Reliability of Triage Nurses and Emergency Physicians for the Interpretation of the C-3PO Rule for Head Trauma in Children

Abstract

IntroductionThe C-3PO rule has been validated for use by emergency physicians to identify young children at risk of skull fracture following head trauma. The use of the rule by triage nurses could improve patient flow in the emergency department. ObjectivesTo evaluate the interobserver agreement of triage nurses and emergency physicians in the interpretation of the C-3PO rule in a pediatric emergency department. MethodsThis was a prospective observational study performed in a consecutive sample of children visiting a single emergency department. Participants were all children younger than 24 months of age who presented at the emergency department for head trauma that had occurred in the previous 24 hours. The primary outcome was the interobserver agreement between nurses and emergency physicians as to whether the child was at high risk of skull fracture according to the interpretation of the C-3PO rule. All study participants were evaluated sequentially by a triage nurse and an emergency physician. Outcome of evaluation was kept blinded between nurses and physicians. The primary analysis was the interrater reliability using the kappa score. The sample size was set to provide lower boundary of 0.70 for a 95% confidence interval (95% CI) for kappa coefficient of at least 0.80. ResultsA total of 226 children were evaluated by a physician and a nurse. Among them, 10 had skull fractures. A total of 34 nurses and 42 physicians evaluated between 1 and 21 children. The interrater reliability was excellent, as demonstrated by a kappa score of 0.85 (95% CI: 0.77–0.92). Moreover, all children with skull fractures were categorized at “high risk” by the nurse and the physician. ConclusionThis study demonstrates an almost perfect interrater reliability between triage nurses and emergency physicians in interpreting the C-3PO rule when evaluating children who presented at an emergency department for head trauma.Contribution to Emergency Nursing Practice:•This study demonstrates an excellent reliability between triage nurses and emergency physicians in interpreting the C-3PO rule when evaluating children who presented at an emergency department for a head trauma.•Based on this, triage nurses could apply the rule at triage to identify children younger than 2 years of age at risk of skull fracture.