title: Interobserver agreement in emergency department triage.
abstract: OBJECTIVE
  We measure the interobserver reliability of the triage process, examine the effect of vital signs on the triage process, and provide a context for the prior observation of poor interobserver agreement between in-person and telephonic interviews.
  
  
  METHODS
  We performed a prospective observational study using a randomized crossover design at a university teaching hospital emergency department. Patients were eligible if they spoke English, were not presenting for a reevaluation, and were unlikely to be harmed by the delay created by a second triage interview. Every eligible patient underwent 2 independent, sequential, in-person ED intake interviews conducted by experienced ED triage nurses. After taking a history, each nurse chose 1 of 5 hypothetic triage designations (ED by 911, ED within 2 hours, see a physician within 8 hours, see a physician within 24 hours, or home care-see a physician in >24 hours) and, after being told the patient's vital signs, again selected a designation.
  
  
  RESULTS
  Three hundred sixty-three patients presented during the study period: 113 were ineligible, 34 were missed by the investigators, and 15 refused to participate. Nineteen nurses participated in the triage of the 201 study patients. Agreement between 2 in-person designations made without knowledge of vital signs was poor (percent agreement 53%; kappa=0.30; tau(b)=0.50). Knowledge of vital signs did not improve agreement (percent agreement 49%; kappa=0.25; tau(b)=0.45).
  
  
  CONCLUSIONS
  There was poor interobserver agreement between certified triage nurses using a 5-item triage scale designed for telephonic triage. These findings suggest that only a small portion of the poor interobserver agreement observed in a prior study of telephonic versus in-person triage can be attributed to the use of the telephone.
authors.affiliation: University of California-Los Angeles Emergency Medicine Center, University of California-Los Angeles School of Medicine, Los Angeles, CA, USA.
authors.forename: Joe
authors.initials: J
authors.lastname: Nakagawa
authors.forename: Sripha
authors.initials: S
authors.lastname: Ouk
authors.forename: Brad
authors.initials: B
authors.lastname: Schwartz
authors.forename: David L
authors.initials: DL
authors.lastname: Schriger
mesh_terms: D018592:Cross-Over Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006785:Hospitals, University / Q000458:organization & administration; D006801:Humans; D015141:Los Angeles; D009741:Nursing Staff, Hospital; D015588:Observer Variation; D011446:Prospective Studies; D013689:Telephone; D014218:Triage / Q000458:organization & administration / Q000592:standards* / Q000706:statistics & numerical data