Gill J M, Reese C L, Diamond J J
Department of Family & Community Medicine, Medical Center of Delaware, Wilmington, USA.
Ann Emerg Med. 1996 Nov;28(5):474-9. doi: 10.1016/s0196-0644(96)70108-7.
To assess agreement among health professionals with regard to the need for urgent care among emergency department patients.
We conducted a chart review of 266 ED patients in an urban teaching hospital. Eight health professionals (four emergency nurses, two emergency physicians, two family physicians) used identical criteria to retrospectively rate urgency. Agreement was measured for all reviewers, as well as among health professionals of the same specialty. Agreement was also measured between one ED nurse's retrospective assessment and the prospective assessments of the triage nurses who had seen the patients on presentation.
The percentage of patients rated as needing urgent care by the retrospective reviewers ranged from 11% to 63%. Agreement among the retrospective reviewers was fair (kappa = .38; 95% confidence interval, .30 to .46) and was no better among reviewers of the same specialty. We found only slight agreement between the nurse reviewer's retrospective assessment and the triage nurses' prospective assessments (kappa = 19; 95% confidence interval, .07 to .31).
Even when using the same criteria, health professionals frequently disagree about the urgency of care in ED patients. When retrospective reviewers disagree with a prospective assessment of urgency, the potential exists for denial of payment or even lawsuits. Because the subjectivity of urgency definitions may increase disagreement, the development of more objective and uniform definitions may help improve agreement.
评估医疗专业人员对于急诊科患者紧急护理需求的一致性。
我们对一家城市教学医院的266名急诊科患者进行了病历审查。八名医疗专业人员（四名急诊护士、两名急诊医生、两名家庭医生）使用相同标准对紧急程度进行回顾性评分。对所有审查人员以及同一专业的医疗专业人员之间的一致性进行了测量。还测量了一名急诊护士的回顾性评估与患者就诊时进行分诊的护士的前瞻性评估之间的一致性。
回顾性审查人员评定为需要紧急护理的患者百分比在11%至63%之间。回顾性审查人员之间的一致性一般（kappa = 0.38；95%置信区间，0.30至0.46），同一专业的审查人员之间的一致性也没有更好。我们发现护士审查人员的回顾性评估与分诊护士的前瞻性评估之间只有轻微一致性（kappa = 0.19；95%置信区间，0.07至0.31）。
即使使用相同标准，医疗专业人员对于急诊科患者护理的紧急程度也经常存在分歧。当回顾性审查人员与紧急程度的前瞻性评估存在分歧时，可能存在付款被拒绝甚至诉讼的情况。由于紧急程度定义的主观性可能会增加分歧，制定更客观和统一的定义可能有助于提高一致性。
