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Reliability and validity of an Italian four-level emergency triage system
  1. Nicola Parenti1,
  2. Roberta Manfredi1,
  3. Maria Letizia Bacchi Reggiani2,
  4. Diego Sangiorgi2,
  5. Tiziano Lenzi1
  1. 1Department of Emergency Medicine of the Community Hospital Santa Maria della Scaletta, Imola, Italy
  2. 2Cardiovascular Department, University of Bologna, Bologna, Italy
  1. Correspondence to Maria Letizia Bacchi Reggiani, Cardiovascular Department, University of Bologna, Via Massarenti 9, Bologna 40138, Italy; nipar71{at}


Objectives To measure the reliability and predictive validity of a four-level triage system (I-4L).

Methods This observational study was conducted in an urban hospital. Five nurses were randomly selected to assign a triage level to 246 paper scenarios, using the I-4L model. The I-4L model is a four-level triage system: urgency category (UC) 1 requires immediate response; UCs 2, 3 and 4 require assessment within 20, 60 and 120 min, respectively. Weighted κ statistics were used to measure the inter-rater and intrarater reliability of the triage tool and the validity of the model was assessed based on the accuracy in predicting admission and in predicting a reference standard's triage code.

Results The I-4L model's inter-rater reliability was κ=0.73 (95% CI 0.67 to 0.79), and the intrarater reliability was κ=0.82 (95% CI 0.67 to 0.96). Its accuracy of triage rating for admission and for prediction of a reference standard's triage code was good: 79% (95% CI 73% to 86%) and 93% (95% CI 89% to 96%), respectively. The percentages of patients admitted per triage level using the I-4L model was: 100% UC 1; 42% UC 2; 6% UC 3; and 2% UC 4.

Conclusions The I-4L triage model shows a good inter-rater and intrarater reliability for rating triage acuity and for accuracy in patient admission and prediction of a reference standard's triage code.

  • Clinical assessment
  • emergency care systems
  • emergency department
  • Italian emergency triage
  • nursing
  • predictive validity
  • reliability
  • system
  • triage

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  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.