Tips for Triage Nurses

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Tips for Triage Nurses

​​Be Prepare​​d!

The good old Boy Scout motto is the key to anticipating and preparing for a high caseload of calls during the season, the weekend, or any given shift. Gear up mentally. Think about each shift in advance – will it be busy or not? What's going around the pediatric office these days? Is there a full moon? What's the media been pitching lately in terms of health topics? Review your guidelines for "winter" illnesses and read up on topics like RSV and influenza.

Other tips to get ready include taking the time to tidy up the workstation; stocking up on essential forms or office supplies; updating speed-dials on phone, fax, or drop-down windows; and updating reference materials.

Documentatio​​n Do's and Don'ts

When stressed from high call volumes, the focus tends to be on answering the calls as quickly as possible but the documentation of those calls tends to be scant or sometimes relegated to the bin for "document later on." Delaying documentation is a high risk and poor quality endeavor and should never be done. The main way to avoid this pitfall and stressor is to "document-as-you-go." This is where multi-tasking comes into play. Try to fill in some of the patient demographics while you are waiting for the phone to ring. Document as much of the assessment as possible during the phone call. Focus on documenting the positive symptoms and only record the negative symptoms when ruling out something serious. After hanging up the phone, finish documentation with care advice and recommendations for follow-up. When multiple callbacks have to be made, remember that not everything is an emergency. Take the extra 1-2 minutes to complete documentation before taking on that diaper rash call. Following these tips ensures more timely and accurate notes.

Additional AAP Telephone Care Resources

Pediatric Telephone Protocols, 15th Edition​
A go-to resource for telephone care triage, which covers a broad spectrum of caller concerns. 

Pediatric Nurse Telephone Triage
A decision-support tool that is a companion to Pediatric Telephone Protocols, and helps office staff deliver superior telephone advice. 

Breastfeeding Telephone Triage and Advice​​
Resource to help nurses, lactation professionals, and other medical staff confidently advise breastfeeding mothers by phone.​​​​​​

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Tricks of the ​​​​Trade

The following is a list of little tricks that telephone nurses have found to be helpful. These little things can really add up as timesavers.

  1. Headsets are a must! A headset keeps both hands free for documentation and/or getting reference material. For those who do not like headsets, consider a shoulder rest to free up the hands.

  2. Get the caller to focus on the immediate complaint. If having difficulty identifying the true reason for the call, ask "What is the one thing or symptom that made you call for advice right now?"

  3.  If there are several difficulty breathing calls at the same time, handle one at a time by ensuring that it is not a 911 event, then provide a quick treatment recommendation (ie. start a neb for asthma; provide warm mist for croup), inform the caller/s that there are multiple emergencies and instruct them to start the treatment advice and await a call-back in 10-15 minutes. Go on to the next call, give the same type of quick advice and then make follow-up calls to evaluate the therapies and complete the assessment, disposition, and care advice.

  4. Use a four-tier IN/OUT box for: 1) Unanswered calls; 2) Completed Calls to be faxed or filed; 3) Calls that need follow-up; and 4) Calls that need physician intervention.

  5. Keep a few good references close by: a telephone triage guideline book, a medication handbook, a medical dictionary, and a basic pediatric textbook.

  6. Be organized. Don't let messes pile up. Telephone triage has been compared to air traffic control: ask yourself "where is the best place to treat this patient — home, office, clinic, ED, ambulance?"

  7. Use a sports-type water bottle to prevent spills on the keyboard or papers. 

  8. Remember to get up, stretch, get a drink, or go to the bathroom.​

Communication: C​​an You Hear Me Now?

Communication amongst the triage staff is very important for patient care, and even more important for staff morale. A simple white board works well at the main triage station, where nurses can write any pertinent information for that day or shift. This might include patients who might call back or need follow-up, a change in the physician on-call schedule or the "symptom of the day." 

Discuss telephone triage as part of staff meetings periodically. The agenda might include time for business, case reviews, and in-service education from hospital staff or external speakers. The most valued agenda item often proves to be an open forum at the end of the meeting. This is where the best sharing of experience, knowledge, and style occurs. It is a safe time to ask clinical questions, discuss frustrations or stressors or talk about the positive sides to telephone triage.​


The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.

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