422 A Multicenter Study on the Comparison of Inter-Rater Reliability Between a Four- and a Five-Level In-Hospital Triage Scales

To compare the inter-rater reliability of an Italian four-level triage scale, the triage emergency methods (TEM v2), and a Swedish five-level triage scale, the Rapid Emergency Triage and Treatment System (RETTS). This is a validation multicenter study conducted in two Italian and two Swedish emergency departments (ED) from March 2014 to December 2014 . Inclusion criteria for center were: to perform triage using the TEM v2 (Italian centers) or RETTS (Swedish centers) scale. Ten nurses from Italian centers and ten nurses from Swedish centers were included if they had undergone a course in the triage scales during the last three years. We used 46 triage scenarios from a medical database. Each scenario included demographic and clinical characteristics: sex, age, main chief complaint at triage, past diseases, vital signs and pain score. Each participant independently assigned triage scores to the 46 scenarios using the TEM v2 or RETTS scale. We tested the inter-rater reliability using a kappa statistic and the Intraclass Correlation Coefficient (ICC) using STATA 13 software. A P < .05 was used to define statistical significance. The mean age of patients included in 46 scenarios was 43 years, 60% male; trauma was the main complaint. The nurses' triage experience from Italian and Swedish group was similar: mean 8.9 years (DS 5.7) vs 5.1 years (DS 2.1) years; median 8 years (range 1-20) vs 5.5 years (range 2.5-7.5); p =0.072. The rate distribution of high (level 1 and 2) and low triage levels was similar among Italian nurses (4-level TEM v2) and the Swedish nurses (5-level RETTS): high codes 28.3% (TEM) vs 43.5% (RETTS); 71.7% (TEM) vs 56.5% (RETTS). The overall inter-rater reliability was moderate-strong for RETTS: K = 0,42 (CI 95; 0.37-0.47), ICC = 0.96 (CI 95%; 0.65-0.98); good-almost perfect for TEM: k=0.66 (CI 95%; 0.61-0.71), ICC = 0.98(CI 95%; 0.97-0.99). The 4-level TEM showed a similar good inter-rater reliability among all triage acuity levels: K inter range from 0.60 (code 2) to 0.74 (code 4). The 5-level RETTS had the lowest reliability for code 4 (K inter =0.25), the best for code 1 (K inter= 0.6). The four- and five-level triage scales tested in this study showed a similar good inter-rater reliability. Our results are in contrast with previous studies which showed better performance of 5-level scales. Limitation is that there are triage scenarios and not real patients.