title: Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France.
abstract: BACKGROUND
  For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.
  
  
  METHODS
  We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.
  
  
  RESULTS
  Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).
  
  
  CONCLUSIONS
  The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.
authors: Laboratoire de Santé Publique, Faculté de Médecine, Equipe de recherche EA 3279 Evaluation hospitalière-Mesure de la santé perçue, Marseille, France. anne-claire.durand@ap-hm.fr
authors: Anne-Claire
authors: AC
authors: Durand
authors: Stéphanie
authors: S
authors: Gentile
authors: Patrick
authors: P
authors: Gerbeaux
authors: Marc
authors: M
authors: Alazia
authors: Pierre
authors: P
authors: Kiegel
authors: Stephane
authors: S
authors: Luigi
authors: Eric
authors: E
authors: Lindenmeyer
authors: Philippe
authors: P
authors: Olivier
authors: Marie-Annick
authors: MA
authors: Hidoux
authors: Roland
authors: R
authors: Sambuc
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D004630:Emergencies / Q000145:classification*; D016529:Emergency Nursing / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital; D005260:Female; D005602:France; D006760:Hospitalization; D006780:Hospitals, Rural; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data*; D008875:Middle Aged; D015588:Observer Variation; D012372:ROC Curve; D014218:Triage / Q000706:statistics & numerical data*; D055815:Young Adult