Reliability of the Canadian Emergency Department Triage and Acuity Scale: Interrater Agreement,☆☆,,★★

Presented at the 6th International Conference on Emergency Medicine, Sydney, Australia, November 1996, and the annual meeting of the Society of Academic Emergency Medicine, Washington DC, May 1997.
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Abstract

Study objective: To determine the rate of interobserver reliability of the Canadian Emergency Department Triage and Acuity Scale (CTAS). Methods: Ten physicians and 10 nurses were randomly selected to review and assign a triage level on 50 ED case summaries containing presenting complaint, mode of arrival, vital signs, and a verbatim triage note. The rate of agreement within and between groups of raters was determined using κ statistics. One-way, 2-way analysis of variance (ANOVA) and combined ANOVA were used to quantify reliability coefficients for intraclass and interclass correlations. Results: The overall chance-corrected agreement κ for all observers was .80 (95% confidence interval [CI] .79 to .81), and the probability of agreement between 2 random observers on a random case was .539. For nurses alone, κ=.84 (95% CI .83 to .85, P =.598), and for doctors alone, κ=.83 (95% CI .81 to .85, P =.566). The 1-way, 2-way ANOVA and combined ANOVA showed that the reliability coefficients (84%) for both nurses and physicians were similar to the κ values. A combined ANOVA showed there was a .2-point difference with physicians assigning a higher triage level. Conclusion: The high rate of interobserver agreement has important implications for case mix comparisons and suggests that this scale is understood and interpreted in a similar fashion by nurses and physicians. [Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S: Reliability of the Canadian Emergency Department Triage and Acuity Scale: Interrater agreement. Ann Emerg Med August 1999;34:155-159.]

Section snippets

INTRODUCTION

Triage is a fundamental process for the safe and efficient use of an emergency department. Despite this, there are wide variations in existing triage scales and systems within and between different countries. The Canadian Association of Emergency Physicians (CAEP) proposed the use of a single 5-level triage scale for all Canadian EDs in 1995.1 This scale was based on the National Triage Scale (NTS) implemented in Australia in 1994.2, 3 The CAEP scale was made a mandatory element in the Canadian

MATERIALS AND METHODS

Fifty actual cases, 10 from each triage level, were selected sequentially from the ED of a tertiary care ED with 50,000 patient visits per year. A written summary included the presenting complaint, the mode of arrival, vital signs, and a verbatim copy of the triage note. Ten nurses (5 part-time and 5 full-time) and 10 physicians (5 full-time ED physicians and 5 part-time physicians) were randomly selected to participate in the study. No participant had any formal training or experience with the

RESULTS

Nine of the nurses and 8 of the physicians returned spreadsheets with all data required for analysis.

The overall chance-corrected agreement κ for all observers was .80 (95% confidence interval [CI] .79 to .81), and the probability of agreement between 2 random observers on a random case was .539. For nurses alone, κ=.84 (95% CI .83 to .85) and P =.598; for doctors alone, κ=.83 (95% CI .81 to .85) and P =.566. The probability of a randomly selected observer selecting the same level as an earlier

DISCUSSION

We found excellent rates of agreement (κ=.80) between physicians and nurses despite the heterogeneity of their background and lack of formal training on the use of the scale. This is in contrast to numerous studies that report very poor agreement rates.8, 9, 10, 11, 16, 17 The triage scales and methods chosen to determine interobserver agreement are probably responsible for the widely disparate results between our study and those reported elsewhere. It is not surprising that comparisons of

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  • Cited by (0)

    From the Division of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, and the Department of Emergency Medicine, Atlantic Health Sciences Corporation, Saint John Regional Hospital, Saint John, New Brunswick, Canada,* and the Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Center, Hamilton, Ontario, Canada.

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    Address for reprints: Robert C Beveridge, MD, MSc, FRCPC, Department of Emergency Medicine, Saint John Regional Hospital, PO Box 2100, Saint John, New Brunswick, E2L 4L2, Canada;506-648-6958, fax 506-548-6055; E-mail [email protected].

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