Limitations in validating emergency department triage scales

Turnover led to the requirement that all triage staff undergo Continuing Education on the CTAS guidelines during the year between the two trials (one-day seminar using the same CAEP/NENA materials and the CEDIS Chief Complaint List).

Inter-observer reliability (IR) was performed between the original charted CTAS score and the NR score.

Data were collected in aggregate fashion to test the inclusiveness and performance of the chosen indicators.

Multiple indicators were classified as CC #1, #2, and #3.

IR results were compared using raw and quadratic weighted Kappa [4–7] (Quick Calcs by Graph Pad Software Inc. The NR was externally tested for accuracy in the use of the CTAS guidelines using a random case subset and independent review by a Master’s prepared ED nurse educator (RM) with research experience in CTAS Guidelines (both adults and pediatrics) and inter-observer reliability testing.

Focus groups chose, by consensus, five Indicator Groups for triage performance review that were felt to represent common and clinically important Chief Complaints (CCs).

With increasing demand on EDs and increasing crowding issues, studies must examine factors that influence patient flow.

Evaluation of the accuracy and reliability of CTAS performance becomes essential for reliable information.

Most studies to validate triage scoring are sophisticated double triage prospective designs, are difficult to apply across systems in real life, contain an intrinsic bias toward better performance, use classroom-based testing methods, do not address one or the other of accuracy or reliability, or do not pave the way for outcome-based decisions.

In this study we evaluate an inexpensive and easy method to assess CTAS performance in a community emergency department (ED) using (1) a limited set of clinical indicators to allow manageable data analysis, and (2) a nurse reviewer trained in the CTAS National Guidelines (CAEP/NENA).

A simple method for quality review uses a small set of indicators, capturing a majority of cases.

Performance consistency and data collection using indicators may be important areas to direct training efforts.

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A second CC permitted either CC to include the patient in a count for the appropriate indicator.

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