Effect of Visual Cues, Vital Signs, and Protocols on Triage: A Prospective Randomized Crossover Trial

Abstract

Study objectives: We sought to compare triage designations derived from in-person and telephone interviews and systematically examine the effect of visual cues, vital signs, and complaint-based protocols on the triage process. Methods: We conducted a 2-phase, prospective, observational study employing a randomized, crossover design in a university teaching hospital emergency department. In both phases, every eligible patient underwent sequential in-person and telephone triage interviews conducted by certified ED triage nurses. After taking a history, each nurse chose 1 of 5 hypothetical triage designations and, after being told the patient’s vital signs, again selected a designation. Phase 1 designations were based solely on nurses’ clinical expertise. In phase 2, both nurses used complaint-based protocols. Results: Agreement between telephone and in-person designations was poor (percent agreement, 43.1% to 48.8%; κ, .19 to .26; τb , .34 to .45 for the 4 primary comparisons). Knowledge of vital signs and use of protocols did not improve agreement or increase identification of patients requiring admission to hospital. Conclusion: These data establish that telephone and in-person triage are not equivalent and suggest that visual cues may play an important role in the triage process. It is unclear whether telephone triage is an adequate method of assigning patients to an appropriate level of care. [Salk ED, Schriger DL, Hubbell KA, Schwartz BL: Effect of visual cues, vital signs, and protocols on triage: A prospective randomized crossover trial. Ann Emerg Med December 1998;32:655-664.]