A mother comforts her daughter who lies on a couch with her teddy bear. The mother is on the phone with her pediatrician regarding the child's fever.

Choosing the Correct Protocol in Nurse Triage: An In-Depth Discussion of Fever Protocol

As part of the nurse triage process, nurses need to select guided protocols to evaluate patient symptoms and make decisions on their care dispositions. Which protocol a triage nurse uses depends on the symptoms. However, one symptom often presents itself in conjunction with others: fever. When this happens, it may be tempting to select the fever protocol, but a triage nurse should only use it when a fever is the only symptom a patient experiences.

Most of the time, a fever is not an immediate cause for concern. It indicates that a patient’s body has identified an illness and is currently fighting off infection. That said, there are circumstances where a fever can be a sign of something more serious. That’s why triage nurses should be careful when evaluating a patient’s fever over the phone. Here is the information they should keep in mind when selecting the fever protocol, starting with the age group of the patient.

Fever for Patients Under 3 Months

Children under three months of age do not have well-developed immune systems. This means that they may not show any symptoms of an illness besides a fever. This makes triage more difficult, which is why its associated fever protocol is more conservative and often refers children in this age group for in-person evaluation by their pediatricians.

Fever for Patients Over 3 Months

Children ages three months and above have immune systems that often demonstrate other signs of illness in combination with a fever. Think vomiting, diarrhea, and a runny nose, for starters. While a fever can be indicative of a serious health issue when accompanying these other symptoms, it’s usually not a point of concern if: a) the child is acting normally, or b) it’s the only symptom. For the latter, the only time when this doesn’t apply is when a fever is the only symptom and there is no obvious reason for it. In such cases, it may have to be observed carefully and evaluated further depending on the clinical status of the child.

Fever for Adults

Adults don’t tend to get fevers very often. They’ve developed stronger immune systems since childhood, and typically show other signs of infection if a fever is present. As a result, low-grade fever by itself is not very concerning unless the patient has an underlying condition that makes them immunocompromised. These underlying conditions are taken into account using nurse triage software.

Selecting the Appropriate Protocol

Because there can be some initial ambiguity when it comes to the reason for a fever in a patient, it’s important that triage nurses understand and choose the appropriate protocol that addresses all relevant signs and symptoms presented by the caller. Our nurses do this using the most up-to-date Schmitt-Thompson triage protocols, including those for COVID-19. 

As we already mentioned, a fever protocol is only used when the patient has no other symptoms. This is because all triage protocols include fever as part of their symptom decision tree, so it’s still accounted for when a nurse evaluates all symptoms to arrive at the correct disposition. When fever is the only one, the nurse asks detailed questions to learn if the caller is immunocompromised or at risk in some other way.

Caller Behavior

When the patient is a child, triage nurses must interact with their parent or guardian. This adds another layer to the triage process, especially when the caller is emotional. One of the scariest things for a new parent is not knowing what to do when their child has a fever. That’s why a telehealth nurse must demonstrate the proper behavior to keep a parent calm and obtain the information they need to choose the correct protocol.

Your Nurse Triage 

Do you need updated triage protocols, triage software, or additional triage call center support? We can provide all three:

We offer daytime and after-hours versions of Schmitt-Thompson protocols for a nominal fee. 

Our triage software is HIPAA compliant, customizable, and secure. It’s also able to share patient data directly with a provider’s existing EMR. 

Our call center is staffed with registered nurses who can address your patients 24/7, acting as an extension of your practice.

Let’s schedule some time to discuss your needs, as well as the details of a full-service program.

About TriageLogic

TriageLogic is a URAC-accredited, physician-led provider of top-quality nurse telehealth technology, remote patient monitoring, and medical call center solutions. Founded in 2007, the TriageLogic Group now serves more than 9,000 physicians and covers over 25 million lives nationwide.

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