedical personnel or paramedics who respond to 911 calls for ambulance, fire, or police. They assess by phone the need for emergency service and are responsible for dispatching medical rescue vehicles to victims. Most medical dispatchers are high school graduates, two thirds are female, and most have no previous medical training. EMDs often receive some training for responding to a range of commonly encountered crisis-level medical problems.

Who Are the Callers?

Over the last 30 years, researchers have identified predictable caller populations (e.g., by gender or age), call patterns and peak call periods, and common health complaints. Armed with this knowledge, staff in offices, HMOs, and emergency departments can prepare with specialized training, protocols, and staffing adequate to meet the need at predicted high-volume periods.


Not surprisingly, frequent callers are often from high-risk age groups: the very young, the very old, and women of childbearing age. In internal medicine, women called twice as often as men. The percentage of calls made about children less than 4 years of age tends to be disproportionately large compared to the number of children in a given pediatric practice.

Research consistently identifies older adults as relatively frequent callers. In internal medicine practices, researchers found that clients over 65 constituted 29.3% of those receiving telephone care, the largest proportion when compared to other age categories (Wheeler, 1993).


In family practice settings, peak calling time was between 10 a.m. and noon, with the majority of calls occurring Monday through Friday. There is also a pattern of late afternoon calls. Researchers theorize that clients become aware of their own symptoms after the demands of work are finished. When calling about their children, parents notice that the children are not well when they are reunited with them after work.

In both the emergency department (ED) and office settings, there is a substantial volume of calls on weekends, holidays, and after hours when offices are closed and access to healthcare is limited. Half of all after-hours calls in a family practice occurred on weekends.


Not surprisingly, in the primary-care setting a few complaints make up the bulk of calls. Most common are upper respiratory infections (URIs), fever, gastrointestinal (GI) problems, viral infections, minor trauma, back pain, anxiety, otitis, and urinary infections. In pediatric practice settings, 85% of the calls are typically about respiratory problems, fever, GI problems, skin and infectious diseases, and trauma. Thus, about twenty-five common complaints make up 80% of calls in primary care settings. In the ED, the top presenting problem categories (44% of the total) were GI, respiratory, OB/GYN, and trauma. (Wheeler, 1993)

Who Performs Telephone Triage?

The question of who should perform telephone triage is a hotly debated issue. Should it be a physician, a nurse practitioner, an RN, an LVN, or a receptionist? Physician Barton Schmitt, a pioneer in telephone triage, suggests a good rule of thumb might be to use “the lowest paid person who can safely do the job” (Schmitt, 2004). In many cases the RN may be best suited to this role.


  • Registered nurse (RN)
    • Clinical experience of 10 years in medical surgical, pediatric unit
    • Emergency department triage experience preferred (walk-in or telephone)
  • Current BLS certification
  • High levels of experience or expertise in:
    • Crisis intervention
    • Teaching/coaching
    • Diagnostic/monitoring
  • Demonstrates good judgment and critical-thinking skills
  • Tolerates ambiguity well
  • Demonstrates compassionate and caring manner with clients
    • Telephone “charisma”
    • Forms instant rapport
    • Customer service–oriented
    • Helpful, warm
  • Excellent communication skills (written and verbal)
    • Articulate
    • Able to communicate well at fifth- to eighth-grade level
    • Engaging telephone manner
    • Concise, clear documentation skills
    • Proven typing skills at 30 WPM
    • Computer literate (as appropriate)
  • Functions well in a high-stress environment and under time pressure
  • Excellent negotiation skills
  • Works well independently
  • Life experience as parent/caregiver
  • Works effectively with:
    • Culturally diverse populations
    • Educationally diverse and illiterate populations
    • Non-English-speaking populations
    • High-risk populations
  • Bilingual


Telephone triage programs are systems with integrated elements—staff, training, protocols, documentation forms, and standards—that work together to provide safe, timely delivery of care or access to care. Researchers have not yet determined which protocol system works best; however, it is safe to assume that protocols and forms grounded in the nursing process and related research, with built-in fail-safe systems, offer the best decision-making support for telenurses.

Telenurse Functions

Patricia Benner (2001) first defined nursing expertise in From Novice to Expert. Through her research, she identified key domains of nursing expertise; with minor modifications, most of these domains apply directly to telepractice.

  • The helping function. In telephone triage, the key functions of the helping role are creating a healing relationship through (1) attending to (listening) or “presencing” (i.e., being present), (2) maximizing clients’ control, and (3) providing comfort through the voice (rather than touch).
  • The diagnostic function. Strictly speaking, telephone triage is not intended to provide diagnoses. However, within limits, nurses can detect and document significant changes in the client’s condition, perform pattern recognition and matching, anticipate problems, and formulate treatment strategies.
  • The crisis-intervention function. Nowhere else is the “instant grasp of rapidly changing situations” more vital than in crisis intervention by phone. Telenurses are often inadvertently cast in the role of first responder as they receive field calls regarding imminent births, trauma, suicide, and ingestions. (Not all communities have fully developed 911, suicide prevention, or rape crisis hotline systems.)
  • The monitoring function. Currently, most telenurses advise and may even monitor simple home treatment interventions and instruct clients in self-evaluation. In the future, the newly emerging area of disease management will likely make telemonitoring a standard function of telepractice. As technology and the field of telehealth continue to grow and expand, the trend toward telemonitoring will grow, allowing more clients to be treated at home.

Best Practices

Best practices are defined as the most efficient and effective ways of accomplishing a task while achieving the best results. Best practices are based on repeatable procedures that have proven themselves with large numbers of people over time. The concept of best practices derives from the belief that proper processes, checks, and testing can produce a desired result with fewer problems and unforeseen complications. Best practice is the assertion that there is a technique, method, process, or activity that is more effective at delivering a particular outcome.

In the world of telephone triage, best practice translates to employing the best human elements (staff), utilizing the best critical-thinking strategies and processes (nursing process), and using the best tools (standards-based protocols and forms). Thus, best practice depends on adequate numbers of experienced, qualified staff with solid communication skills, both written and spoken. (This sample score sheet can be used to assess a telenurse’s skills.)


To the degree that protocols are standards-based, they can reduce ever-present risks related to decision-making errors. Following are standards for telephone triage protocols based on those developed by the Institute of Medicine for decision-support systems (Wheeler, 2009; IOM, 2000):

  • Validity. If protocols are followed, it will lead to expected outcomes.
  • Reliability/reproducibility. Given the same data, other groups of nurses would produce the same results.
  • Clinical applicability. Protocols explicitly state the populations to which they apply.
  • Flexibility. There is a “user’s guide” with complete operating instructions, including underlying assumptions and exceptions to recommendations.
  • Clarity/user friendliness. Protocols are written in unambiguous language using precisely defined terms in an easy-to-follow mode of presentation.

Minimal best practices for protocols include an annual review and updates, comprehensive coverage of presenting problems, and integrated forms.

Teletriage and the Nursing Process

Generally speaking, telephone triage nurses utilize a slightly modified version of the standard nursing process (assessment, diagnosis, planning and intervention, and evaluation). The diagnosis consists instead of formulating a working diagnosis, or impression. Planning and intervention is addressed by the selected protocol’s disposition and advice and is always provisional. Evaluation is carried out when the nurse provides patient teaching for self-evaluation through follow-up instructions from the protocol.


Assessment is the most important and substantive step of telephone triage, since pattern recognition is dependent upon the systematic collection of data. Always start the assessment process with the documentation form rather than the protocol. Elicit and document information from the caller using global assessment tools such as the mnemonics SAVED, SCHOLAR, PAMPER, or activities of daily living (ADL), as appropriate (see “Assessment and Documentation” below).

Once you have a general sense of the problem(s), use the protocol that best matches the patient’s presenting problem. When patients present with multiple symptoms, use the protocol that has the highest likelihood of leading to an appointment, or ask the patient which symptom is the most bothersome.


In telephone triage, the “diagnosis” step requires interpreting and analyzing patient data, identifying patient resources, and formulating a working diagnosis, or impression. Using the patient’s own words combined with the approved terminology and abbreviations, the nurse documents the impression. Following are examples:

  • Abdominal pain, severe, sudden onset
  • Ear trauma, severe pain
  • Vaginal discharge, Hx. STI Exp.

Planning/intervention is determined after pattern recognition and matching. Patterns (symptom complexes) are classified according to the level of acuity, or disposition: emergent, urgent, acute, and nonacute levels. The nurse prevents, reduces, or resolves problems identified by adhering to the protocol disposition and directives.

The treatment plan is composed of two parts: the disposition and the advice.

  • Disposition: Always advise the patient when and where to come for treatment. The site of care may vary depending on the hour and day of the call. After hours, patient may need to be seen in the ED. Keep abreast of changes in clinic hours, which may be expanded to include evenings, weekends, and holidays.
  • Advice: Home treatment advice often includes information related to over-the-counter (OTC) medications and common home treatments.

In telephone triage, evaluations that would normally be performed by the nurse in face-to-face encounters must be carried out by the patient. Thus, “evaluation” is modified to become “patient self-evaluation instructions.” The nurse may also choose to monitor progress and self-care activities via follow-up calls to determine if home treatment is effective or if upgrading is needed. Review as appropriate any emergent, urgent, or acute symptoms for which the patient must continue to observe.

  • Follow-up Instructions: In addition to the disposition and treatment plan, always include standard follow-up instructions and a disclaimer in the instructions to the caller.
  • Patient Call-back: Always advise the caller to call back if the symptoms worsen or new symptoms arise.
  • Nurse Follow-up Calls: Routine follow-up calls should be done for children under 2 years and for abdominal pain, fever, diarrhea, or marked change in activities of daily living.

Protocols vs. Professional Judgment

Confusion often revolves around what ultimately determines the correct disposition—protocols or professionals? This issue continues to be debated. If the premise that protocols are the bottom line were true, then the nurse wouldn’t really matter. In fact, one expert maintains that information technology can potentially transform nurses from active decision makers into passive “system operators.” On the other hand, some experts suggest that protocols may actually interfere with critical thinking at times (Gladwell, 2005).

While protocols are an important component of the telephone triage system, the bottom line is the experienced, well-trained RN. Current standards of practice stress that RNs should perform decision making because protocols alone cannot guarantee safe practice.


Are protocols decision-making or decision-support tools?

Some designers favor protocols as decision-making tools, maintaining that nurses should use protocols based on strict algorithms. Others see the RN as the true decision maker, with the protocols serving as decision-support tools. Decision-making systems may allow unqualified operators to make decisions that are beyond the level of training and experience, whereas decision-support systems remind an experienced decision maker of information once known but possibly forgotten.

Decision-making tools are designed to be followed rigidly by answering yes or no to decision tree questions in order to reach a final disposition. This approach is based on black-and-white thinking, or “binary code,” which assumes that the information received is both accurate and sufficient in quantity and quality to determine a disposition. Such tools can break down in the “real world” of telephone triage.

Decision-support tools are based on pattern recognition, encouraging the RN to use critical-thinking skills, context, and pattern matching to determine a disposition. This approach mimics the way the brain solves problems by presenting the user with patterns to match with the patient’s presentation. The examples presented in this course are based on a decision-support approach.


All successful nursing care hinges on good communication. In telephone triage, the challenge is to push the limits of what is possible and unique to this quality. The manner of communication is as important as what is communicated. Nurses must inspire, negotiate, persuade, and engender trust. Telecharisma is a “magical” characteristic of telenurses. From their first words of greeting to the way they listen, respond, and ask questions, charismatic nurses demonstrate warmth, caring, and trustworthiness.

Successful communication requires a sender, a message, a mechanism, and a receiver. For the message to be complete, information usually has to flow in both directions. Experts have found that too little or too much information impairs critical thinking and diminishes the chances of the message being received and understood. The prospect of too little information is increased due to lack of sensory input and information.

Thus, because the “signal” is weak, barriers that in person are not very formidable can become nearly insurmountable on the telephone. Messages may be impaired by lack of trust or by unexplored feelings, needs, and biases. Clients’ and nurses’ beliefs, attitudes, and perceptions of symptoms become obstacles in themselves. Ineffective communication may also lead to increased legal liability and substandard client care.

In telephone triage practice, nurses can facilitate communications by closely attending to and receiving messages, clarifying or asking for detail, reflecting, and paraphrasing to check accuracy. At the bedside, speech, smell, touch, sight, and emotional cues paint a rich picture of the client’s condition. On the phone, communications are limited to verbal and emotional cues. The risk of miscommunication is great. Although it is possible to gain limited tactile and visual information gathered by proxy from callers, nurses receive, analyze, solve problems, and instruct without observing the client.

The sections below offer three best practices to enhance critical thinking: adequate time, open-ended questions, and speaking directly to the patient.

Allow Enough Time

Careful communications require adequate time. If callers perceive the nurse as “time driven,” offering few explanations, and making little attempt to build rapport, communication breakdowns increase. Some callers, dissatisfied with the brevity of the call and lack of emotional support, will fail to follow the nurse’s advice.

When it comes to “talk time” in telephone triage, there are no shortcuts. Adequate time enhances decision making and critical thinking. A landmark study compared performances of pediatric nurse practitioners with pediatricians (Perrin & Goodman, 1978). The authors discovered that pediatric nurse practitioners performed as well as or better than physicians in telephone triage. The nurse practitioners were judged to be warmer and more open to questions and left callers feeling more satisfied. They spent significantly more time per call than physicians (MDs, 3 to 5 minutes; RNs, 5 to 7 minutes). Perrin and Goodman consider that the additional minutes reflected an investment in client education, not inefficiency. Current standards have raised this time frame to 7 to 10 minutes or more, depending upon the type of call and caller (Wheeler, 2009).

Use Open-Ended Questions

Open-ended questions provide for better and more reliable data gathering by encouraging the clients to perform the work of describing symptoms. Asking leading questions—a flawed technique often related to being time-driven—simply elicits yes or no answers, thereby yielding faulty data. Resist using leading questions, which cloud the picture by providing the answer in the question. Such questions—“Is the pain severe?” “Are you having bloody stools?” “Are you having difficulty breathing?”—usually elicit yes or no answers. Open-ended questions—“How would you describe the pain?” “What are your stools like?” “What can you tell me about your breathing?”—eliminate yes or no responses. Always start data collection with open-ended questions.

There are several exceptions to the policy of utilizing open-ended questioning. Exceptions include crisis-level calls and calls from children, frail elders, and poor historians. In such instances, use facilitative questions such as: “Is the pain better, worse, or the same as it was yesterday?” “Is the bleeding dark red or light red?” This is a compromise between open-ended and leading approaches that may still yield better data than leading questions.

With the crisis intervention call, where decisions must be made within seconds, leading questions are appropriate. Appropriate questions would be: Is the victim conscious? Breathing? When an immediate disposition is imperative, open-ended questions are too time-consuming.

Speak Directly with the Patient

Many pitfalls can be avoided by talking directly to the patient wherever possible, although with children under the age of 8 years, some older callers, or poor historians, this may not be feasible. Many calls are mistriaged by not making the extra effort to speak directly with the client. This strategy will not only improve the quality of information collected and foster trust and compliance, but it can also expedite the call.


In telephone triage, decisions must be made under conditions of uncertainty and urgency. Uncertainty is due to partial or inaccurate information and urgency is based on the fact that telephone triage is a high-stakes activity, with calls being processed in an average of 7 to 10 minutes. “Under time pressure, people use less information to make decisions, which are often suboptimal” (Lephrohon & Patel, 1995).

Decision making is made more complex by sensory deprivation, conflicting goals (such as call quotas vs. quality interactions), “noise” (irrelevant data, long-winded histories), and multitasking (thinking, listening/talking/questioning, reading, writing, synthesizing information, pattern recognition). The nurse must focus on what is most salient—the meaningful bits of information—and identify patterns to form reasonable working diagnoses.

Telehealth nursing is considered a high-stress activity due to its fast pace and potential for crisis-level calls, both of which can interfere with critical thinking. Research on RN decision making in an emergency department focused on how experienced nurses make real-world decisions in telephone triage. They discovered that nurses, without the aid of formal protocols, used pattern recognition, rules of thumb, and context as major strategies to make decisions (Lephrohon & Patel, 1995).

Mental skills are at the core of telephone practice and require a supportive environment. Working short staffed; in a high-volume, noisy environment; and without protocols, training, or documentation will only heighten stress and uncertainty, thereby diminishing mental skills. On the other hand, a quiet, moderate call-volume environment with adequate numbers of qualified, experienced, and trained staff who are equipped with guidelines or protocols and documentation forms reduces uncertainty and supports mental clarity.

Human beings tolerate ambiguity differently. Thus, managers may use psychological testing to screen prospective staff for tolerance of ambiguity, selecting the best and most stress-resilient decision makers.


Critical-thinking skills and a systematic approach can remedy many potential pitfalls. Attorney Robert Smith (2005) applies the phrase layers of safety in relation to telephone triage practice.

  • Identify what is salient and ignore what is not.
  • Apply rules of thumb to make rapid decisions.
  • Utilize “red flags” to rapidly identify high-risk problems or populations.
  • Employ consistent, comprehensive data-collection strategies.
  • Use the nursing process, modified for telephone triage.
  • Use a documentation form with the nursing process embedded.
  • Use protocols that support the nursing process.

The Role of Intuition

Researchers have paid a lot of attention to the role of intuition in decision making. They maintain that intuition can be developed and offer a variety of suggestions. Gary Klein (2003) advises learning to detect problems through emotional cues—a “gut feeling” when something isn’t right. He recommends developing an active stance, so that if something doesn’t make sense, it acts as an alarm that is not to be dismissed. He also suggests becoming conscious of organizational barriers such as rigid procedures or institutionalized inertia. Finally, he suggests reframing the situation and consulting with colleagues to review with fresh eyes.

Malcolm Gladwell (2005) states that good decision making relies on a balance of conscious and instinctive thinking. Reducing complex problems to their simplest elements aids in decision making. He warns that too much information can paralyze the unconscious. In other words, remember to keep it simple.

Rosalinda Alfaro-Le Fevre (2006), recommends improving critical-thinking skills by avoiding behaviors such as stereotyping others, resisting change, and seeking conformity. In addition, she suggests reducing barriers to intuition: anxiety, stress, fatigue, lack of time, feeling judged, and environmental distractions.

Rules of Thumb

A rule of thumb is a way of proceeding based on experience and sound judgment. Rules of thumb provide practical methods that can generally be relied upon for an acceptable result. Gary Klein, an expert in medical decision making, studied groups of ICU nurses, firefighters, and others who make decisions under pressure (2003). He discovered that these experts don’t logically and systematically compare all available options. In real life, that methodology is too slow. Instead, they quickly size up situations and act, drawing on experience and intuition. Rules of thumb often underlie their expertise and intuition.

The following rules of thumb represent experts’ collective “pearls of wisdom” in telephone triage. They are a body of knowledge that every telenurse should commit to memory. Through study and integration of these rules, novice practitioners can improve their decision-making proficiency and efficiency. (This section is not exhaustive; add your own “rules” as appropriate.)


  • Always err on the side of caution.
  • When in doubt, send ’em out.
  • Beware the middle-of-the-night call.
  • Be alert to possible atypical, silent, or novel presentation.
  • Serious symptoms may present as a single symptom or a complex of symptoms.
  • Always speak directly with the client when possible.
  • Assume the worst until proven differently.
  • Make corrections for your own fallibility.
  • The more vague the symptoms, the greater the need for good data collection.
  • Speed does not equal competence; avoid premature closure.
  • Never abandon the caller in crisis.
  • Temperature extremes often trigger medical problems.
  • All severe pain should be seen urgently.
  • Several calls in a short period of time may be an indicator of acuity.
  • Beware the developing disease.

Age is a major feature in many rules of thumb. For instance, extremes of age can markedly affect the immune response as well as the ability to regulate body temperature, as illustrated by these two key rules of thumb:

  • The older (younger) the patient, the greater the risk of hypo- or hyperthermia.
  • Assess all sick children and older adults for dehydration or sepsis.
Infants and Children
  • Kids get sicker quicker.
  • To avoid night calls, visits, and crises, give day appointments.
  • Neonates are at increased risk for overwhelming infection due to prematurity, traumatic delivery, maternal illness, or neonatal stress.
  • All confusion in children is considered emergent.
  • Always err on the side of caution with children, especially with infants and toddlers.
  • Pediatric populations are at greater risk for hypothermia and hyperthermia.
  • For children under 4 years, symptoms tend to be very generalized; for those over 4 years, symptoms tend to be more specific.
  • Infants under 3 months of age with fever of 38°C (100.4°F) should be seen immediately.
  • All parents have the potential to abuse their children physically at some time.
  • Assume any symptom of STDs (discharge, lesions) in a child to be sexual abuse until proven otherwise.
  • Always elicit an immunization history; lack of, or inadequate, immunizations place a child at risk.
  • Assess all children with unexplained symptoms for possible unintentional or purposeful ingestion/exposure to toxins, inhalants, and street or prescription drugs.
  • Any teenager who is depressed is at risk for suicide.


Teenagers are especially vulnerable to depression and suicide due to several factors: easy access to alcohol and drugs, increased sexual activity, complex societal demands, negative role models, and increased family disruption. The precipitating factor may be: a loss or betrayal of trust; romantic break-up; failure in school or sports; move to a new neighborhood; peer pressures; conflict regarding dependence and independence; poverty; unwanted pregnancy; sexual problems, rape, incest, sexual dysfunction, gender identity problems; peer- or media-emphasized suicide; treatment for mental illness; and/or any legal problems.

Older Adults
  • Symptoms in older adults may be atypical, silent, or late (e.g., the patient may interpret fatigue merely as a symptom of pneumonia or infection).
  • All sudden confusion in older adults is considered emergent.
  • Assess all older adults for dehydration status.
  • Older adults are at risk for adverse drug reactions (ADRs). The greater the number of drugs, the greater the incidence of ADRs. Moreover, as the number of daily doses increases, compliance may decrease.
  • Assess all older adults with unexplained symptoms for ADRs, "chemical restraints," or possible ingestion (intentional or accidental). Exposures may be due to toxins, alcohol, or overmedication with prescription or OTC medications.
  • Older adults may be poor or forgetful historians. Err on the side of caution.
  • Elderly white, retired widowers are at highest risk for completed suicide.

Symptom-based rules of thumb include the following:

  • Once an ectopic, always an ectopic.
  • Any bleeding in pregnancy is considered an ectopic until proven otherwise.
  • All severe pain must be seen within 8 hours or less.
  • Beware of any pain that awakens the patient or prevents sleep at night.
  • Epigastric pain in males >35 and females >45 is considered an MI until proven otherwise (Clawson & Dernecoeur, 2005).
  • Any pain between the navel and the nose is chest pain until proven differently.
  • All first-time seizures must be seen.
  • All rashes are contagious until proven otherwise.

Trauma-based rules of thumb include the following:

  • Never remove impaled objects.
  • With face or jaw trauma, always check for head injury.
  • All breaks in skin made by human teeth are presumed to be a human bite.
  • All snakes are considered poisonous until proven otherwise.
  • All chemical and electrical burns are potentially worse than they appear initially.
  • Always be alert to unwitnessed accidents and to mechanism of injury (major trauma: motor vehicle accidents, falls >15 feet, blunt trauma).
  • Question carefully caretakers’ assessments of trauma. They may focus on a minor problem (avulsed tooth) and miss a more serious one (head injury).
  • Trauma with suspicious history should be considered possible abuse.

The “eight Es” of myocardial infarction include these risk factors:

  1. Extreme emotion
  2. Extreme exertion
  3. Extreme weather (heat wave/cold snaps)
  4. Extreme eating
  5. Extreme age (over 75 years)
  6. Extreme epigastric distress
  7. Essential hypertension
  8. Early morning

“Red Herrings”

A major task in decision making is to determine which data are relevant and which are not. Data must be collected, considered, weighed, and even ignored in order to perform pattern recognition and arrive at a proper disposition. For example, key pieces of contextual information—age, gender, and previous medical history—are always salient; key symptoms may be salient; and others more general and nonspecific symptoms may be given less weight.

There will also be information that is irrelevant and must at times be consciously ignored in order to come to safe decisions. Such data might be called "red herrings"; they are distractors and divert the nurse from more significant data. Red herrings may cause the nurse to jump to conclusions, to stereotype, or to end the call prematurely.

Red herrings can originate with the patient or the nurse. The patient may deny or misinterpret symptoms, or they might miscommunicate. The nurse may misinterpret symptoms or patient history. For example, a patient who was “seen recently in the ED” may now be experiencing new, unrelated symptoms, which the nurse must evaluate. A patient who is “on an antibiotic” should not lull the nurse into complacency; methicillin-resistant staphylococcus aureus (commonly known as MRSA) may be the culprit.

One useful rule for avoiding red herrings is to “beware the developing disease.” Do not be misled by initial presentations that seem nonacute. What starts out as vague abdominal pain with low-grade fever may quickly develop into the classic picture of appendicitis. Follow-up calls should be mandatory for possible developing diseases, and especially for abdominal pain, respiratory problems, diarrhea, nausea and vomiting, fever, or marked change in activities of daily living (ADLs).

Common Pitfalls

For more than thirty years, researchers have repeatedly identified common pitfalls in telephone triage practice. The most common of these pitfalls include inadequate talk time, insufficient history taking and documentation, stereotyping of clients and problems, second guessing or over-reliance on callers, premature closure, and improper use of or failure to use protocols.

Stereotyping of callers can be avoided by obtaining the age, gender, and medical history. It is easy to mistake the caller’s gender or age from the voice. Nurses can also avoid stereotyping symptom patterns by careful and sensitive assessment of the problem and patient history and by taking care not to jump to conclusions. For example, burning on urination in an older female cannot simply be dismissed as a urinary tract infection; it may be symptomatic of a sexually transmitted disease. By the same token, the nurse who assesses a teenage girl who complains of abdominal pain without exploring the prospect of sexual activity, unprotected sex, and possible pregnancy runs the risk of potential delay in care.

Second-guessing is often referred to as the “you’re not sick until I say you are” syndrome. To avoid making erroneous assumptions, telenurses resist either being dismissive of the caller’s concerns or over-investing in the caller’s assessment. Callers who claim that the problem is an emergency may have correctly assessed the situation, and telenurses should take them seriously.

On the other hand, the caller who has self-diagnosed a problem may lull the nurse into a false sense of security. For example, the caller who begins by saying, “My new medication makes me feel dizzy” or “I was carrying some logs and now my shoulder really hurts” or “I have the flu,” may have seriously misrepresented the problem. This initial patient description must be set aside while the nurse elicits more details. Don’t assume that such symptoms are a result of a medication, musculoskeletal injury, or the flu, respectively. These complaints could be related to conditions like stroke, myocardial infarction, or sepsis, for example.

Even though protocols may be well designed and comprehensive, there are several ways in which the nurse can misuse them: (1) fail to use the protocol, (2) use the wrong protocol, or (3) use the protocol improperly. Failure to use protocols is obviously risky, but easily occurs when the nurse finds that no protocol seems to apply to the presenting problem. This is commonly referred to as the “out of protocol” experience.

Failing to collect enough information can lead to selecting the wrong protocol. This was dubbed the “wrong train syndrome” by Clawson and Dernecoeur (2005), who state, “If you get on the wrong track at the station, no matter how fast you travel, you still end up in the wrong place.” Nurses may choose the correct protocol but fail to follow it correctly by choosing the wrong disposition. This can be remedied through providing comprehensive user’s guide instructions and protocol competency training.

Managers should also be aware of the pitfall of using protocols to take the place of formal instruction. Over-reliance on the protocol tool can lead to errors in triage. Training for critical thinking in history taking, communications, assessment, and decision making is key to safe practice. Potential problems can be averted through instruction in the correct and safe operation of the protocols and documentation form. Such instruction also prevents “protocol bias,” which develops when RNs who have been using one type of protocol must begin using a new one.

Electronic protocols and computers are—and always will be—essential to telephone triage as the workhorses for tracking and trending. However, if electronic protocols are given too significant a role, nurses may become passive. What is required is a balance between nursing judgment and protocol.


The telephone triage process should begin with a rapid prioritization to determine callers who urgently need appointments. Expert nurses quickly build a picture through gathering key chunks of information: the patient’s age, gender, chief complaint, literacy or language level, emotional state (determined via the words, tone, pacing of voice), and, sometimes, previous medical history. This key contextual information can quickly identify high-risk patient or problems. This process, while appearing superficial, yields valuable information and often takes as little as 60 seconds. Alternatively, problems can arise when a protocol design fails to offer options for rapid prioritizing.

Some problems require more thorough questioning, and RNs thus pursue data collection to a greater degree. For example, in the case of chest pain, the nurse quickly elicits the large chunks of information (age, gender, symptoms) and makes a decision. In other cases, such as vague abdominal pain, the nurse may spend more time gathering quantities of detailed information.

While performing a global assessment, you may quickly assess an emergent situation that requires aborting the assessment process and bringing the caller to the emergency department; however, in most cases the call requires a brief problem statement and patient history.


To prevent medical error, tools must meet standards for reliability. In telephone triage, the entire system (protocols, forms, training, standards) should be structured to reduce the prospect of failure, regardless of environmental factors. For example, the protocol and documentations form should be integrated and include built-in fail-safe requirements to follow the nursing process steps and force users to collect adequate amounts of key information (age, allergies, previous medical history and medications, problem, patient history, etc.). This forces the practitioner to meet clear-cut standards.

Documentation and Charting Essentials

Begin the history-taking process by verifying the patient’s contact information (address and phone number). Remind the patient that this information is important in case you become disconnected; many callers’ only or primary phone is a cellphone, and cellphones sometimes disconnect at a critical moment. Also, tell the caller that you will need a brief health history (chronic illness, current daily medications, and drug allergies) before discussing their current problem. Obtaining a brief health history as a first step creates context and immediate sense of patient risk.

Elicit information in any order that seems appropriate to the caller and the situation. It is not necessary to let the form dictate the order of data collection. In real-world situations, people volunteer information initially. Try to strike a balance between listening to what may be a caller’s long-winded explanation and communicating your need to gather information in a timely fashion. Write notes into the appropriate spot on the form as the caller volunteers information, then fill in the gaps with follow-up questions from the protocol.

Patients often present symptoms in erratic and disorganized ways. They may focus on one symptom to the exclusion of other, more important ones. An example might be the parent who is concerned about a child losing a tooth due to trauma, when the more serious problem is possible head injury. Avoid being caught up in the patient’s perception and start the triage process with assessment questions and the documentation form. The rationale is to quickly sketch an outline of the problem. The next step is to fill in the details using a specific protocol.

Resist the urge to select a protocol too quickly. Confining the interaction for the “first pass” reduces the risk of jumping to conclusions. As uncomfortable as uncertainty may be, choosing a protocol prematurely may lead you down the wrong path.


Charting must be concise but complete, including accurate, timely observations in the patient’s own words, always using approved abbreviations and terminology.

  1. Quantify where possible, avoid vague expressions.
  2. Use time frames (8, 16, 24, 48 hours) as related to symptom duration or treatment plan.
  3. Form a “provisional, working diagnosis” or “impression.”
  4. Document advice per protocol name or number.
  5. Document protocol deviations/override/modifications.

This sample documentation form (Wheeler, 2009) is based on the concept of charting by inclusion. Charting by inclusion requires that the RN chart normal negatives (pertinent negatives) as well as abnormal findings. Pertinent negatives are “findings that are normal and significant” (e.g., no black or bloody stools). If you are charting by inclusion, pertinent negatives should always be written. In telephone triage, the issue of charting by inclusion or exclusion is best addressed by in-house counsel and written policies.

“Red Flags” and High-Risk Patients

Research has identified several broad categories of high-risk patients and symptoms. These groups are signified by the acronym SAVED. These five categories are also known as “red flags.” Red flags help all practitioners to function more effectively. When red flags are raised, nurses are encouraged to use their intuition.


“It is easier to identify an emergency than to rule one out” (Lephrohon & Patel, 1995). Severe pain (9 on scale of 10), severe bleeding (spurting, bright red), or severe trauma (falls from a height over 15 feet) are all conditions that the average layperson could identify as urgent. Strange symptoms include ill-structured, vague, atypical, or unusual presentations—symptoms that only astute professionals might recognize as urgent. Sudden, unexpected, or new symptoms; recurrent symptoms; or a marked change in the patient’s condition all qualify as suspicious or strange.

The “big six”—head, abdomen, chest, respiratory, dizziness, and flu symptoms—are also considered suspicious. These symptoms always require thorough investigation, primarily because they are often linked to underdiagnosed but potentially serious conditions such as ectopic pregnancy, myocardial infarction, or appendicitis.

Suspicious symptoms also apply to situations where the nurse has a “gut feeling” or a hunch about a problem. In such situations, if the nurse is uncomfortable with the protocol disposition, it is important to upgrade a problem or bring the patient in sooner.


Age is one of the most important pieces of data obtained. The very young, very old, and women of childbearing age are always considered high-risk patients. Due to immature immune systems, premature infants and those under 3 months of age are at highest risk. The “frail elderly” (anyone over 75 years of age or suffering from multiple or chronic diseases, functional disability, or psychosocial problems) are vulnerable due to failing immune responses. The childbearing years—always a high-risk period associated with pregnancy, birth control, and STIs—now extends from age 11 into the 60s.


Veracity refers to the ability to reproduce the facts of the situation accurately without communication barriers. Obstacles to communication include: second-party calls, low literacy callers, language barriers, extremely young or very inexperienced mothers, or caretakers unfamiliar with the patient.


Nurses can pick up many cues through careful attention to the words, tone, and pacing of the caller’s voice. There may be hysteria or denial, inappropriate affect in caretaker or parent, or a history of psychiatric problems or substance abuse. Anxiety is always a red flag. Frequent calls in a short period of time can be an indicator of both caller anxiety and problem acuity.


Generally, debilitation refers to chronic illness. Chronic illnesses may include (but are not limited to) cancer, diabetes, heart disease, hypertension, mental disorders, asthma, or COPD. For the immunocompromised, debilitation may involve lack of adequate immunizations, chemotherapy, HIV, splenectomy, steroid therapy, transplants, or nephrotic syndrome.

Distance can often pose a problem in gaining timely access to care. For example, a patient/caretaker may be calling from a remote location several hours from hospital, or the patient must take sporadic public transportation at night. In urgent situations, if timely arrival is difficult due to the lack of a car, the nurse must upgrade the disposition.

To summarize, quickly prioritize by using SAVED with the documentation form. Ask questions in any order, or simply let the caller tell their story at first. Use open-ended questions where possible.

S Severe/strange/suspicious symptoms
  • Severe pain, bleeding, trauma, diarrhea, vomiting, etc.
  • In children or elders, severe diarrhea, dehydration, infection symptoms
A Age
  • All women of childbearing age
  • Sexually active adolescents (male or female)
  • All frail elderly
  • Men over age 35
  • Women over age 45
V Veracity
  • Second-party calls
  • Low literacy
  • Language barrier
  • With elders, suspected substance abuse; incoherent or slurred speech in patient caretaker; caretaker unfamiliar with patient
E Emotional status
  • Hysteria or denial; inappropriate affect in caretaker
  • Parent or caretaker with history of abuse (physical or sexual), psychiatric problems, or substance abuse
D Debilitation & distance
  • Chronic illnesses
  • Parent/caretaker calling from remote location over one hour from hospital
  • In emergent situation, patient unable to reach care within one hour due to traffic or lack of available car; reliance on public transportation that is sporadic or nonexistent at certain hours

Documenting high-risk patients and symptoms using SAVED can “defend” dispositions. For example, the statements “abdominal pain, previous Hx ectopic” or “nosebleed, severe, unresponsive to home Tx x 30 min” provide information that identifies a problem’s severity and that it was due to a previous medical history or a failure to respond to home treatment, respectively.

Problem and Patient Histories

Researchers have consistently pointed out the need to collect essential information related to the problem and patient history. The acronym SCHOLAR outlines key questions to elicit data on the problem history, and the acronym PAMPER elicits key information about the patient history. These mnemonics can easily be built into documentation forms as both prompts and question/answer (Q&A) tools to support nurses. (While other well-known nursing mnemonics such as PQRST or SOAP may work well for face-to-face assessment, more detail is needed in telephone triage interactions.)

S Symptoms and associated symptoms
  • Is it an isolated symptom or complex of symptoms?
  • Course of symptoms: Is it better? Worse? The same?
C Characteristics
(aids in precise description)
  • Quantitative (scale from 1 to 10)
  • Qualitative (sharp, dull, pounding)
H History of complaint In the past, What was done? By whom? When? Results?
O Onset of symptoms
  • When did they started?
  • How long have they been present?
  • Was the onset sudden or gradual? (sudden = higher acuity)
L Location of symptoms
(strive for precision, e.g., RUQ, LLQ, etc.)
  • Localized? (higher acuity)
  • Generalized? (lower acuity)
  • Radiation?
A Aggravating factors What activity, foods, position, etc., make it worse?
R Relieving factors What activity, foods, position, etc., make it better?
P Pregnancy/breastfeeding For all women between the ages of 12 and 50, unprotected intercourse?
A Allergies Foods, chemicals, drugs, insect bites, cosmetics?
M Medications Daily over-the-counter, prescription, and birth control? As appropriate, recreational drugs, alcohol?
P Previous chronic illness Recurrent illness, multiple surgeries, family history?
E Emotional state Psychiatric history, current reaction to illness?
R Recent Injury, Illness, Ingestions Recent accident or child/elder/spouse abuse/neglect? Exposure to communicable disease? Possible covert/unwitnessed ingestion?

Assessing Children, the Elderly, and Poor Historians

With children, some elders, and poor historians, it is difficult to get adequate information for two reasons: (1) the patient is preverbal or a poor historian, and/or (2) the patient has vague or ill-structured symptoms. In these cases, SCHOLAR and PAMPER may be unworkable. Instead, assess activities of daily living (ADLs) to elicit and compare the client’s current state with their baseline state. With children and elders, baseline indicators of current health or illness provide the clearest picture when symptoms are vague, ill-structured, or absent.

Since toxicity and dehydration are common risks with children, gather this information and then compare it to the descriptors in protocols for “Toxicity and Dehydration Assessment.” Marked changes in any of these indicators can be a sign of severe illness.

Breast/bottle/food # Oz/cups/glasses per 24/16/8 hours
Emesis/diarrhea/urine # Diapers/episodes per 24/16/8 hours
C Color Lips/skin/nailbeds
R Respirations Rapid/slow/labored
A Activity Work/play/daily routine
S Skin turgor Dry lips/tongue/tenting/sunken or bulging fontanel
S Sleep pattern Too much or too little
D Difficult to awaken or to keep awake
E Expression decreased
M Movement little to none spontaneous
E Eye contact/focus decreased
R Recognition of caregiver/parent decreased
I Interactivity decreased
T Talking/babble decreased


Once the nurse has elicited key information utilizing the documentation form and assessment tools, telenurses can form a provisional or working diagnosis, also called an “impression.” Use the patient’s chief complaint in his or her own words (headache, nosebleed, vaginal bleeding), then add modifiers or qualifiers to designate the level of acuity. Using a pain scale of 1 to 10 you might document as follows: “abdominal pain, 9/10, sudden onset”; “ankle pain, 4/10, trauma history.”

Next, it is time to choose a protocol. In some cases, the nurse will use the generic protocol, a core protocol that serves as “infrastructure” for all other protocols. Protocol selection is based on the principle of prioritizing. Always choose the protocol that matches the most serious-sounding symptom or one which most likely will lead to an appointment.

Patients rarely present with the classic picture of any disease. Individuals’ disease presentations vary due to immune response, medical history, age, and the timing of the call in relation to the disease process. Thus, telenurses must carefully navigate the myriad of possible presentations. A myocardial infarction may present as one key symptom (like chest pain), a few generalized symptoms (nausea, vomiting, sweating), or the full-blown classic picture (crushing chest pain accompanied by shortness of breath, nausea, vomiting, dizziness, sweating, anxiety). It is the role of the RN to determine what constitutes a match.

A Generic Protocol

Most providers maintain numerous protocols from which to choose. However, because of the myriad presentations and the uniqueness of individuals, protocols may not cover every condition. This leads to what is commonly known as the “out of protocol experience”; it is remedied by the generic protocol (or fallback protocol), which can act as a safety net.

The generic protocol (Wheeler, 2009) is especially useful in three instances: (1) when the nurse does not know which protocol to use, (2) when no other protocol quite fits the situation, and (3) when responding to calls about infants, elders, or poor historians whose presenting symptoms are vague or ill-structured. (It might also be used as a training device for novice practitioners.)

Sepsis and Dehydration Protocols

There are two key protocols that no pediatric manual should be without: sepsis (toxicity) and dehydration. Children are especially vulnerable to these two serious conditions. Both protocols should describe key behavioral patterns related to these conditions based on the parameters outlined in activities of daily living (ADL) tools. For example, with possible sepsis, the child may exhibit extremes of behavior: extremely irritable, crying inconsolably, unable to be comforted. At the other end of the spectrum, a child who is quiet, not moving, very withdrawn, and difficult to engage presents another pattern of severe illness. Refusal to eat, drink, or breastfeed nearly always indicates patterns of extreme illness in children.

With dehydration, the nurse should elicit and be alert to the context and combined effect of conditions that can worsen dehydration. These include extreme heat or humidity, exercise, fever, nausea and vomiting, diarrhea, low or no fluid intake, as well as age, chronic disease, degree and duration of fever, patient medical history, depressed thirst response, and medications.

Four-Tier Triage

While the standard five-tier triage model may apply in face-to-face situations, the limits of telephone triage allow for only three or four disposition categories. These include emergent, urgent, acute, and nonacute. Each category refers to a flexible timeframe within which the nurse determines what is safe, prudent, and reasonable. Thus, the nurse has the professional responsibility to use his or her best professional judgment.

  1. Emergent-level calls. Generally speaking, these calls require paramedic transport. They involve severe, life-threatening symptoms. Patients must be kept NPO (nothing by mouth). Whenever possible, try to remain on the line with the caller or implement a three-way conference call as appropriate with services such as suicide prevention, 911, poison control, or rape crisis. When callers are advised to go to the ED or to labor and delivery, always call and notify the department of the impending patient arrival.
  2. Urgent-level calls. Urgent-level callers should be seen within 1 to 8 hours. However, some urgent symptoms may need to be seen as soon as possible at the most appropriate site. These patients must be kept NPO and will require paramedic transport if there is no readily available car or if the driver (caretaker/parent) is alone and/or too anxious to drive.
  3. Acute-level calls. In this model, acute-level calls are seen within 8 to 24 hours or given a next-day appointment.
  4. Nonacute-level calls. Generally speaking, nonacute-level callers are directed to come in as appropriate. Nonacute symptoms usually can be managed with telephone advice and/or an appointment.

When In Doubt

“When in doubt, always err on the side of caution” is a cardinal rule in telephone triage. Nurses must rely on their best professional judgment and use every means at their disposal to ensure that patients are treated in a timely manner. Time frames designated on the template are intended as a general guide. When in doubt, have the patient come in sooner rather than later.

Nurses may upgrade dispositions as appropriate (from urgent to emergent, nonacute to acute). However, nurses must never downgrade (urgent to nonacute) without physician consultation. If the patient is noncompliant, always seek advice from the physician advisor.


End each call with the final question “Is anything else worrying you?” or “Do you have any additional questions?” This step may reveal a caller’s entirely different motivation and may even open the door to a new triage process.

Documenting a closing statement helps ensure that the patient has given informed consent. In other words, they comprehend the provisional diagnosis and proposed treatment, with the following understanding:

  • This is an impression, not a medical diagnosis.
  • The advice or home treatment is based on the impression.
  • If a patient disagrees with the impression, they may have an appointment.
  • If symptoms worsen or fail to respond to the home treatment, the patient agrees to call back or come in.
  • The patient agrees to the plan.

Elicit and document what the caller plans to do at the end of the call. This will demonstrate that there was agreement to a certain plan of action. Further, it ensures that the patient understands what to do and under what conditions they may need to ask for further help. Also, utilize the chain of command; don’t be afraid to go to the next higher level. Additional “layers of protection” or risk management might also include:

  • Taking continuing education courses
  • Knowing your Nurse Practice Act
  • Using written guidelines and protocols
  • Obtaining copies of your job description, job qualifications, policies, and procedures in writing


In the current managed-care environment, which seeks to contain costs by reducing inappropriate ED (with paramedic transport) and office visits, telenurses are sometimes forced to act as gatekeepers. As a result, nurses and receptionists may unwittingly be caught in a bureaucratic trap.

With the nurse or the physician, two specific risk management issues—delay and denial of care—can haunt every decision made. That is because telenurses provide access to appointments and entry to the ED. Delays or denial of care can result in harm to the patient. In the following case, delay in getting an infant to the nearest ED had tragic consequences.


At 3 a.m. a mother called an HMO regarding her infant, who had a fever of 103°F. The nurse failed to obtain a complete history and gave routine advice for fever control. She consulted with the pediatrician on call but failed to provide a complete picture of the infant’s illness. On the orders of the pediatrician (who was acting on the nurse’s incomplete information), the nurse directed the parents to an ED that was part of the HMO plan and about 45 minutes away. (The nearest ED was about 20 minutes away.) En route, the child experienced a cardiac arrest due to hypoperfusion syndrome and meningitis. Because of impaired circulation, the child’s hands and feet had to be amputated. A jury awarded the parents $45 million in damages (Hartnett, 1998).

Patients themselves may contribute to delays through their own reluctance to call 911. A recent study found that people who are charged for emergency services were less likely to call 911. In the study, researchers found that although 89% of people surveyed said they would use EMS services to go to the hospital, only 23% of patients arrive by ambulance (Brown et al., 2000). The following case illustrates this.


A recently discharged patient called the doctor’s office requesting to be “rehospitalized.” He told the receptionist that he “felt sicker than when he was discharged.” Following office protocol, the receptionist inappropriately told the patient that he needed to see the doctor first. The patient was finally seen at the end of the day. He collapsed and was taken to the ED via ambulance, where he died (Saxton, 1999).

The telenurse’s priority is to ensure patients’ timely access to emergency services rather than considering who will pay for paramedics. The nurse should always be alert to the possibility of patients’ concerns with payment issues. This “hidden agenda” may lead the caller to minimize disclosure of symptoms in order to avoid incurring the costs associated with paramedic transport. Detailed written policies and procedures should clearly address the access issue and the correct procedure to follow.

While malpractice claims from traditionally high-risk populations (pediatrics, geriatrics, and women of childbearing age) remains high, what has changed is that many claims from high-risk populations are now related to lack of timely access to specialists. Due to cost-containment strategies, callers often need to be screened by their primary-care provider prior to seeing a specialist. This policy may dangerously delay access to the patient’s OB/GYN, pediatrician, internist, or oncologist. Bureaucratic obstacles to timely access can be subtle.

Many offices and group practices utilize secretaries, unlicensed assistive personnel (UAPs), LVNs, and LPNs to manage calls. This prompts several questions: How much legal risk is there? What are these personnel qualified to do? Can physicians or RNs delegate the important task of telephone triage to them? Can unlicensed personnel perform limited telephone triage with a “list of emergent symptoms” or abbreviated protocols?

In the managed-care environment (with a goal of managing patient access and demand), could even appointment making, without an initial assessment, be a form of “unintentional triage” and thereby an exposure to risk? This is one of the most problematic issues confronting telephone triage. The following case studies demonstrate this.


John Dodd, a 44-year-old male, called the doctor’s office at 9:30 a.m. complaining of “heartburn, nausea, tingling in his arms and legs, diarrhea, and body aches.” The receptionist told him that his symptoms sounded like the flu and promised to call back with an appointment, which she failed to do. At 3:15 p.m. Mr. Dodd called again, now complaining of “chest pain and shortness of breath.” Per the receptionist’s instruction, he arrived at 5 p.m. for an ECG. Following the ECG, he collapsed and died of a myocardial infarct. (Wheeler, 2006)

In the next case, an elderly patient volunteered no symptoms; indeed, he may not have experienced anything that he would consider a symptom. In the elderly, symptoms may be subtle or even silent. Perhaps, in this patient’s mind, he was simply calling to talk to his doctor, a trusted advisor, about the fact that he had been feeling tired. Perhaps he wanted to discuss with his doctor whether he needed an appointment.


An elderly gentleman called the clinic, insisting on speaking with “his doctor.” The receptionist responded that the doctor was on vacation, offering an appointment the following week when the doctor returned. When the man was eventually seen some weeks later, the doctor discovered his patient had suffered a heart attack when he had initially contacted the office. The patient apparently did not recognize his symptoms as serious, and the receptionist did not ask about them but simply gave him an appointment. Thus, the patient was not assessed, a delay in care ensued, and the patient suffered further damage to his heart. (Wheeler, 1999)

Well-meaning but misguided patients often stereotype or mislabel their own symptoms and attempt to decide for themselves when they need to be seen (appropriately or inappropriately). They may base decisions on what is convenient or reasonable for them. This practice compounds the possibility of triage error, underscoring the need for RNs to elicit symptoms prior to appointment giving. Establishing a general policy that all symptom-based calls should be triaged by the RN may seem overly zealous but may actually help systems to run more efficiently and safely while avoiding risk.

Take the Test


American Academy of Ambulatory Care Nursing (AAACN)

Emergency Nurses Association

Teletriage Systems (Author Sheila Wheeler’s website)


Alfaro-LeFevre R. (2006). Applying Nursing Process: A Tool for Critical Thinking (6th ed.). Philadelphia: Lippincott, Williams & Wilkins.

American Academy of Ambulatory Care Nursing. (2007). Telehealth Nursing Practice Administration and Practice Standards (4th ed.). Pitman, NJ: Anthony J. Janetti.

American Academy of Ambulatory Care Nursing. (2003). Telehealth Nursing Practice Core Course Manual. Pitman, NJ: Anthony J. Janetti.

American College of Emergency Physicians. (2006). Providing telephone advice from the emergency department. Retrieved February 2011 from

Benner P. (2001). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice-Hall.

Benner P, Tanner C, & Chesla C. (1996). Expertise in Nursing: Caring, Clinical Judgment and Ethics. New York, NY: Springer.

Briggs JK. (2007). Telephone Triage Protocols for Nurses. Philadelphia. Lippincott Williams and Wilkins.

Brillman J, Wachter DA, et al. (1999). Pediatric telephone triage protocols: Standardized decision-making or false sense of security? Annals of Emergency Medicine, 33(4), 368–94.

Brown AL, et al. (2000). Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Circulation 102, 173.

Clawson JJ & Dernocoeur KB. (2005). Principles of Emergency Medical Dispatch (3rd ed.). Salt Lake City: National Academies of EMD.

Coleman A. (1997). Where do I stand? Legal implications of telephone triage. Clinical Nurse, 6(3), 227–31.

Edwards B. (1998). Seeing is believing: Picture building: A key component of telephone triage. Journal of Advanced Nursing, 7(1), 51–57.

Edwards B. (1994). Telephone triage: How experienced RNs reach decisions. Journal of Advanced Nursing, 19(4), 717–24.

Gladwell M. (2005). Blink. New York: Little, Brown.

Hartnett T. (1998). Keep your clinical call center out of legal hot water. Demand & Disease Management, 4(4), 49–64.

Hickey M., et al. (2005). Telephone Triage for Oncology Nursing. Pittsburgh, PA: Oncology Nursing Society.

Hutcherson CM. (2001). Legal considerations for nurses practicing in a telehealth setting. Online Journal of Issues in Nursing, 6(3), Manuscript 3. Retrieved February 2011 from

Hutcherson CM. & Williamson, S.H. (1999). Nursing regulation for the new millennium: The mutual recognition model. Online Journal of Issues in Nursing, 4(1), Manuscript 2. Retrieved on December 18, 2009, from

Institute of Medicine (IOM). (2000). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy of Sciences.

King L. (1997). Intuition: A critical review of the research and rhetoric. Journal of Advanced Nursing, 26(1), 194–202.

Klein G. (2003). Intuition at Work. New York: Random House.

Lephrohon J & Patel V. (1995). Decision making strategies for telephone triage in emergency medical services. Medical Decision Making, 15(3), 240–53.

Long VE & McMullen, P.C. (2003). Telephone Triage for Obstetrics and Gynecology. Philadelphia, PA: Lippincott Williams and Wilkins.

Mueller NM, et al. (2000). Telephone Nursing Practice in Adult Urology. Pitman, NJ: Society of Urologic Nurses and Associates.

Perrin E & Goodman HC. (1978). Telephone management of acute pediatric illness. New England Journal of Medicine, 298, 130–35.

Poole SR. (2003). The Complete Guide to Developing a Telephone Triage and Advice System for a Pediatric Office Practice During Office Hours and/or After Hours. Elk Grove Village, IL: American Academy of Pediatrics.

Saxton JW. (1999). Liability exposure in a managed care environment. Physician’s News Digest, August. Retrieved February 2011 from

Schmitt BD. (2009). Pediatric Telephone Protocols (12th ed.). Baltimore: Lippincott, Williams & Wilkins.

Selwa LM, et al. (2002). Neuro-Triage Telephone Advice. St. Paul, Minn.: American Academy of Neurology.

Smith R. (2005). Interview with Sheila Wheeler, San Anselmo, California, April 27.

Tanner CA. (1998). Clinical Judgment and Evidence-Based Practice: Conclusions and Controversies. Portland, OR: Oregon Health Sciences University.

Utilization Review Accreditation Commission (URAC). (2011). Health call center accreditation standards summary. Retrieved February 2011 from

Wheeler SQ. (2009). Telephone Triage Protocols for Adult Populations. McGraw Hill: New York.

Wheeler SQ. (2006). Risk Management in Telephone Triage: Trends, Advances, and Risks. San Anselmo, CA: TeleTriage Systems.

Wheeler SQ. (1999). Anecdote related to S. Wheeler during conference presentation of “Telephone Triage: Essentials for Expert Practice,” at the Contemporary Forums Conference, Dublin, California.

Wheeler SQ. (1993). Telephone Triage: Theory, Practice and Protocol Development. Albany, NY: Delmar Publishers.

Winfrey ME, Smith AR. (1999). The suspiciousness factor: Critical care nursing and forensics. Critical Care Nursing, 22(1), 1–7.

Wood DA. (2004). On the level(s): A five-tier triage scale system, which better streamlines emergency care, gains popularity among ED nurses. Nurseweek, June 8. Retrieved February 2011 from

Take the Test

Wild Iris Medical Education
Providing accredited healthcare continuing education since 1998