Professional Nurse Triage Services

Telephone triage is more than answering health questions. Telephone triage nurses must be able to assess a client's health concerns without the advantage of visual inspection or face-to-face interaction. Nurses must rely on their communication skills, knowledge of disease processes, and normal growth and development for all age groups in order to ascertain an accurate understanding of the client's symptoms. Triage nurses must have impeccable listening skills to notice the non-verbal clues the client is giving regarding pain, anxiety, fear, and level of comprehension.

There is a difference between health advice lines and triage lines. Health advice lines are usually community-based information services that offer answers to general healthcare questions. Triage services are typically offered by healthcare facilities and are used in association with a physician's office. They take calls from patients who are attempting to contact the physician or other healthcare provider after usual office hours, for specific health concerns, or urgent medical needs. The triage nurse must assess the severity of the patient's symptoms and then guide the patient to the appropriate level of care.

Triage nurses do not diagnose clients over the phone. The function of the telephone triage nurse is to determine the severity of the caller's complaint using a series of algorithms developed by a coordinated effort of physicians and nurses, direct the caller to the appropriate emergency services if necessary, recommend the suggested medical follow-up based on their assessments and established triage protocols, and provide health information. This process is called the "disposition" in triage settings.

Each triage nurse has computer software with triage algorithms. The algorithms are programs that provide the nurse with pathways to follow as she or he investigates the patient's complaint. Demographic data is assessed also, such as age, gender, height, weight, etc.

The algorithms are designed to assist the nurse in a complete and accurate assessment of the client—without jumping to conclusions—based on a set of symptoms, combined with medical history. Symptoms are assessed by asking questions starting with the most acute and working down in severity to the least acute, in order to determine the need for emergency intervention. Depending on the answers to these questions, the software program then guides the nurse through specific pathways to obtain the needed information and help the nurse to determine the course of action, based on the various possible causes for the current problem. Thorough documentation is part of the process and completion must be just as diligent as charting on bedside procedures.