The Goal of the Telephone Triage Process



By Rose Moon, RN, BSN

Telephone triage processes are proven to improve access to care professionals, lower patient anxiety, save on ER costs, and prevent unnecessary health complications. The primary goal of the telephone triage process is to deliver safe, quality-oriented telephone triage partnered with outstanding customer service. The health, safety, and wellbeing of the patient is at the forefront of every telephone encounter. 

The purpose of the telephone triage process is to assess the patient’s current signs and symptoms, concurrently evaluating their past medical history and current medications. It performs the patient assessment in accordance with protocols which guide the nurse to determine the proper triage disposition to direct care to the safest, most cost-effective solution available at that time. 

Triage nurses don’t always have to be right; we just can’t afford to be wrong. Click To Tweet

To accomplish the goals of the telephone triage process, an organization needs to recruit, hire, train, and retain experienced telephone triage nurses. Two valued components that will result in quality patient outcomes are providing comprehensive, detailed orientation, as well as equipping the nursing staff with needed tools: gold-standard telephone triage protocols. 

However, the final determining factor of quality phone triage lies in the training of nurses to utilize the protocol tool properly. Anyone can read a protocol. It is the knowledgeable triage nurse who applies the following attributes of enhanced assessment skills, superior judgment, prior nursing experience, and exceptional decision-making abilities to the protocol tool that results in safe, quality outcomes and cost-effective patient care. 

Performing hands-on patient assessment allows the healthcare provider to visualize cyanosis, smell foul drainage, palpate an abdomen, and use a stethoscope to assess patients’ lung sounds. Telephone triage nurses don’t have such luxuries to assess patient needs. They’re limited to their ability to query and listen intently to the caller to obtain the necessary details of the patient’s medical symptoms and then direct medical care accordingly.

Successful triage nurses live by the following golden rules of the telephone triage process:

  • Every call is life threatening until proven otherwise.
  • Complete an ABCD assessment with every telephone encounter: Airway, Breathing, Circulation, Deficit (Neuro).
  • Assessing patients over the phone is high risk; therefore, take the callers word as truth. 
  • Follow your sixth sense: protocols are decision support tools; nursing judgment determines outcomes.
  • Know your patients’ medical history and current medications.
  • Assess your callers as well as your patients. Be a patient advocate.
  • Never provide a dosage of a medication without a complete patient assessment. 
  • Always confirm labeled dosage of a medication as well as the means in which the caretaker plans to administer the drug.
  • Always assess the caller’s level of comfort with the established plan of care before ending the call:
  • “Are you comfortable with these recommendations?”
  • “Now tell me what you plan to do next.”
  • If it isn’t documented, it didn’t happen. Use defensive documentation. Paint a picture.
  • Regardless of the reason for the call, always obtain a rectal temperature on an infant under the age of three months.
  • Document the exact mechanism of injury.
  • Be alert for red flags. Any time a caller uses or implies one of the following phrases be sure to clarify the underlying meaning. Carefully analyze your disposition and recommendation for follow-up care:
  • Grunting or moaning
  • Lethargic or listless
  • Sleeping more than usual 
  • Just doesn’t look right, act right, or is fussy
  • Sleeps through a rectal temperature
  • High pitched cry or unusual, funny cry
  • History of sickle cell or immune deficiency 
  • Frequent caller
  • Caller that expresses anxiousness or numerous questions after discussing a plan of care
  • Patient symptoms of headache, dizziness, disorientation, nausea, fatigue, or irritability; flu versus carbon dioxide exposure
  • At the conclusion of the patient telephone encounter, instruct callers to call back or seek medical evaluation if current symptoms become worse or additional signs and symptoms of concern develop.

Triage nurses don’t always have to be right; we just can’t afford to be wrong. Always err on the side of caution.

Learn more about telephone nurse triage and how to implement successful triage nurse centers by downloading the free e-book: Telephone Nurse Triage Handbook