Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France

Abstract

BackgroundFor several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.MethodsWe conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.ResultsOf 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).ConclusionsThe lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.

A model of complaint based for overcrowding emergency eepartment: Five-Level Hacettepe Emergency Triage System

“…When patients determined at 3-level Triage by TTS were evaluated by ESI, their ESI levels were found as ESI 1 in 0.1% of them, as ESI 2 in 26.2%, as ESI 3 in 39.5%, as ESI 4 in 27.5% and as ESI 5 in 6.8%. [47] In a study by Durand et al, [41] including evaluations of decisions distinguishing patients between urgent and not urgent by doctors and nurses in France, there was a high level of agreement between the two groups in terms of cranial injury, gynecologic and toxicologic indications while there was a low level of agreement between the two groups in terms of urinary system and hospitalization. Doctors had higher sensitivity (94% to 43.1%) and specificity (89.5% to 30.9%) than nurses in terms of hospitalization of urgent and non-urgent patients.…”

“…Doctors had higher sensitivity (94% to 43.1%) and specificity (89.5% to 30.9%) than nurses in terms of hospitalization of urgent and non-urgent patients. [41] In a study by Kahveci et al, [45] comparing emergency residents and paramedics, there was agreement between two groups in 47% of 3-level triage decisions (Kappa=0.47) and 45% of 5-level ATS triage decisions (Kappa=0.45).…”

“…Studies about which of these health workers perform more accurate triage are insufficient. [40][41][42][43][44][45] Although ESI 5-level triage system has higher reliability and validity, it is unlikely to be routinely applied in the emergency departments of our country since it requires experience and education and, it is difficult to find a triage expert. Evaluation time is long in triage area and violent actions are made by patients who do not tolerate waits in overcrowded emergency departments (1.000 or more patients/day).…”

Emergencies and Disaster Medicine

“…En effet, les deux facteurs organisationnels affectant la satisfaction des patients sont directement liés à la problématique de l'encombrement des urgences. Il n'existe pas de définition universel des 'patients non urgents' [21,22]. la littérature a décrit une très grande variabilité dans la proportion des patients non urgents (4.8 à 90%) ; un manque de reliabilité et de reproductibilité des méthodes et les critères de catégorisation des patients aux urgences [23].…”

A Urgência No Atendimento Ao Idoso: Estudo De Caso

“…A superlotação dos hospitais está relacionada, dentre outras questões, ao excesso de pacientes não urgentes, o que poderia ser minimizado com a devida triagem dos usuários para a correta determinação da prioridade de tratamento (DURAND et al, 2011b). Entretanto, conforme Gentile et al (2010), não existe um método consensual de triagem, que seja confiável e reprodutível.…”