Special Circumstances

SCOPE: Triage Nurse, RN, Registered Nurse

POLICY: Potentially complicated or high-risk scenarios may occur. Promptly recognizing the situation and implementing strategies to reduce risk is essential. The triage nurse will maintain the same standard of care regardless of caller or presented situation. All calls related to issues below will be reported immediately to supervisor.


  1. Frequent Caller 
    1. The patient’s chief complaint will be carefully evaluated each call encounter and handled as indicated based upon assessment.
    2. If the caller is thought to be accessing the nurse triage line inappropriately; the nurse will report to supervisor for possible solution.
  2. Caller contacts triage line more than twice in an eight-hour period or more than three times in a twenty-four-hour period. 
    1. Patient should be referred to ED, Urgent Care Center, or on call provider as indicated. Self or home care option is no longer an independent option.
  3. Caller is not with patient
    1. If the patient is identified as not being with the caller, the triage nurse will recommend the caller to:
      • Call back when patient is present or request to have responsible party who is currently with the patient to call the triage nurse.
      • Go to ED if the caller feels symptoms are urgent
      • Call 911 if caller believes the symptoms are life threatening
  4. Angry/Aggressive/Abusive callers
    1. The triage nurse will attempt to diffuse the situation to determine reason for call
      • If clinical, the nurse will proceed with triage process and disposition
      • If related to experience, the triage nurse will either transfer caller to supervisor or offer a call back from supervisor.
  5. Threats of violence (excluding suicidal or homicidal threats)
    1. Calls should be taken seriously and reported to proper authorities immediately
  6. Unable to reach caller during call back
    1. If recording device is reached, the following information will be left on voicemail.
      • State your name, title, and that you are returning a call made
      • Convey that caller may call back at any time
  7. Triage Nurse will not create a phone encounter in Anytime Pediatrics platform for callers that are unable to be reached via phone.
  8. Caller requesting to speak to physician:
    1. Triage nurse will offer to complete triage of patient to determine disposition and need to reach out to physician.
    2. If triage nurse determines physician contact is not necessary at this time, patient will be instructed to call back during business hours.
    3. Triage nurse may contact on call provider per patient request for practices who specify that this path of communication may occur.
  9. Concern for complex medical needs: 
    1. If the triage nurse is concerned about underlying symptoms or chronic disease processes affecting the triage process:
      • For Pediatric patients, triage nurse should use “Chronic or Complex Disease Protocol”
      • The triage nurse may opt to consult with physician to determine best disposition if needed.
  10. Caller is a minor
    1. Efforts should be made to involve responsible adult unless it is believed doing so would put minor at risk or violate state law regarding the ability for a minor to seek assistance for treatment or care related to pregnancy, sexually transmitted infections, mental illness, substance abuse, etc.
    2. If the problem is believed to be life threatening or pose a risk to the life of the minor, the triage nurse will act in the best interest of the minor in a timely manner while diligently attempting to contact the responsible adult/parent.
  11. Caller expresses suicidal or homicidal ideation
    1. The triage nurse will attempt to remain on the phone with the caller until a responsible adult arrives.
      • Call 911/local police for area in which caller is located (the triage nurse may need to reach out to the charge nurse for assistance)
  12. Every effort will be made to obtain information to be shared with authorities.
  13. In the event the caller is thought to be an imminent risk to self or others; the nurse must take appropriate action. 
    • Call 911/local police for area in which caller is located.
  14. Suspected Domestic Violence
    1. The nurse will act in the interest of the suspected victim.
      • The nurse will assess the victim for life threatening conditions and proceed with offering a recommendation based on condition.
      • The nurse will attempt to understand if the victim is in a safe location.
      • This nurse will instruct patient to call local law enforcement.
  15. Caller requesting information related to pregnancy prevention or termination
    1. The triage nurse will provide information available within the established protocols
    2. The triage nurse will offer information to the caller regarding community resources
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