This lesson offers two examples of nurse triage support — one that’s done correctly, and one that isn’t.

Our patient is baby Georgia, whose mother has called the triage line to see if she needs to be taken to the ER. For the past two weeks, Georgia has developed mild nasal drainage, congestion, and a non-productive, dry-sounding cough. Tonight, she has a fever of 101. Although she’s been playful, she seems tired, and cries, naps, and clings more often than usual. While these may not raise any major red flags, it’s important to keep these facts in mind regarding children too young to verbalize opinions:

• Newborns are considered high risk, especially through age 7. They account for more than 90 percent of under-referrals that result in a serious adverse outcome.

• Newborns with serious chronic diseases may experience abrupt symptom changes during the first week of life.

• Newborns with a serious illness may exhibit very subtle symptoms. These can include poor sucking, sweating during feedings, changes in muscle tone, decreased activity, change in color, or a sudden change in feeding.

Here are some examples of childhood disease and the subtle symptoms exhibited by each:

Bacterial Sepsis — fever or hypothermia, very weak, shock.
Congestive Heart Failure — poor color, sweating during feeds.
Herpes simplex — clusters of vesicles.
Meningitis — viral or bacterial.
Severe dehydration from inadequate breast milk production — weight loss, sunken AF, possible stroke during the second week of life.
SVT (supraventricular tachycardia) — prolonged crying, sweating during feeds, tachypnea, tachycardia

Triage nurses should ask questions that focus on symptoms:

Is your baby acting sick in any way? (Remember that new parents may think that only a cough, cold, or runny nose are symptoms of an illness.)
Does your baby have any symptoms?
What’s your baby’s temperature?
Has your baby’s color changed?
How is your baby’s breathing?
Make sure to go into more detail. Count respirations, look for retractions or nasal flaring, compare skin color during and after a cough, and review the duration of sickness.

Review: What does Triage Nurse #1 do wrong? 

The goal of any nurse triage is to develop a plan of action, then take the patient to the most appropriate level of care by the safest route. Triage nurses must be as prudent as any in-house nurse, and should avoid negligence — the failure to communicate significant information in a timely manner to the patient or physician.

Nurses should take the time to:

• Elicit enough information to make an informed decision.
• Ask a lot of questions!
• Be vigilant on the phone when gathering information like past medical history, medications, allergies, and chronic disease.

Review: What does Triage Nurse #2 do right?

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TriageLogic is a URAC-accredited, physician-led provider of top-quality nurse telehealth technology, remote patient monitoring, and medical call center solutions, all for the purpose of encouraging positive patient behavior and improving access to healthcare. Founded in 2007, the TriageLogic Group now serves more than 9,000 physicians and covers over 25 million lives nationwide. They continue to partner with private practices, hospitals, and corporations throughout the U.S.