The process of triaging involves screening patients, assessing the acuity of their medical conditions, and making critical decisions about patient risks. Triaging decisions impact the interventions, treatments, and recommendations that patients must follow. In response to the COVID-19 pandemic, volunteer triage nurses assembled in hospitals around the world to manage the surge in demand for care. They acted as frontline gatekeepers and the first points of contact for potential COVID-19 patients. Based on a patient’s description of their symptoms, triage nurses needed to make lifesaving decisions such as when to call 911, whether to schedule a video visit, whether a hospital visit was necessary, or if a patient could stay home or call back if and when symptoms worsened - such decisions were constrained by changing information and guidelines and limited resources. The complexity of the triaging process during a pandemic increases significantly when symptoms of other known diseases, chronic and acute conditions are confounded with the symptoms of an emergent pathogen. Therefore, it is critical to understand the constraints triage nurses face and the strategies they use to make decisions during a pandemic of this scale and complexity, so that we can design future hospital triaging systems for pandemic readiness. To better understand how triage nurses made decisions, what constraints they faced, what strategies they used to make their decisions, and how they felt doing this work during a pandemic, we conducted interviews, analyzed triage call transcripts, and administered workload surveys in two academic medical centers. 

Results show that nurses encountered significant constraints in providing recommendations to patients, especially because the pandemic limited the traditionally available healthcare resources. The nurses could not ask patients to visit the hospital like they could have in pre-pandemic times, so determining the most appropriate next step for the patient was difficult. In effect, triage nurses were no longer fielding simple phone calls to direct patients to specific hospital units for treatment. A major organizational constraint faced by nurses was the need to handle the large and rapid volumes of patient calls while experiencing a high degree of staff shortage. Furthermore, COVID-19 specific triaging protocols were not available, further constraining nurses to use existing respiratory illness triage guidelines for COVID-19. Worse still, the list of symptoms of COVID-19 continually expanded, making it challenging and mentally demanding for the nurses to chart out a clear course of recommendation for the patient. Nurses worked with evolving evidence and ambiguous guidance about COVID, especially at the beginning of the pandemic. Routine triage algorithms became less useful due to COVID-19 symptoms significantly confounding with common flu, cold, asthma, anxiety attacks, and other respiratory or cardiac conditions. Therefore, they had to bank more on their prior expertise and experience to fine-tune and make decisions. Their expertise was found to be lifesaving, sometimes helping to instantly recognize an urgent situation that required a 911 call or an immediate visit to the emergency room. Nurses also balanced limited healthcare resources with patient preferences and needs. They used a variety of information sources, including national, state, and local public health guidance. However, the changing guidelines and the evolving scientific evidence posed significant challenges in making and managing their decisions and added to their time demands. Teamwork and organizational support played important and positive roles in triaging and knowledge sharing. There was considerable variability in how nurses perceived their own risk of getting COVID-19 and in their confidence in managing symptoms if they became COVID positive. In the initial months of the pandemic, triage nurses were fearful of bringing the virus to their family but expressed confidence due to the safety precautions they followed. In general, the nurses experienced significant mental demands, physical fatigue, and workload during the pandemic – they managed a high volume of calls during every surge, leading to significant workload and exhaustion. But they also expressed a great sense of satisfaction in helping patients during this dire time of need.

Project outcomes and findings will benefit triage nurses worldwide by highlighting the important work of triage nurses, showcasing their expertise for better knowledge sharing, and presenting their challenges for better policy making and organizational support and readiness. The project trained a STEM graduate student in solutions to complex and urgent real-world problems by providing interdisciplinary training. 

These results show that, as part of enhancing organizational readiness and future preparedness of our healthcare system, designing an effective triaging system requires a tight integration of information technology and human resources, and an effective organization of the work system infrastructure to better aid triage nurses and support a fragile healthcare workforce, including first responders during a pandemic. The results and recommendations from this work will be published in scientific journals and conference proceedings. 

Last Modified: 05/29/2022
Modified by: Priyadarshini Pennathur