Inconsistency of Emergency Department Triage

Abstract

Study objective: To measure the interrater and intrarater agreement of existing emergency department triage systems. Methods: This 2-phase experimental study of triage nurses’ and EMTs’ ratings for 5 scripted patient scenarios used in-person interviews and follow-up written surveys. Results: Eighty-seven participants (>90% of those eligible) with 55 (63%) completed both phases of the study. Interrater agreement on triage category was poor (κ=.347 overall). Only 13 of 55 (24%) participants rated the 5 cases the same severity in both phases; Kendall correlation (τ-B) comparing phases 1 and 2 varied from .145 to .554. Estimates of admission probability varied widely. Estimates of the appropriate time to physician evaluation (from immediate to 24 hours) was often incongruous with severity ratings (eg, 54% of those participants rating a case the lowest severity recommended evaluation within 8 hours). There was good agreement on estimated need for an ED monitored bed or diagnostic studies. Conclusion: Triage assessments (both interrater and intrarater) by experienced personnel are inconsistent using these 5 standardized patient scenarios. These results challenge the reliability of current ED triage practice. [Wuerz R, Fernandes CMB, Alarcon J, for the Emergency Department Operations Research Working Group: Inconsistency of emergency department triage. Ann Emerg Med October 1998;32:431-435.]