Evaluation of the Emergency Severity Index (version 3) Triage Algorithm in Pediatric Patients

Objectives: As demand for emergency services outpaces available allocated resources, emergency department (ED) triage systems face increasing scrutiny. Longer waits for care make the use of reliable, valid triage systems imperative to patient safety. Little is known about the reliability and validity of triage systems in children. The purpose of this study was to evaluate the reliability and validity of the Emergency Severity Index version 3 (ESIv.3) triage algorithm in a pediatric population. Methods: This two‐phase investigation used both retrospective chart review and prospective, observational designs. Interrater reliability was evaluated using ED triage scenarios, a prospective cohort of ED patients presenting to triage, and retrospective triage assignments using the original triage note. ED triage nurses, nurse investigators, and physician investigators performed retrospective blinded triages using only the original triage note to assess reproducibility. In the second phase, validity was assessed using a retrospective analysis of observed resource use, ED length of stay, and hospitalization compared with resource utilization estimated at triage by the ESI. Results: In the reliability phase, weighted κ for ED nurse triage of standard scenarios ranged from 0.84 to 1.00, representing excellent agreement. Twenty ED pediatric patients were triaged simultaneously by an ED triage nurse and the nurse investigator. Weighted κ was 0.82 (95% confidence interval = 0.66 to 0.98), also representing strong agreement between raters. When used for retrospective chart review, the weighted κ statistics ranged from 0.42 to 0.84, representing poor to good agreement among the different categories of reviewers. During the validity phase, 510 patients were included in the final data analysis. Hospitalization, ED length of stay, and resource utilization were strongly associated with ESIv.3 category. Conclusions: The ESI triage algorithm demonstrated reliability and validity between triage assignment and resource use in this group of ED pediatric patients.     

Reliability and Validity of Scores on the Emergency Severity Index Version 3

OBJECTIVES: No widely used triage instrument accurately assesses patient acuity. The Emergency Severity Index (ESI) promises to facilitate reliable acuity assessment and possibly predict patient disposition. However, reliability and validity of ESI scores have not been established in emergency departments (EDs) outside the original research sites, and version 3 (v.3) of the ESI has not been evaluated. The study hypothesis was that scores on the ESI v.3 show good interrater reliability and predict hospital admission, admission site, and death. METHODS: The authors conducted an ED-based cross-sectional retrospective study of 403 systematically selected ED records of patients who presented to an academic medical center. Twenty-seven variables were abstracted, including triage level assigned, admission status, site, and death. Using a standard process, the researchers determined the true triage level. Weighted kappa and Pearson correlation were used to calculate interrater reliability between true triage level and triage score assigned by the registered nurse (RN). The relationships between the true ESI level and admission, admission site, and death were assessed. RESULTS: Interrater reliability between RN ESI level and the true ESI level was kappa = 0.89; Pearson r = 0.83 (p < 0.001). Hospital admission by ESI level was as follows: 1 (80%), 2 (73%), 3 (51%), 4 (6%), and 5 (5%). A higher percentage of ESI level-1 and level-2 patients (40%, 12%) were admitted to the intensive care unit than ESI levels 3-5 (2%, 0%, 0%). Admission to telemetry for ESI levels 1-5 was 20%, 19%, 7%, 1%, and 0%, respectively. Three of four patients who died were ESI level 1 or 2. CONCLUSIONS: Scores on the ESI assigned by nurses have excellent interrater reliability and predict hospital admission and location of admission.     

Implementation and Refinement of the Emergency Severity Index

OBJECTIVES: To implement a new five-level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures. METHODS: The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed. RESULTS: Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n = 62 nurses), and 0.73 for patient triages (n = 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 58/63 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. CONCLUSIONS: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.     

The Emergency Severity Index Triage Algorithm Version 2 Is Reliable and Valid

OBJECTIVES: Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. METHODS: In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. RESULTS: Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n = 3289) and 0.69 to 0.87 for patient triages (n = 386). Outcomes for the validity cohort (n = 1042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. CONCLUSIONS: ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.     

Interrater Agreement between Nurses for the Pediatric Canadian Triage and Acuity Scale in a Tertiary Care Center

Objectives: The objective was to measure the interrater agreement between nurses assigning triage levels to children visiting a pediatric emergency departments (EDs) assisted by a computerized version of the Pediatric Canadian Triage and Acuity Scale (PedCTAS). Methods: This was a prospective cohort study evaluating children triaged from Level 2 (emergent) to Level 5 (nonurgent). A convenience sample of patients triaged during 38 shifts from April to September 2007 in a tertiary care pediatric ED was evaluated. All patients were initially triaged by regular triage nurses using a computerized version of the PedCTAS. Research nurses performed a second evaluation blinded to the first evaluation using the same triage tool. These research nurses were regular ED nurses performing extra hours for research purposes exclusively. The primary outcome measure was the interrater agreement between the two nurses as measured by the linear weighted kappa score. Secondary outcomes included the proportion of patient for which nurses did not apply the triage level suggested by Staturg (override) and agreement for these overrides. Results: A total of 499 patients were recruited. The overall interrater agreement was moderate (linear weighted kappa score of 0.55 [95% confidence interval {CI} = 0.48 to 0.61] and quadratic weighted kappa score of 0.61 [95% CI = 0.42 to 0.80]). There was a discrepancy of more than one level in only 10 patients (2% of the study population). Overrides occurred in 23.2 and 21.8% for regular and research triage nurses, respectively. These overrides were equally distributed between increase and decrease in triage level. Conclusions: Nurses using Staturg, which is a computerized version of the PedCTAS, demonstrated moderate interrater agreement for assignment of triage level to children presenting to a pediatric ED.     

Emergency Triage: Comparing a Novel Computer Triage Program with Standard Triage

Background: Emergency department (ED) triage prioritizes patients based on urgency of care; however, little previous testing of triage tools in a live ED environment has been performed. Objectives: To determine the agreement between a computer decision tool and memory‐based triage. Methods: Consecutive patients presenting to a large, urban, tertiary care ED were assessed in the usual fashion and by a blinded study nurse using a computerized decision support tool. Triage score distribution and agreement between the two triage methods were reported. A random subset of patients was selected and reviewed by a blinded expert panel as a consensus standard. Results: Over five weeks, 722 ED patients were assessed; complete data were available from 693 (96%) score pairs. Agreement between the two methods was poor (κ= 0.202; 95% confidence interval [95% CI] = 0.150 to 0.254); however, agreement improved when using weighted κ (0.360; 95% CI = 0.305 to 0.415) or “within one” level κ (0.732; 95% CI = 0.644 to 0.821). When compared with the expert panel, the nurse triage scores showed lower agreement (0.263; 95% CI = 0.133 to 0.394) than the tool (κ= 0.426; 95% CI = 0.289 to 0.564). There was a significant down‐triaging of patients when patients were triaged without the computerized tool. Admission rates also differed between the triage systems. Conclusions: There was significant discrepancy by nurses using memory‐based triage when compared with a computer tool. Triage decision support tools can mitigate this drift, which has administrative implications for EDs.     

The use of the Soterion Rapid Triage System in children presenting to the Emergency Department

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system's reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system's validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system's validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281-99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83-0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.     

Utility of the Emergency Severity Index by Accuracy of Interrater Agreement by Expert Triage Nurses in a Simulated Scenario in Japan: A Randomized Controlled Trial

ObjectiveThe Emergency Severity Index (ESI) is a highly reliable and valid triage scale that is widely used in emergency departments in not only English language regions but also other countries. The Japan Triage and Acuity Scale (JTAS) is frequently used for emergency patients, and the ESI has not been evaluated against the JTAS in Japan. This study aimed to examine the decision accuracy of the ESI for simulated clinical scenarios among nursing specialists in Japan compared with the JTAS.MethodA parallel group randomized trial was conducted. In total, 23 JTAS–trained triage nurses from 10 Japanese emergency departments were randomly assigned to the ESI or the JTAS group. Nurses independently assigned triage categories to 80 emergency cases for the assessment of interrater agreement.ResultsInterrater agreement between the expert and triage nurses was κ = 0.82 (excellent) in the ESI group and κ = 0.74 (substantial) in the JTAS group. In addition, interrater agreement by acuity was level 2 = 0.42 (moderate) in the ESI group and level 2 = 0.31 (fair) in the JTAS group. Interrater agreement for triage decisions was classified in a higher category in the ESI group than in the JTAS Scale group at level 2. Triage decisions based on the ESI in Japan maintained the same level of interrater agreement and sensitivity as those in other countries.ConclusionThese findings suggest that the ESI can be introduced in Japan, despite its different emergency medical background compared with other countries.     

Accuracy of the Emergency Severity Index Triage Instrument for Identifying Elder Emergency Department Patients Receiving an Immediate Life‐saving Intervention

Objectives: The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life‐saving intervention in the emergency department (ED). Methods: The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1‐month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life‐saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review. Results: Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty‐six patients received an immediate life‐saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI] = 23.3% to 61.3%); the specificity was 99.2% (95% CI = 98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients). Conclusions: The ESI triage instrument identified fewer than half of elder patients receiving an immediate life‐saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage. ACADEMIC EMERGENCY MEDICINE 2010; 17:238–243 © 2010 by the Society for Academic Emergency Medicine     

Reliability and Validity of a New Five-level Triage Instrument

OBJECTIVES: Triage is the initial clinical sorting process in hospital emergency departments (EDs). Because of poor reproducibility and validity of three-level triage, the authors developed and validated a new five-level triage instrument, the Emergency Severity Index (ESI). The study objectives were: 1) to validate the triage instrument against ED patients' clinical resource and hospitalization needs, and 2) to measure the interrater reliability (reproducibility) of the instrument. METHODS: This was a prospective, observational cohort study of a population-based convenience sample of adult patients triaged during 100 hours at two urban referral hospitals. Validation by resource use and hospitalization (criterion standards) and reproducibility by blinded paired triage assignments compared with weighted kappa analysis were assessed. RESULTS: Five hundred thirty-eight patients were enrolled; 45 were excluded due to incomplete evaluations. The resulting cohort of 493 patients was 52% female, was 26% nonwhite, and had a median age of 40 years (range 16-95); overall, 159 (32%) patients were hospitalized. Weighted kappa for triage assignment was 0.80 (95% CI = 0.76 to 0.84). Resource use and hospitalization rates were strongly associated with triage level. For patients in category 5, only one-fourth (17/67) required any diagnostic test or procedure, and none were hospitalized (upper confidence limit, 5%). Conversely, in category 1, one of twelve patients was discharged (upper confidence limit, 25%), and none required fewer than two resources. CONCLUSIONS: This five-level triage instrument was shown to be both valid and reliable in the authors' practice settings. It reproducibly triages patients into five distinct strata, from very high hospitalization/resource intensity to very low hospitalization/resource intensity.     

Effects of a Triage Process Conversion on the Triage of High‐risk Presentations

Objectives: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time‐sensitive therapy. Methods: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time‐sensitive care. Results: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. Conclusions: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time‐sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.     

Development and interrater reliability of the UK Mental Health Triage Scale

Mental health triage scales are clinical tools used at point of entry to specialist mental health service to provide a systematic way of categorizing the urgency of clinical presentations, and determining an appropriate service response and an optimal timeframe for intervention. The aim of the present study was to test the interrater reliability of a mental health triage scale developed for use in UK mental health triage and crisis services. An interrater reliability study was undertaken. Triage clinicians from England and Wales (n = 66) used the UK Mental Health Triage Scale (UK MHTS) to rate the urgency of 21 validated mental health triage scenarios derived from real occasions of triage. Interrater reliability was calculated using Kendall's coefficient of concordance (w) and intraclass correlation coefficient (ICC) statistics. The average ICC was 0.997 (95% confidence interval (CI): 0.996–0.999 (F (20, 1300) = 394.762, P < 0.001). The single measure ICC was 0.856 (95% CI: 0.776–0.926 (F (20, 1300) = 394.762, P < 0.001). The overall Kendall's w was 0.88 (P < 0.001). The UK MHTS shows substantial levels of interrater reliability. Reliable mental health triage scales employed within effective mental health triage systems offer possibilities for not only improved patient outcomes and experiences, but also for efficient use of finite specialist mental health services.     

Refining Emergency Severity Index Triage Criteria

Objectives: The Emergency Severity Index (ESI) version 3 is a five‐level triage acuity scale with demonstrated reliability and validity. Patients are rated from ESI level 1 (highest acuity) to ESI level 5 (lowest acuity). Clinical experience has demonstrated two levels of ESI level 2 patients: those who require immediate intervention and those who are stable to wait for at least ten minutes. Studies have found that few patients are rated ESI level 1, and it has been suggested that revisions to the ESI might result in appropriate reclassification of some sickest level 2 patients as level 1. The purpose of this study was to identify level 2 patients who might be reclassified as level 1 patients. Methods: This was a multisite, prospective study. The authors identified ESI level 2 patients who required immediate, lifesaving intervention and calculated chi‐square statistics and odds ratios for variables that predicted which ESI level 2 patients actually received immediate intervention. Results: Immediate lifesaving interventions were provided for 117 (20.2%) of the 589 patients included in the study. Seventeen predictors of the need for immediate intervention were identified. The strongest predictor was the triage nurse's judgment of the need for immediate intervention, especially airway and medications. Conclusions: Specific clinical findings at triage for a subset of ESI level 2 patients were associated with immediate delivery of lifesaving interventions. Revisions to the ESI level 1 criteria may be beneficial.     

Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit

Objective: The Emergency Triage Education Kit was designed to optimize consistency of triage using the Australasian Triage Scale. The present study was conducted to determine the interrater reliability of a set of scenarios for inclusion in the programme. Methods: A postal survey of 237 paper‐based triage scenarios was utilized. A quota sample of triage nurses (n = 42) rated each scenario using the Australasian Triage Scale. The scenarios were analysed for concordance and agreement. The criterion for inclusion of the scenarios in the programme was κ ≥ 0.6. Results: Data were collected during 2 April to 14 May 2007. Agreement for the set was κ = 0.412 (95% CI 0.410–0.415). Of the initial set: 92/237 (38.8%, 95% CI 32.6–45.3) showed concordance ≥70% to the modal triage category (κ = 0.632, 95% CI 0.629–0.636) and 155/237 (65.4%, 95% CI 59.3–71.5) showed concordance ≥60% to the modal triage category (κ = 0.507, 95% CI 0.504–0.510). Scenarios involving mental health and pregnancy presentations showed lower levels of agreement (κ = 0.243, 95% CI 0.237–0.249; κ = 0.319, 95% CI 0.310–0.328). Conclusion: All scenarios that showed good levels of agreement have been included in the Emergency Triage Education Kit and are recommended for testing purposes; those that showed moderate agreement have been incorporated for teaching purposes. Both scenario sets are accompanied by explanatory notes that link the decision outcome to the Australasian College for Emergency Medicine Guidelines on the Implementation of the Australasian Triage Scale. Future analysis of the scenarios is required to identify how task‐related factors influence consistency of triage.     

Application of emergency severity index in pediatric emergency department

BACKGROUND:

The purpose of triage is to identify patients needing immediate resuscitation, to assign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures as appropriate. This study aimed to use emergency severity index (ESI) in a pediatric emergency room.

METHODS:

From July 2006 to August 2010, a total of 21 904 patients visited the International Department of Beijing Children’s Hospital. The ESI was measured by nurses and physicians, and compared using SPSS.

RESULTS:

Nurses of the hospital took approximately 2 minutes for triage. The results of triage made by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This finding indicated that the nurses are able to identify severe pediatric cases.

CONCLUSION:

In pediatric emergency rooms, ESI is a suitable tool for identifying severe cases and then immediate interventions can be performed accordingly.KEY WORDS: Pediatrics, Emergency Department, Triage, Emergency severity index     

The Decision to Use Topical Anesthetic for Intravenous Insertion in the Pediatric Emergency Department

Objectives: Topical anesthetic creams to reduce the pain of intravenous (IV) placement may be more effectively used in the emergency setting if they are applied by nurses in the triage area of the emergency department or soon after the patient is placed into a room. This strategy requires accurate prediction of which patients will require IV placement. The objective of this study was to compare triage nurse judgment regarding IV placement in pediatric patients with a triage prediction rule using chief complaint, referral status, and high‐risk medical history. A secondary objective was to evaluate whether the presence of the anesthetic cream placed in triage influenced the subsequent decision to place an IV and thus invalidate the prediction strategy. Methods: Triage nurses were randomly assigned to a prediction score group (PRD), classifying patients as “IV likely” if the prediction score was ≥2, or an “own judgment” (RN JDGMT) group, classifying any patient that he or she considered to have a ≥50% risk of receiving an IV. The rate of actual IV placement in the emergency department treatment rooms was compared between the triage prediction strategies. To assess the influence of the presence of lidocaine 2.5% and prilocaine 2.5% (EMLA cream) on the judgment to place an IV, only 75% of the “IV likely” patients had EMLA applied in triage; the IV placement rate was compared between “IV likely” patients who did or did not have EMLA applied. Results: The authors enrolled 3,790 of 5,025 (75.4%) of eligible patients. The RN JDGMT group predicted 165 of 250 (66%; 95% confidence interval = 59% to 72%) of IVs placed, compared with 127 of 305 (41%; 95% CI = 36% to 47%) in the PRD group (p < 0.0001). Positive predictive values were 59% and 53% for the RN JDGMNT and PRD groups, respectively. There was no difference in IV placement rates in the “IV likely” patients who did and did not have EMLA applied. Conclusions: Triage nurse judgment to predict eventual IV placement had greater sensitivity and similar predictive value compared with a prediction model based on medical history and chief complaint. The triage placement of topical anesthetic in pediatric patients did not change the eventual rate of IV placement.     

Triage tool inter-rater reliability: a comparison of live versus paper case scenarios.

BACKGROUND: Published studies of triage scale inter-rater reliability assessment have been conducted mostly using paper case scenarios. OBJECTIVE: To determine if this method of inter-rater reliability assessment generated significantly different measures from those generated from live triage cases. METHODS: This was a multicenter, prospective, observational cohort study of a population-based random sample of patients triaged at 2 emergency departments during a period of 4 months. All patients presenting to the emergency department within the study periods were simultaneously and independently triaged using a 5-level triage acuity scale by 2 to 3 research triage nurses blinded to each other's assessment and to the study objective. After 6 months, the same nurses were asked to assign triage scores to paper case scenarios of the same patients that they had each previously triaged. RESULTS: Each of the 9 research nurses triaged approximately 90 cases. The inter-rater reliabilities as measured by an intraclass correlation coefficient were 0.9 (95% CI = 0.87 to 93) for the live triage assessments and 0.76 (95% CI = 0.73 to 0.79) for the paper case scenarios. The mean triage score assigned to the live cases was significantly less than that assigned to the paper-based cases (3.17; 95% CI = 3.08 to 3.26) (p < 0.001). CONCLUSIONS: There is moderate to high agreement between live cases and paper case scenarios, and the inter-rater reliabilities, although significantly different, are acceptable in both cases. It is impossible to determine which triage setting provides a more accurate triage score but paper case scenarios generally receive lower triage scores than live cases.     

EVENDOL, a new behavioral pain scale for children ages 0 to 7 years in the emergency department: design and validation

Numerous behavioral pain measures have been validated for young children, but none is appropriate to assess pain in emergency departments (EDs), where caregivers need a simple, easily completed scale. Our objective was to elaborate and validate a tool, relevant in any painful situation, with agitation or prostration, and for any age under 7 years. Five items (scored 0 to 3) were developed by pediatric pain and emergency caregivers. The new scale, called EVENDOL, was tested at children's arrival and after analgesics, at rest, and during mobilization. The validation study included 291 children from birth to 7 years old in 4 French EDs, and independent observations by the ED nurse and a researcher. The Cronbach coefficient was excellent (0.83 to 0.92). Construct validity was demonstrated by a decrease in scores after nalbuphine: 8.14 to 3.62 of 15 at rest (P<.0001), 11.87 to 6.65 at mobilization (P = .0011); by good correlations between EVENDOL and nurse or researcher numerical scores: 0.79 to 0.92 (P<.0001); by good correlations between children's self-assessment scores and EVENDOL in children ages 4 to 7 (0.64 to 0.93). Discriminant validity with tiredness, anxiety, and hunger was good. Interrater reliability was excellent between nurses and researcher (weighted kappa 0.7 to 0.9), and in a group of 6 nurses (simultaneous assessment of 122 videos). The treatment threshold was determined at 4 of 15. EVENDOL has excellent validity and can be used for all children under age 7 in EDs, for any age and any pain, acute as well as more prolonged.     

The Effect of Triage-applied Ottawa Ankle Rules on the Length of Stay in a Canadian Urgent Care Department: A Randomized Controlled Trial

Objectives: To determine whether triage nurses ordering ankle or foot radiographs according to the Ottawa Ankle Rules (OAR) before physician evaluation decreases the length of stay for patients visiting an urgent care department. Methods: From July to September 2004, a randomized controlled trial of consecutive adult patients with ankle or foot twisting injuries who arrived at an urgent care department was conducted. Patients were included if their age was 18 years or older and their injury had occurred within seven days. They were excluded if there were neurovascular deficits, limb deformities, open fractures, or nonisolated ankle or foot injuries. Patients were randomly allocated to a roentgenogram–ordering clinical pathway (intervention) or to standard departmental care (control). Those assigned to the intervention group had triage nurses applying the OAR, and those with positive OAR were sent for roentgenograms before physician evaluation. Physicians were blinded to negative OAR nurse assessments. Investigators were blinded to group allocation. The primary outcome was the total mean length of stay (TLOS). The secondary outcomes were patient satisfaction (five‐point ordinal scale) and the proportion willing to return to the site for future care. Two–independent sample t‐test was used to analyze the TLOS. The Kruskal‐Wallis test was used to analyze satisfaction ratings differences between groups. Fisher's exact test was used to analyze the willing‐to‐return outcome. This study had 80% power to detect an effect size of 25 minutes. Results: Two hundred thirty‐two patients were eligible; 130 patients gave consent and were enrolled. Three patients were then excluded, three were lost to follow‐up, and one left without being seen. The intervention and control groups had mean TLOS of 73.0 minutes and 79.7 minutes, respectively. There was a statistically nonsignificant time difference of ?6.7 minutes (95% CI =?20.9 to 7.4) between groups. There were no differences in patient satisfaction ratings (p‐value = 0.343) or WOR (3.8%; 95% CI =?3.3% to 11.0%). Conclusions: The use of OAR and the ordering of roentgenograms by triage nurses before physician evaluation for twisting ankle or foot injuries does not decrease the length of stay in an urgent care department.