DOES A PHYSICIAN VISUAL ASSESSMENT CHANGE TRIAGE

A prospective comparative trial was conducted to determine the effect of a physician's visual assessment of emergency patients on triage cat egorization and ability at triage to predict admission. The setting wa s a university, county, referral center and residency training site. P articipants 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) wh o saw the patient and by an emergency physician (EP) who had the optio n of performing a visual assessment. Triage categorization was compare d 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 t he EP compared with RN categorization, interobserver agreement was 59. 8%, kappa = .21. For triage categories not visualized by EP compared w ith 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 phy sicians and nurses decreased by more than half. Physicians who include d visual assessment in patient triage were less likely to agree with R N categorization. A visual assessment by the physician improved the se nsitivity for predicting admission with an only small cost in specific ity. Copyright (C) 1997 by W.B. Saunders Company