Table 2.

Characteristics of nurse triage in primary care (N = 37)

Author (year)	Triager	Team or alone	Triage algorithm	Triage Classification	Tool
Barnett (2009)	RN	Team (specialist medical, nursing, and allied health personnel)	Enrolled and un-enrolled patient can call →nurse answers (using triage response scale)	1) emergency services respond within 10 min (ambulance, police, fire brigade) 2) face-to-face assessment is required within 1 h 3) face-to-face assessment is required within the next business day 4) referrals that are not appropriate for face-to-face assessment by a public mental health service clinician
Cariello (2003)	RN	Alone	Patient self-report symptom via phone →RN assesses and triage patients using computer-accessed clinical algorithms →patient received feedback via phone	1) emergency care: 911 or Emergency room 2) urgent care: Call PCP/MD 3) routine care: PCP/MD office visit 4) home care/ complementary medicine/do nothing	Computerized telephone nurse triage: 24 h a day, 7 days a week. no charge for cost
Cox (2000)	Practice nurse	Alone	Patient with sore throats visit clinic →RN assesses and triage patients using sore throat protocol. Triage time limited 5 min. →patient received feedback	1) refer to doctor for assessment 2) penicillin erythromycin 3) aspirin gargles, rest, fluids. Review 1 week if no improvement sooner if deteriorate.
Cynthia (2001)	RN with a week training	Alone	Patient check computerized assessment form →Centramax software produce protocol (‘yes’ or ‘no’) →RN assesses and triage patients using produced protocol → patient received feedback	1) life threatening 2) emergent 3) urgent 4) non-urgent 5) advice	Centramax software
Eldh (2020)	District nurse(nurse specialist)	Alone			Digital communication system
Elliott (2020)	RN	Team (nurse, GP, receptionist)	Standard nurse-led triage service Patient visit or call to request same-day appointments →RN assess and triage patients →patient received feedback Total nurse triage service Patient call to request same-day or routine appointments →RN assess and triage patients →patient received feedback	1) advice only 2) appointment with nurse 3) routine GP appointment 4) same-day appointment with GP 5) prescription or ‘sick note’ 6) referral for further care 7) GP home visit 8) emergency 999 call
Evans (2001)	Nurse got training session	Team (GP or GDP, nurse)	Patient call →RN records the patient’s demographic information, history, chief complaint using computerized assessment form →Centramax software produce protocol (‘yes’ or ‘no’) →RN triage patients using produced protocol → patient received feedback	1) self-care at home 2) transfer to the on call dentist 3) visit an accident & emergency department	Developed computer driven decision support software, examined by 16 dentist
George (2005)	psychiatric nurse, RN	Team(psychiatric nurse, social worker, psychiatrist)	Patient call community team →administrative assistant screen and refer to the triage officer if need →nurse triage patient → patient received feedback - triage hour: 8:30 to 17:00 Monday to Friday. - weekends: senior nurse on the acute inpatient unit	1) advice 2) referral	Peter James Centre model of triage Form a triage team, meet every morning & review; monitoring waiting list; liaising with ER; being involved with the GP Shared Care Committee; attend the monthly Community Team Leaders meeting
Gibbons (2010)	RN	Alone	Patient visit clinic →RN assess and examine patient using traffic light system →patient received feedback	1) immediate contact on call ophthalmologist at local hospital 2) within 24 h make appointment via local eye clinic 3) within one-week fax referral letter to eye clinic 4) not emergencies, routine referral if unable to manage in practice	Traffic light system
Giesen (2007)	RN	Team (nurse, GPs)		1) life threatening: Triage nurse informs GP at once. GP interrupts work and immediately goes to patient. 2) acute: GP goes to patient as soon as possible—within 1 h at most. 3) urgent: Complaint(s) should be evaluated within 2 h for medical or emotional reasons. 4) routine: Triage nurse arranges an appointment with the GP or gives advise him/herself.
Goransson (2020)	RN	Alone
Gormley (2003)	RN	Alone	Patient visit hospital →RN assess and judge if the patient has inflammatory arthritis or not→ patient received feedback
Harmsen (2005)	RN(mainly GP nurse)	Team (RN, GP)	RN assesse survey vignettes → patient received feedback	GP co-operative or urine sample or instructions about collecting urine or advice given	Telephone triage guide (not mandatory)
Hathorn (2009)	Triage-trained nurse	Alone		1) urgent: less than 2 weeks 2) soon: less than 6 weeks 3) routine: less than 18 weeks
Holmström (2007)	RN	Team (RN, GP)			Decision aid software programs for telenursing
Huibers (2012)	RN	Alone	Patient call →RN assess and triage patients using HAAKplus instrument →patient received feedback	1) life-threatening 2) acute 3) urgent 4) non-urgent	Quality of consultation: HAAKplus instrument Appropriateness of triage: 3 items of HAAKplus: urgency estimation, follow-up advice and timing
Kempe (2006)	RN with over 4 years of pediatric clinical experience and with specialized training in telephone triage	Team (RN, pediatrician)	Patient call →RN assess and triage patients using computerized protocols that guide them through a sequence of questions, the answers to which dictate a recommended triage disposition. →RN can adjust disposition decision only with the agreement of a second triage nurse.	1) urgent(visit within 4 h) 2) next day (visit in 4 h but within 24 h) 3) later visit (visit in 24 h) 4) home care (care at home without a visit)	Computerized protocols
Leydon (2013)	specialist nurse	Team (frontline call-taker, specialist nurse, welfare rights team)	Patient call →frontline call-taker answers the call and collects routine data →frontline call-taker may determine that a caller needs to be triaged to a specialist nurse if they are calling with a medical query (question about symptoms, treatment, or prognosis). →specialist nurse triage patients →patient received feedback
Light (2005)	12 pediatric nurses trained in the use of standardized triage protocols	Alone	Patient call →RN assess and triage patients using computerized charts →patient received feedback	1) go to ED 2) be Seen Immediately 3) be Seen in 24 h 4) home care
Magann (2022)	Call center nurse	Team (call center: 22 full-time nurses, 5 patient service coordinators, 8 appointment center personal)	[call center process] Patient call call-center →patient self-report their symptom using computer software menus designed to provide questions based on initial complaint and responses. →RN review the records and triage patients →patient received feedback	1) self-care: advice given only, no prescriptions were called in for the patient 2) self-care with prescriptions 3) appointment: needs to be seen sooner in the clinic that her regularly scheduled appointment 4) emergency: come to the emergency room or to labor and delivery depending on her gestational age.	Computer software menus with the obstetric triage protocols (labor and delivery experience, trained computer software), Women’s health APN, a fourth year OB-GYN resident, MFM
Majeed (2023)	RN	Team (greeter nurse →triage nurse →triage physician)	Patient arrives at the triage clinic →initial encounter with greeter nurse →if patient are not critically ill, appropriately managed in health care center or refer to secondary/tertiary care. →If patient critically ill, encounter with triage nurse →triage nurse assess and triage patients →patient received feedback	[greeter nurse] 1) care our health care center 2) refer triage nurse 3) refer secondary/tertiary care [triage nurse] 1) emergency: triage physician after 5 min waiting time 2) priority: triage physician after 30–90 min waiting time 3) routine: within shift
Marklund (2007)	RN	Team (nurse, pharmacists, dentist, GPs, hospital doctors all over the country)	Patient call →RN assess and triage patients based on the guidelines set out in the decision support and experience → patient received feedback	1) self-care advice 2) refer to primary health care center 3) refer to accident and ED	Digital decision support model
Marvicsin (2015)	NP, nurse midwives	Alone (NP or midwives)	Patient call →NP or midwives triage caller →patient received feedback	1) ER/urgent care 2) ER or urgent care visit was averted 3) information or advice only
McGra (2000)	RN	Team (RN, physician, nurse practitioner, physician assistant)	Patient call →RN triage patients →patient received feedback	1) emergency center 2) same-day appointment at a primary care clinic or the urgent care clinic 3) self-care education
McGrath (2008)	RN	Team (RN, GP)	Patient call →RN triage patients using paper protocols. But telephone triage nurse is not permitted to make a diagnosis over the phone → patient received feedback	1) ambulance 2) nursing advice and reassurance 3) local medical appointment the next day 4) advice or treatment from their local doctor on call 5) refer to the local ED(patient requiring assessment)
Moll van Charante (2006)	RN	Team (GP & nurse)	Patient call →RN assess and triage patients →patient received feedback	1) nurse telephone advice alone 2) refer to GP on duty 3) referral to A & E
Navratil-Strawn (2014)	RN with AARP certification and Medicare immersion training	Team (triage nurse, Nurse HealthLine staff for non-triage calls)	Patient call →RN assess and triage patients →patient received feedback	1) ER to a lower level of care: the caller’s pre-call intent was to seek care in an emergency room but the nurse recommended a lower level of care, such as an urgent care visit or a visit to a doctor’s office or self-treatment at home 2) non-ER/office visit to a lower level of care 3) same level of care: the nurse agreed with the caller’s pre-call intent and then provided information to prepare the member for that level of care 4) non-ER level of care to ER 5) non-ER visit to higher, on-ER level of care
O’Cathain (2007)	Telephone assessment nurses: mean age 42, length of nursing experience = 20yr	Alone	Patient call →RN assess and triage patients →patient received feedback	1) self-care 2) service at a later date 3) immediate contact with a service	Computerized decision support software
Reblora (2021)	RN	Team (doctor, nurse)
Richards (2000)	RN	Team (1 triage nurse, 1 triage doctor)	Patient call →receptionist initially triage patients →RN assess and triage patients using computer-based protocol →patient received feedback	1) telephone advice 2) nurse appointment(same day or routine) 3) doctor appointment(same day or routine) 4) doctor home visit	Computer-based protocol
Richards (2002)	Practice nurse	Team (practice nurse, receptionist)	Patient call →RN assess and triage patients using computerized management protocols →patient received feedback	1) telephone advice only 2) same day nurse appointment 3) same day GP appointment 4) home visit 5) routine nurse or GP appointment.	Computerized management protocols
Richards (2004a)	RN	Nursing team (one full-time nurse, 9 practice nurses)	[Practice based triage] Patient call to requests same day appointment →RN assess and triage patient using several clinical protocols on the patient record system, not computerized algorithms →patient received feedback [NHS Direct triage] Patient call to requests same day appointment →RN assess and triage patient using NHS Direct computerized decision making algorithms →patient received feedback	Telephone support alone, refer to GP, same day appointment with a nurse or GP, home visit, routine appointment with a nurse or GP	NHS Direct computerized decision making algorithms in NHS Direct triage team
Richards (2004b)	6 practice nurses, who had received 30 h of minor illness management training	Team (GP, practice nurse)	Patient call to requests same day appointment →RN assess and triage patient using computerized management protocols →patient received feedback	1) telephone advice only from the nurse or GP 2) same day nurse appointment 3) same day GP appointment 4) home visit 5) routine nurse or GP appointment	Computerized management protocols
Rosen (2000)	RN	Team (nurse, GPs)
Scalvini (2005)	RN	Alone	Patient transmit one-lead ECG recording by a mobile or fixed telephone →nurse reporting and interactive teleconsultation(providing information on health status, symptoms, weight, diuresis, drug adjustment, optimization), tele-assistance, monitoring →patient received feedback	1) telephone consultation 2) refer further investigations and consultation with GP 3) refer hospital
Trip (2021)	Oncology nurse or trained non-clinical handler	Team (oncology nurse, non-clinical handler)	1) Patient call in hour(weekdays 8:00 to 17:00) →oncology nurse assess and triage patient →patient received feedback 2) Patient call in out of hours →trained non-clinical handler initially triage patient using the United Kingdom Oncology Nursing Society toolkit →patient received feedback	1) advice 2) oncology department review 3) GP review 4) referred to their local accident and ED

Note. A&E = Accident & Emergency; APN = Advanced Practice Nurse; ED = Emergency Department; ER = Emergency Room; GPs = General Practitioners; hr = hour; MD = Medicinae Doctor; MFM = Maternal-Fetal Medicine; min = minutes; NP = Nurse Practitioner; OB-GYN = Obstetrics and Gynecology; PCP = Primary Care Practitioner; RN = Registered Nurse