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 established triage guidelines from the RNs' teaching manual. Kappa statistics (95% CI) and the mean percentage of correct responses (+/-1 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 (+/-1 SD) for the RNs was 64.2% (+/-8.0%) and for the PEPs was 53.5% (+/-8.1%, p < 0.01). There was no significant difference within groups by experience level (< 10 vs. > or =10 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.