Comparison of Triage Assessments among Pediatric Registered Nurses and Pediatric Emergency Physicians

Abstract

Objectives:To compare triage level assignments, using simulated written case scenarios, in a pediatric emergency department (ED) among registered nurses (RNs) and pediatric emergency physicians (PEPs) and to compare the triage level assignments among RNs and PEPs with a consensus criterion standard. Methods: This was a cross-sectional mailed questionnaire survey. The study was conducted at a pediatric tertiary care center with more than 65,000 annual patient visits. Participants were PEPs and RNs working in the ED. Dillman's Total Design Method, with three mailouts, was used for questionnaire construction and implementation. The survey included 55 case scenarios of patients presenting to the ED. Participants were instructed to assign triage level on each case, using the following four-level triage scale: 1 = resuscitation/emergent, 2 = urgent, 3 = less-urgent, and 4 = non-urgent. A priori, all cases were assigned a triage level by consensus agreement of three PEPs, using estab-lished triage guidelines from the RNs' teaching manual. Kappa statistics (95% CI) and the mean percentage of correct responses (Ϯ1 SD) were calculated. Results: There was a 100% response rate (39 RNs, 24 PEPs). The kappa level of agreement (95% CI) was 0.453 (0.447 to 0.459) among the RNs and was 0.419 (0.409 to 0.429) among the PEPs. The mean percentage of correct responses (Ϯ1 SD) for the RNs was 64.2% (Ϯ8.0%) and for the PEPs was 53.5% (Ϯ8.1%, p < 0.01). There was no significant difference within groups by experience level (<10 vs. Ն10 years) or by the type of work schedule (day vs. evening vs. overnight) or full-time vs. part-time status. Conclusions: The level of agreement and accuracy of triage assignment was only moderate for both RNs and PEPs. Triage, a crucial step in emergency care, requires improved measurement.

Interrater Agreement between Nurses for the Pediatric Canadian Triage and Acuity Scale in a Tertiary Care Center

“…4,11,12 Few studies have evaluated the reliability of triage tools for children. 10,[13][14][15][16] Interrater agreements in these studies varied, with kappa scores ranging from 0.26 to 0.55. All these studies were based on case scenarios rather than a clinical setting.…”

Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital

“…Finally, previous studies reported agreement varying from 53% to 64% between triage nurses assigning a triage level to written case scenarios when compared with a panel of 3 experts. 10,12,13 Other triage tools have also demonstrated strong association between triage levels and markers of clinical severity for children. In 2005, Baumann and Strout 19 reported a high correlation between triage levels assigned by nurses using the Emergency Severity Index and hospital admission rate, resources use and LOS in the ED among 510 children visiting an ED.…”

“…The "urgency" of a clinical situation can be relatively subjective. Previous studies have evaluated the validity of triage tools by comparing the triage level of live patients or case scenarios with either a panel of experts, 10,[12][13][14][15] or hospital admissions or resources used. [16][17][18][19] These later studies have suggested that admission to hospital, length of stay (LOS) in the ED and resources use are appropriate proxy markers for patient severity.…”

Reliability of a Computerized Version of the Pediatric Canadian Triage and Acuity Scale

“…These studies used the same case scenarios as the present study and were performed in the same ED in 2000 and 2002. 21,22 The k scores for these previous studies ranged from 0.45 to 0.51 for the nurses and from 0.39 to 0.42 for the physicians. The agreement reported in the present study (k scores, 0.51 and 0.55) is higher than previous evaluations of the same case scenarios in the same setting.…”

“…The same scenarios have been utilized in previous studies. 21,22 The nurses were not allowed to take notes regarding the case scenarios and were asked not to discuss the cases among themselves.…”