Pediatric telephone triage protocols: Standardized decisionmaking or a false sense of security?

Study objective: To determine whether implementation of a set of standardiz ed pediatric telephone triage protocols results in consistent triage dispos itions when applied by different operators. Methods: A descriptive study with interrater comparisons was performed. Tel ephone 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, N urses assigned patients' complaints to severity categories using 9 respirat ory complaint protocols extracted from a commercially available pediatric t elephone triage tool. Protocol selection and severity endpoints were record ed. Interobserver agreement among nurses was analyzed by the kappa statisti c. Comparisons of operator characteristics and triage results were carried out by ANOVA. Results: Interrater agreement in triage disposition among nurses was poor ( kappa, .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 pe r protocol in a given case. A post-hoc comparison of the mean disposition s everity 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 sta ndardize care. This is particularly important in the case of triage, with c urrent trends toward medical decisionmaking by less skilled providers with diminishing patient contact. Although triage protocols may be useful to gui de clinical thinking, their consistency must be Validated before they may b e safely disseminated for general use.