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 categorization and ability at triage to predict admission. The setting was a university, county, referral center and residency training site. Participants 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) who saw the patient and by an emergency physician (EP) who had the option of performing a visual assessment. Triage categorization was compared 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 the EP compared with RN categorization, interobserver agreement was 59.8%, kappa = .21. For triage categories not visualized by EP compared with 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 physicians and nurses decreased by more than half. Physicians who included visual assessment in patient triage were less likely to agree with RN categorization. A visual assessment by the physician improved the sensitivity for predicting admission with an only small cost in specificity.