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Predicting admission at triage: are nurses better than a simple objective score?
  1. Allan Cameron1,
  2. Alastair J Ireland2,
  3. Gerard A McKay1,
  4. Adam Stark4,
  5. David J Lowe2,3
  1. 1Acute Medicine Unit, Glasgow Royal Infirmary, Glasgow, UK
  2. 2Emergency Department, Glasgow Royal Infirmary, Glasgow, UK
  3. 3Academic Unit of Anaesthesia, Pain and Critical Care Medicine, School of Medicine, University of Glasgow, Glasgow, UK
  4. 4Medical School, University of Glasgow, Glasgow, UK
  1. Correspondence to Dr David J Lowe, Emergency Department, Glasgow Royal Infirmary, Room 2.73, New Lister Building, 10-16 Alexandra Parade, Glasgow G31 2ER, UK; davidlowe{at}nhs.net

Abstract

Aim We compared two methods of predicting hospital admission from ED triage: probabilities estimated by triage nurses and probabilities calculated by the Glasgow Admission Prediction Score (GAPS).

Methods In this single-centre prospective study, triage nurses estimated the probability of admission using a 100 mm visual analogue scale (VAS), and GAPS was generated automatically from triage data. We compared calibration using rank sum tests, discrimination using area under receiver operating characteristic curves (AUC) and accuracy with McNemar's test.

Results Of 1829 attendances, 745 (40.7%) were admitted, not significantly different from GAPS’ prediction of 750 (41.0%, p=0.678). In contrast, the nurses’ mean VAS predicted 865 admissions (47.3%), overestimating by 6.6% (p<0.0001). GAPS discriminated between admission and discharge as well as nurses, its AUC 0.876 compared with 0.875 for VAS (p=0.93). As a binary predictor, its accuracy was 80.6%, again comparable with VAS (79.0%), p=0.18. In the minority of attendances, when nurses felt at least 95% certain of the outcome, VAS’ accuracy was excellent, at 92.4%. However, in the remaining majority, GAPS significantly outperformed VAS on calibration (+1.2% vs +9.2%, p<0.0001), discrimination (AUC 0.810 vs 0.759, p=0.001) and accuracy (75.1% vs 68.9%, p=0.0009). When we used GAPS, but ‘over-ruled’ it when clinical certainty was ≥95%, this significantly outperformed either method, with AUC 0.891 (0.877–0.907) and accuracy 82.5% (80.7%–84.2%).

Conclusions GAPS, a simple clinical score, is a better predictor of admission than triage nurses, unless the nurse is sure about the outcome, in which case their clinical judgement should be respected.

  • triage
  • nursing, emergency departments
  • management, emergency department management
  • efficiency
  • clinical assessment

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