Brillman J C, Doezema D, Tandberg D, Sklar D P, Skipper B J
Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque 87131-5246, USA.
Am J Emerg Med. 1997 Jan;15(1):29-33. doi: 10.1016/s0735-6757(97)90043-7.
A prospective comparative trial was conducted to determine the effect of a physician's visual assessment of emergency patients on triage categorization and ability at triage to predict admission. The setting was a university, county, referral center and residency training site. Participants were a consecutive sample of emergency department patients presenting between the times of 0700 and 2300 hours for 5 weeks. All patients were assigned a triage category by an emergency nurse (RN) who saw the patient and by an emergency physician (EP) who had the option of performing a visual assessment. Triage categorization was compared for interobserver agreement (Kappa [kappa] statistic) and by ability to predict admission (MacNemar's test). A total of 3,949 patients was entered. The patients that physicians visually assessed were triaged by nurses as more ill (P < .001). For triage categories visualized by the EP compared with RN categorization, interobserver agreement was 59.8%, kappa = .21. For triage categories not visualized by EP compared with RN categorization, interobserver agreement was 67.9%, kappa = .45 (P < .001). Sensitivity of EPs to predict admission is as follows: all RN triage, 41.3; not seen by EP, 54.9; seen by EP, 69.3. Specificity is as follows: all RN triage, 93.7; not seen by EP, 88.5, seen by EP, 83.9. When physician visual assessment was done, agreement between physicians and nurses decreased by more than half. Physicians who included visual assessment in patient triage were less likely to agree with RN categorization. A visual assessment by the physician improved the sensitivity for predicting admission with an only small cost in specificity.
开展了一项前瞻性对照试验，以确定医生对急诊患者的视觉评估对分诊分类以及分诊时预测入院的能力的影响。研究地点为一所大学、县转诊中心及住院医师培训基地。参与者为连续5周在07:00至23:00之间就诊的急诊科患者样本。所有患者均由看过患者的急诊护士（注册护士）和可选择进行视觉评估的急诊医生进行分诊分类。比较了观察者间的一致性（Kappa统计量）以及预测入院的能力（麦克尼马尔检验）。共纳入3949例患者。医生进行视觉评估的患者被护士分诊为病情更重（P <.001）。与护士的分诊分类相比，医生进行视觉评估的分诊分类中，观察者间一致性为59.8%，kappa = 0.21。与护士的分诊分类相比，医生未进行视觉评估的分诊分类中，观察者间一致性为67.9%，kappa = 0.45（P <.001）。急诊医生预测入院的敏感性如下：所有护士分诊，41.3；医生未看过的，54.9；医生看过的，69.3。特异性如下：所有护士分诊，93.7；医生未看过的，88.5；医生看过的，83.9。当进行医生视觉评估时，医生与护士之间的一致性下降了一半以上。在患者分诊中纳入视觉评估的医生与护士的分类更难达成一致。医生的视觉评估提高了预测入院的敏感性，而特异性仅略有降低。
