Examining the Necessity of Nurse Triage Protocols

Procedure can sometimes feel overly complicated. Sometimes it may be tempting to rush through without ticking every ‘t’ or making sure every ‘i’ is dotted. However, when it comes to triage protocols, any deviation from policy can have monumental dividends. Protocols ensure that safety precautions are met and that no patient care gets lost in the shuffle. 

triage protocols

What Is the Triage Strategy?

The word triage has origins in the French trier which means to separate, sift, or select. The practice has been used for at least 200 years for the prioritization of medical care and has been used in nurse call centers to determine proper order of treatment since the 1960s. Triage allows nurses to organize patient load by severity of symptoms, and in order to do so, nurses must lean on a comprehensive list of triage protocols.

What Are Triage Protocols?

Triage protocols are a symptom-based set of directives that allow nurses to quickly and confidently assess patient symptoms and direct them to the right level of care based on the severity of their current symptoms. They are not meant for diagnosis, which falls outside of a nurse’s scope. Instead they help nurses explore a caller’s symptoms and then recommend a proper course of action.

Most United States telephone triage providers—over 96% including CareXM—use the Gold-Standard Schmitt-Thompson Protocols. These are akin to a medical checklist optimized for telephone triage. Split between pediatric and adult cases, the protocols are organized by symptoms. After assessing the patient’s symptoms, the attending nurse finds the appropriate protocol based on the presenting symptom that is most prevalent or troubling.

Due to the encyclopedic nature of the protocols, nurses can triage any caller regardless of previous medical history or condition. The advice is targeted for treatment based on symptoms. The general protocols cover over 99% of all symptoms and are constantly being updated as medical understanding continues to improve.

Some protocols are more niche and specific to different disciplines (i.e. psychiatry or obstetrics), but a nursing telephone triage provider such as CareXM is likely to use more generalized triage protocols. These ensure nurses ask all the right questions and patients receive consistent and accurate advice. The directives may encourage nurses to recommend opting for home remedies, making an appointment, or visiting a specialist or an urgent-care facility as appropriate.

triage protocols

What Are the Three Categories of Triage?

A triage nurse will sort patients calling in into one of three general categories: immediate, urgent, and delayed. Patients with symptoms that qualify as immediate must be treated at once or death is imminent. Patients in the urgent category require significant intervention and should receive it as soon as possible. Patients in the delayed category need medical help but urgency is not critical.

Why Are Nursing Protocols Important?

Nursing triage protocols are the lifeblood of what an on-call nurse or telephone representative does. Triage nurses must assess patient symptoms rapidly and correctly so they can send patients to where they need to be for treatment as quickly as possible. Part of this ability comes with experience and part is being set up for success with a thorough set of protocols.

Triage protocols are vital to the treatment process so that each patient is dealt with in the way they need in the timeframe available resources and staffing requirements allow for. Protocols provide a nurse with an established procedure so he or she knows patients are getting the best possible care. They allow a nurse to ask standardized questions and give consistent care advice to patients calling in.

This consistency is also a safeguard against legal action, decreasing liability and patient risk. In fact, following strict procedures has been shown to decrease hospital mortality rates by 38%. In summary, strict adherence to triage protocols enhances patient safety, helps prevent complications, promotes more rapid patient recovery, increases nursing autonomy, minimizes liability, and reduces costs for healthcare facilities and patients.

triage protocols

Following Protocol at CareXM

When you look to CareXM for your telephone triage needs, you can be assured that our nurses and staff follow protocol to the letter. There is no compromising care quality simply because you move triage out of the office. Adherence to proper triage protocols ensures that the work we do follows the same standards they would if a patient came in person. At the same time, outsourcing the triage element of care gives your practice’s staff greater freedom to provide the best care possible. Give us a call to get started.

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