title: Effect of visual cues, vital signs, and protocols on triage: a prospective randomized crossover trial.
abstract: OBJECTIVE
  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%; kappa,.19 to.26; taub,.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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: UCLA Emergency Medicine Center, UCLA School of Medicine, Los Angeles; and the Department of Medicine, Division of Emergency Medicine, University of California, San Diego, USA.
authors.forename: E D
authors.initials: ED
authors.lastname: Salk
authors.forename: D L
authors.initials: DL
authors.lastname: Schriger
authors.forename: K A
authors.initials: KA
authors.lastname: Hubbell
authors.forename: B L
authors.initials: BL
authors.lastname: Schwartz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D018592:Cross-Over Studies; D003463:Cues; D016529:Emergency Nursing; D004636:Emergency Service, Hospital; D005260:Female; D006784:Hospitals, Teaching; D015277:Hotlines; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007407:Interviews as Topic / Q000379:methods*; D015141:Los Angeles; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D008875:Middle Aged; D009730:Nursing Assessment / Q000379:methods*; D015403:Nursing Evaluation Research; D010808:Physical Examination / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014218:Triage / Q000379:methods*