Telephone triage is an integral part of ambulatory care nursing. That being said, the practice is still relatively new, which means a learning curve for practitioners and practices alike. In order to prevent triage red flags, triage nurses should be aware of the most common mistakes so they can avoid them.

A Picture of Successful Triage

Triage is a multifaceted and nuanced discipline, but when performed correctly, it can save lives. The skills required to triage well are not taught in basic nursing undergraduate programs, and those who desire to succeed as triage nurses should make a study of best practices and continue to learn from their mistakes. 

Speaking broadly, the triage process follows this progression: assessment, data collection (both objective and subjective), conclusion of the appropriate triage category, collaboration and planning, intervention, and evaluation. Triage nurses should approach each case individually and see it through to the end.

Identifying Common Telephone Triage Red Flags

The sheer scope of triage makes triage red flags a high probability. However, if triage nurses are prepared for the most common red flags, and if they will follow the protocols designed to set them up for success, they can provide care with discernment to a triumphant end. 

Accepting Self-Diagnosis

A triage nurse does not have the authority to diagnose, and patients are certainly less qualified to do so. Triage nurses should not accept patients’ assumed self-diagnoses, even when they may be as simple as “I have the flu” or “I have the cold.” Follow the protocols to gather all the necessary information from the ground-up.

Jumping to Conclusions

This triage red flag applies to both positive assumptions (he’s vomiting because of the medication he’s taking) and negative assumptions (she’s too young to have a stroke). Triage should be performed with thoroughness and an open mind. This plays into listening to patients, letting them give a full account and asking them questions before coming to a conclusion. Doing so can also alleviate patient anxiety as they feel the nurse is really listening.

Be as thorough as possible. The temptation for both triage nurse and patient is to get through the triage process as quickly as possible so care can be attained sooner. However, it is better to have a clear view of the problem. Make sure every symptom is explored, and consider unique or unexpected circumstances.

Value the patient’s concerns. What may seem like an ordinary condition may be something more threatening that the patient isn’t describing well. If a doubt exists, recommend the patient come in for face-to-face care.

Failure to Speak to the Patient

This triage red flag has two primary forms: ineffective communication with the patient and having a third party as the point of contact. As the patient’s condition allows, speak to the patient personally, not just a family member or friend. This allows nurses to get first-hand descriptions of pain, symptoms, and possible initiating events. Let triage protocols inform the conversation to create the most thorough and helpful dialogue possible.

Failure to Provide Continuity of Care

Care must be considered as a holistic picture. It does not begin and end with the triage call. Previous symptoms and corrective actions must be taken into account. For example, if stomach pains were present last week but not now, they should not be disregarded. Similarly, if a patient has called multiple times, they should receive the complete triage gambit every time.

Triage nurses must also relay all relevant information properly to subsequent parties. This is done through written records and follow-ups with healthcare providers. All considerations must be properly documented and relayed to the next healthcare professional to ensure that nothing is missed. Communicate clearly with providers and make sure they have the full picture.

Functioning Outside of Scope

It is not the responsibility of a triage nurse to diagnose or prescribe. Nurses should gather all the information necessary to form a picture of the patient’s condition and make a judgment call on how best the patient should proceed. 

Over Reliance on Support Tools

Do not let the protocols become a crutch. They are there to help make sure the triage process covers all important points, but it is important for triage nurses to also use their judgment if they feel other or further information is needed.

Knowledge Deficit

This triage red flag can be mitigated by thorough and continuously updated training, but sometimes things arise that are not in a nurse’s scope. No one triage nurse knows everything, and seeking the counsel of another party should be normalized so the patient can get the help they need.

Being Distracted or Multitasking 

Healthcare is a demanding profession. There are many pulls on nurses’ time, and it can be easy to let that consume or lead a nurse to respond in haste or out of fatigue. However, each triage patient has a right to the best and most focused care possible. Making sure triage nurses are unencumbered with other responsibilities or distractions is often an administrative effort. Contracting out the triage process to dispatchers who can attend to it full-time can help. 

Failure to Adequately Assess

This triage red flag is really a combination of all the others. The correct assessment relies on listening carefully to the root of patients’ concerns, exploring every option, taking previous history into account, and pulling from all known medical science. Do not take anything for granted, and if the patient or caller is concerned, the triage nurse should be too.

It is best practice to err on the side of caution. While it may seem fatalistic to anticipate the worst possible outcome, it is better to prepare for the worst case scenario and provide more care than needed as opposed to less. In this way, triage nurses honor the trust placed in them.