Brillman J C, Doezema D, Tandberg D, Sklar D P, Davis K D, Simms S, Skipper B J
Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, USA.
Ann Emerg Med. 1996 Apr;27(4):493-500. doi: 10.1016/s0196-0644(96)70240-8.
Little is known about the accuracy and reliability of current triage methods. We examined agreement among observers with regard to the need for ED care and the ability to predict at triage the need for admission to the hospital and compared these findings with admission rates after medical evaluation and management.
We used a crossover design in which each subject was subjected to nurse or computer-guided triage first, the other type of triage second, and physician triage last. Our null hypothesis: Triage methods will yield the same results. Our patients were a consecutive sample of patients at the ED of a university-affiliated county referral center. Critically ill patients were excluded. Triage categorization was examined for interobserver agreement (kappa-statistic) and prediction of admission (sensitivity, specificity, and predictive values).
Of the 5,106 patients enrolled in the study, 289 (6.2%) were admitted. With regard to the agreement of triage categorizations, we found kappa-values of .452 and .185, respectively, for physician triage compared with nurse (SE +/- .012) and computer triage (SE +/- .012)(P = .001 for the difference between the kappa values). Sensitivity and specificity in predicting admission were 41.3 and 93.8, respectively, for nurses, 61.6 and 87.1, respectively, for physicians; and 68.2 and 73.6, respectively, for computer-aided triage.
We found great variability among physicians, nurses, and a computer program with regard to triage decisions. Comparison of the three groups' triage decisions with actual data after medical evaluation and management showed that none of the three performed well in predicting which patients required admission. Until triage methods are standardized and validated, triage decisions should not be used to determine the timeliness of access to emergency care.
目前关于分诊方法的准确性和可靠性知之甚少。我们研究了观察者之间在急诊护理需求方面的一致性，以及在分诊时预测住院需求的能力，并将这些结果与医学评估和管理后的住院率进行比较。
我们采用交叉设计，每位受试者先接受护士或计算机引导的分诊，再接受另一种分诊，最后接受医生分诊。我们的零假设是：分诊方法将产生相同的结果。我们的患者是大学附属医院县转诊中心急诊科的连续样本患者。危重症患者被排除。检查分诊分类的观察者间一致性（kappa统计量）和住院预测（敏感性、特异性和预测值）。
在纳入研究的5106名患者中，289名（6.2%）被收治。关于分诊分类的一致性，与护士分诊（标准误±0.012）和计算机分诊（标准误±0.012）相比，医生分诊的kappa值分别为0.452和0.185（kappa值之间的差异P = 0.001）。护士预测住院的敏感性和特异性分别为41.3和93.8，医生分别为61.6和87.1，计算机辅助分诊分别为68.2和73.6。
我们发现医生、护士和计算机程序在分诊决策方面存在很大差异。将三组的分诊决策与医学评估和管理后的实际数据进行比较后发现，三组在预测哪些患者需要住院方面均表现不佳。在分诊方法标准化和验证之前，不应使用分诊决策来确定获得紧急护理的及时性。
