Does This Patient Need to Be Evaluated Today?

Designing a Guideline-Driven Triage Process to Determine the Timing of Care for Adults with Respiratory Infection Symptoms

Published in: Joint Commission Journal on Quality Improvement, v. 26, no. 2, Feb. 2000, p. 87-100

Posted on RAND.org on December 31, 1999

by Donna L. Washington, Paul G. Shekelle, Carl Stevens

BACKGROUND: Physicians and nurses often make judgments about the urgency with which patients require evaluation, yet few explicit process-of-care criteria are available to guide these decisions. Using a multidisciplinary expert physician panel and explicit, quantitative group judgment methods, standardized, clinically detailed deferred care criteria were developed to guide emergency department and ambulatory care triage decisions for same-day versus deferred care for patients with respiratory infection symptoms. METHODS: Using a modified Delphi process, an eight-member multidisciplinary expert physician panel rated the safety of deferred care for standardized clinical scenarios. The ratings were converted into explicit criteria and then compared with usual implicit judgment in terms of nurse triage times. RESULTS: The panel achieved 100% consensus on 36 critical clinical factors, each of which precludes deferring care for a patient with respiratory infection symptoms. Based on combinations of 12 additional clinical factors, 48 clinical scenarios were created that the panel rated for deferred care safety. Panelists' ratings agreed for 90% of clinical scenarios. These were formatted into screening criteria. Near-perfect interrater agreement (kappa = 0.9) was found in reproducibility testing. The difference in mean nurse triage times using the criteria compared with implicit nurse judgment was 0.4 minutes (95% confidence interval = -2.1 to 2.9 minutes). CONCLUSIONS: Application of explicit criteria for deferring care of patients with respiratory infection symptoms did not lengthen triage time. This approach may facilitate more efficient resource management for ambulatory settings. However, widespread use before these criteria's, our systematic criteria-based triage should be validated in multicenter clinical trials against an outcome standard and the more common implicit approach.

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