Pediatric Telephone Triage Protocols: Standardized Decisionmaking or a False Sense of Security?,☆☆,

Accepted for presentation at the Society for Academic Emergency Medicine Annual Meeting, Washington DC, May 1997.
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Abstract

Study objective: To determine whether implementation of a set of standardized pediatric telephone triage protocols results in consistent triage dispositions when applied by different operators. Methods: A descriptive study with interrater comparisons was performed. Telephone interviews simulated the setting of a triage station in a university hospital–based pediatric emergency department. A mock parent presented 15 standardized respiratory cases in random order to 12 pediatric ED nurses. Nurses assigned patients’ complaints to severity categories using 9 respiratory complaint protocols extracted from a commercially available pediatric telephone triage tool. Protocol selection and severity endpoints were recorded. Interobserver agreement among nurses was analyzed by the κ statistic. Comparisons of operator characteristics and triage results were carried out by ANOVA. Results: Interrater agreement in triage disposition among nurses was poor (κ, .11; 95% confidence interval, .02 to .20). Protocol selection varied; the group used a mean of 3 different disposition-generating protocols per case. Disposition also varied, with up to 4 different severity endpoints per protocol in a given case. A post-hoc comparison of the mean disposition severity between nurses did not reach significance at an adjusted level (P =.04). Fifty-eight percent of the nurses felt confined by the protocols, and 42% admitted to at least 1 intentional deviation from them. Conclusion: It may not simply be assumed that the use of protocols will standardize care. This is particularly important in the case of triage, with current trends toward medical decisionmaking by less skilled providers with diminishing patient contact. Although triage protocols may be useful to guide clinical thinking, their consistency must be validated before they may be safely disseminated for general use. [Wachter DA, Brillman JC, Lewis J, Sapien RE: Pediatric telephone triage protocols: Standardized decisionmaking or a false sense of security? Ann Emerg Med April 1999;33:388-394.]

Section snippets

INTRODUCTION

Overcrowding in emergency departments, with resulting delays in patient care and increasing numbers of patients leaving without being seen, has underscored the need for more effective systems of triage.1, 2, 3, 4, 5, 6 Cost-containment efforts have also emphasized the need to direct patients away from EDs.7, 8, 9, 10, 11 Various studies have estimated that 11% to 82% of patients presenting to EDs have nonurgent problems that would be more appropriately treated in a less acute setting.12, 13, 14

MATERIALS AND METHODS

A set of commercially available telephone triage protocols25 was evaluated. These protocols direct the triage provider to elicit certain information regarding the patient’s chief complaint, age, symptoms, and medical history. An algorithm based on patient responses eventually leads the triage provider to an endpoint recommending 1 of the following dispositions: (1) call 911; (2) come in to be seen immediately; (3) come in within 24 hours; (4) come in within 48 hours; (5) home care advice. Of

RESULTS

The 12 nurses in our study had means of 13.8 years of nursing experience (range, 3.5 to 24 years); 5 years in the ED (range, 1 to 14.5 years); 8.4 years in pediatrics (range, 1 to 22 years); and 1.58 years of telephone triage experience (range, 0 to 14 years).

The 15 patients had a mean age of 5.4 years (range, 3 days to 16 years). Diagnoses included asthma or reactive airway disease (7 patients), upper respiratory tract infection (3), choking episodes (3), bronchiolitis (1), and cough with

DISCUSSION

Our study of 1 protocol-driven telephone triage system reveals poor correlation among dispositions determined by triage providers presented with a standardized series of cases, despite instructions to follow protocols as closely as possible. Although it is a basic assumption that protocols operate by standardization, our results indicate that nurses did not reliably choose the same protocol in a given case and did not reach the same triage endpoint even when they followed the same protocol.

The

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    Address for reprints: Judith C Brillman, MD, Department of Emergency Medicine, University of New Mexico School of Medicine, Ambulatory Care Center, 4 West, Albuquerque, NM 87131-5246; 505-272-6524, fax 505-272-6503;E-mail [email protected].

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