cording
to the
severity
of their ill¬
ness
3. Initiation of
therapy
when
re¬
quired 4. Ordering diagnostic laboratory or roentgenographic studies that are needed to speed the child's examina¬
tion 5.
Ordering measurement of body temperature, if necessary 6. Making an appropriate position
Triage Abilities of Nurse Practitioner
vs
Pediatrician
(PNPs)
nurse
practitioners
perform triage functions for ill children in a busy pediatric outpatient service was compared to that of a group of peto
diatricians. One hundred thirteen children were seen separately on arrival by a PNP and
by
a
pediatrician.
The PNPs' evaluations agreed with the pediatricians' 84% of the time. Only two significant differences were shown: PNPs were more diligent in recording patient problems, while pediatricians were better able to anticipate the need for roentgenograms and laboratory studies. The results indicate that valuable physician time may be conserved by using the PNP to perform triage in large pediatric outpatient services.
value of
Thetriagecaringsystem largewell-organized ambulatory a
in
an
service
for numbers of patients is well established.1-7 It is clear that effective triage results in identification of the more severely ill child so that he is not ignored in crowded hospital waiting rooms.6 Little has been reported, however, on the comparative abilities of different health professionals to perform effec¬ tive triage.7 It is entirely possible that nurses, nurse practitioners, and others can perform effective triage. The necessity to conserve valuable Received for publication June 7,1974; accepted 25. From Kings County Hospital-Downstate Medical Center, Brooklyn, NY.
Sept
Reprint requests
to
Kings County Hospital\x=req-\
Downstate Medical Center, 451 Clarkson Ave, Brooklyn, NY 11203 (Dr. Russo).
Performance of the above six functions measured to compare the efficacy of pediatricians and PNPs in performing was
physician time in an era of contin¬ uing physician shortages mandates an investigation of this kind. In the present study, the ability of pediatrie nurse practitioners (PNPs) to per¬ form medical triage in a large pediat¬ rie ambulatory service was compared with that of a group of pediatricians. The Pediatrie Ambulatory Service at Kings County Hospital Center was chosen as the study site. An orga¬ nized triage system has been devel¬ oped at this institution and has been in operation for eight years.7 Six PNPs and six pediatricians who have been engaged in performing all tri¬ age functions at the hospital for at least one year comprise the group of triage officers. Patients arrive at the triage area steadily throughout the day. The ma¬ jority of them have no appointment and are acutely ill. Because of the large number of arriving patients, a child may have to wait a long time to be examined by a clinic pediatrician. In this study, references to the clinic pediatrician indicate a pediatrician who is not involved in the triage pro¬ cess but who ultimately examines and treats the patient. Triage officers are used to identify the sicker children and provide them with immediate services while they are waiting to be examined by the clinic pediatrician. They are responsible for providing the following services: 1. Identification of the child's basic
problem(s)
2. Classification of the children
dis¬
MATERIALS AND METHODS
Raymond M. Russo, MD; Vymutt J. Gururaj, MD; Alicia S. Bunye, MD; Yong H. Kim, MD; Sania Ner, MD The ability of pediatric
the
ac-
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/05/2015
triage.
The six pediatricians performing triage all Board-qualified or Board-certified pediatricians who had completed at least two years of experience in the outpatient department prior to the study period. The six PNPs had been trained previ¬ ously in the Kings County Hospital Pediat¬ rie Outpatient Department's pediatrie nurse practitioner program and had suc¬ cessfully completed all course require¬ ments. (This program has been designed to conform with the American Academy of Pediatrics and the American Nursing As¬ sociation's Guidelines for Training Pediat¬ rie Nurse Practitioners.) The PNPs receive a one-year course of training in the Pediat¬ rie Outpatient Department. Six months of this training consists of didactic sessions were
involving physical diagnosis, history-tak¬ ing techniques, and a review of common pediatrie illnesses. The remaining six
months are devoted to the actual eval¬ uation and management of the conditions of acutely ill, pediatrie, walk-in patients under the direct supervision of a full-time staff pediatrician. Much of this latter expe¬ rience takes place in the triage area. Edu¬ cation in the triage function is included in this six months as well. Each of the six PNPs who participated in the study had at least nine additional months of experience in performing triage functions after the formal training period ended. All six pediatricians and all six PNPs participated in the study in order to mea¬ sure the average performance of both groups, and to avoid, as far as possible, the bias of measuring either extremely good or extremely bad individual performances. The study group was assembled by se¬ lecting every fourth family reporting to the outpatient department on five consecu¬ tive mornings (Oct 29 to Nov 2, 1973). Study patients were distributed equally
between the six pairs of triage officers, each pair consisting of one pediatrician and one PNP. Each pair examined 19 pa¬ tients, with the exception of one group who examined 18 patients. The children were examined first by a PNP and then separately and indepen¬ dently by the triage pediatrician. Each evaluation was monitored and the eval¬ uation form collected by a single author (A.S.B.) who observed all the interviews to minimize observer differences. Both eval¬ uations were then subsequently compared. If the author monitoring the dual eval¬ uation thought the parent's description of the child's problem was influenced by the previous evaluation, she was to eliminate the family from the study. When dis¬ crepancies existed, the opinion of the clinic pediatrician who ultimately examined the child was used to substantiate the eval¬ uation of either the triaging pediatrician or the PNP. The authors' opinion was not used to decide which of the two was correct.
At the conclusion of the study, all dis¬ between pediatrician and PNP evaluations were tabulated by the authors, the charts were reviewed, and, where nec¬ essary, the clinic pediatrician who ulti¬ mately performed the definitive examina¬ tion was interviewed. No attempt was made to substantiate the correctness or lack of correctness of the PNP and pediatrician when they both agreed. The purpose of this study was to measure the difference in their perform¬ ance rather than to assess the accuracy of triage officers in general, since this had al¬ ready been reported.7
crepancies
RESULTS The study group was composed of 113 children ranging in age from 5 weeks to 12 years 9 months, with 65 boys and 48 girls included. Perform¬ ance of the aforementioned six func¬ tions was measured for each of the 113 children. The maximum number of discrepancies possible was, there¬ fore, 678. The number of overall dis¬ crepancies in the evaluations of pe¬ diatricians and PNPs was 110, and the discrepancy rate was 16% (110/ 678). Identical evaluations were made 84% of the time. The evaluations were then compared for discrepancies in each of the following six categories: No. (%) of Discrepancies
Identification of problem Classification of severity
Initiating therapy
35 22 4
(32) (20) (4)
Ordering diagnostic procedures Ordering body temperature measurements
Disposition Total
14
23 12 110
it; this is reflected in the figures listed
(12)
in Table 1.
Classification by Severity of Illness
(21)
(11) (100)
Identifying the Patient's Problem The largest number of discrep¬
ancies were found in performance of this function. Thirty-five instances were discovered in which the eval¬ uations either did not list the pa¬ tient's basic problem(s) or identified different problems. This represents 32% of the total number of discrep¬ ancies found. The PNPs were far more diligent in recording patient problems: 73 pa¬ tients (65%) examined by the PNP had an adequate note regarding their basic problem, compared to 52 (46%) of the pediatrician's patients
(P < .01).
In only two instances did the two examiners identify completely differ¬ ent patient problems, the pediatrician being judged correct both times. In the remaining 33 instances, dis¬ crepancies occurred because of a fail¬ ure on the part of an examiner to record the patient's basic problem. In discussing this aspect with the triage pediatrician or PNP at the conclusion of the study, it was clear that this oc¬ curred in those patients returning for a follow-up visit, where the nature of the patient's problem was already well known to the clinic physician and where the triage officer thought there was no need for further com¬
mentary. When the patient's basic problem had not been described, however, the correct evaluator was considered to be the one who listed the problem rather than the one who failed to list
The
triage officer is expected to ap¬ three-point classification to es¬ timate the severity of illness in all incoming patients. This system has ply
a
been described elsewhere.7 Accord¬ ingly, the large number of children with mild illness or nonacute prob¬ lems are classified as nonemergencies. Those patients who are more severely ill or should not be kept wait¬ ing in a crowded area are given a pri¬ ority rating. Finally, the very few patients with potentially life-threat¬ ening conditions are classified as
emergencies.
The number of discrepancies found in classifying patients was 22. The PNP was found to be correct in her classification as often as the pediatri¬ cian (Table 1). A total of 45 patients received a priority classification, 39 by the pe¬ diatrician and 34 by the PNP. Of these, 28 (62%) were so classified by both the pediatrician and the PNP. Of the remaining 17 patients, 11 were given a priority classification by the pediatrician alone and 6 by the PNP alone. The number of correct and in¬ correct priority classifications made is shown in Table 2.
Initiating Required Therapy The triage officer is expected to ini¬ tiate medical treatment when a pa¬ tient can be made more comfortable while waiting to see the clinic physi¬ cian or when the patient has returned specifically for therapy. Thus, chil¬ dren suffering an acute asthmatic at¬ tack receive an injection of epinephrine at triage and those with fever
Table 1.·—PNP and Pediatrician Decisions
Upheld by Clinic
No.
By Identification of problem Classification of severity Initiation of therapy
Ordering diagnostic procedures Ordering body temperature measurements Disposition Total
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/05/2015
PNP
(74) 7(32)
26
4(29) 8 1 46
(35) (8) (42)
Pediatrician
(%) of Correct Decisions By Pediatrician 8(23) 8(36) 3(75) 8(57) 12
(52)
~2 (17) 41 (37)
By Either 1 (3) 7(32) 1(25) 2(14) 3 03) 9(75) 23 (21)
2.—Priority Classifications Upheld by Clinic Pediatrician
Table
No. of Classifications _A_
By PNP
By Pediatrician
Considered correct Considered
Findings
inconclusive
antipyretic.
In only four patients (4%) did the PNP and the pe¬ diatrician differ in this function, and the pediatrician was considered cor¬ rect in his judgment in three of the an
four instances (Table 1).
quickly. Body temperatures
are
measured only if the triage officer thinks it is indicated. The pediatri¬ cian ordered the temperature to be measured for 54 children (48%), while the PNP ordered it to be measured for 63 patients (56%). Both the pedia¬ trician and the PNP tended to order roentgenographic or laboratory pro¬ cedures to the same degree, the pe¬ diatrician ordering tests in six pa¬ tients (5%) and the PNP in ten
patients (9%). There
23 (21%) instances in evaluator ordered the body temperature to be measured while the other did not. For roentgenographic and laboratory procedures, the dis¬ crepancy rate was somewhat less (14 instances or 12%). The pediatrician was more often correct both in ordering measurement of body temperature or roentgen¬ ographic or laboratory study to be un¬ dertaken (Table 1). These differences
which
are
pital. Discrepancies in patient disposition
occurred 12 times for a rate of 11%. There was no essential difference found between PNP and pediatrician in the accuracy of dispositions made
(Table 1).
Ordering Preliminary Diagnostic Procedures and Body Temperature Measurements After having taken a brief medical history and performed a limited phys¬ ical examination, the triage officer is expected to initiate required proce¬ dures and investigations when indi¬ cated, ie, body temperature measure¬ ment, complete blood cell count, roentgenography, etc. This allows better utilization of patient waiting time and permits the clinic physician to evaluate the patient's condition more
tients may receive their definitive evaluation and therapy at triage; (2) they may be referred to a specialty
area, eg, operating room; (3) they may be assigned to a clinic pediatri¬ cian or returned to a physician who has seen them previously; or (4) they may be admitted directly to the hos¬
incorrect
receive
Triage Disposition Several possible dispositions may be made by the triage officer: (1) pa¬
were
one
statistically significant (P < .05).
COMMENT
Of the six categories in which per¬ formance was measured, there were a significant number of discrepancies in pediatrician and PNP evaluation in three: identifying the patient's prob¬ lem, classifying the severity of his ill¬ ness, and ordering measurement of the body temperature. The dis¬ crepancy rate in the other three cate¬ gories was below 15%. The PNP proved to be more faith¬ ful in recording patient problems than the pediatrician, giving her a large performance edge in this cate¬ gory. It is important to remember that 78 of the 113 children had identi¬ cal evaluations by both PNP and pe¬ diatrician in this category, and in only two instances was there serious disagreement between them. In the vitally important function of classifying the severity of a child's ill¬ ness, there was no clear superiority on the part of either pediatrician or PNP. The ability of the PNP to iden¬ tify the child who deserves a priority classification was at least as good as that of the pediatrician. The perform¬ ance of this function is critical to suc¬ cessful triage, and failure to perform well would seriously compromise the use of PNPs in triage. The only significant performance difference occurred in ordering mea¬ surement of body temperature and other diagnostic procedures. Pediatri¬ cians were superior to PNPs in this regard. This is a relatively less impor¬ tant triage function, however, and
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/05/2015
does not constitute a strong reason for precluding the use of PNPs in per¬
forming triage. The discrepancies existing in initi¬ ating therapy and arriving at a dis¬ position were very few, and while the pediatrician was considered correct in three of four instances, no definitive
conclusion can be drawn on the basis of this small sample. The use of health professionals other than the pediatrician or the PNP to perform emergency room tri¬ age remains an area for further study. Certainly nurses who do not have PNP training have performed triage functions in many hospitals. It is conceivable that the ability of an
experienced emergency room nurse to identify a patient's problem, classify the severity of his illness, and make an appropriate disposition can also be shown to equal that of a pediatrician
PNP. In conclusion, the triage PNP is at least equally able to identify patient problems, judge the severity of their illnesses, initiate immediate therapy, and arrive at a correct disposition as is a pediatrician. The use of PNPs to perform triage would appear to be de¬ sirable from the standpoint of con¬ serving valuable physician time with¬ out adversely affecting the quality of or
triage performance.
References 1. Weinerman
ER, Edwards HR: Triage
system shows promise in management of emergency
department
load.
Hospitals
38:55-62, 1964. 2. Torrens PR, Yedvab DG: Income and residence are keys to E.R. usage pattern. Mod Hosp 108 (2):113-116, 1967. 3. Goss MEW, Reed JL, Reader GG: Time spent by patients in emergency room. NY State J Med 71:1243-1246, 1971. 4. Weinerman ER, Rutzen SR, Pearson
DA: Effects of medical triage in hospital emergency service. Public Health Rep 80:389-399, 1965. 5. Weinerman ER, Ratner RS, Robbins A, et al: Yale studies in ambulatory medical care: V. Determinants of use of hospital emergency services. Am J Public Health 56:1037-1056, 1966. 6. Russo RM, Allen JE, Gururaj VJ: Outpatient management of the severely ill child: A timed priority system. Am J Dis Child 124:235-239, 1972. 7. Russo RM, Gururaj VJ, Allen JE: Ambulatory care triage. Am Fam Physician 9:125-130, 1974.
to the
severity
of their ill¬
ness
3. Initiation of
therapy
when
re¬
quired 4. Ordering diagnostic laboratory or roentgenographic studies that are needed to speed the child's examina¬
tion 5.
Ordering measurement of body temperature, if necessary 6. Making an appropriate position
Triage Abilities of Nurse Practitioner
vs
Pediatrician
(PNPs)
nurse
practitioners
perform triage functions for ill children in a busy pediatric outpatient service was compared to that of a group of peto
diatricians. One hundred thirteen children were seen separately on arrival by a PNP and
by
a
pediatrician.
The PNPs' evaluations agreed with the pediatricians' 84% of the time. Only two significant differences were shown: PNPs were more diligent in recording patient problems, while pediatricians were better able to anticipate the need for roentgenograms and laboratory studies. The results indicate that valuable physician time may be conserved by using the PNP to perform triage in large pediatric outpatient services.
value of
Thetriagecaringsystem largewell-organized ambulatory a
in
an
service
for numbers of patients is well established.1-7 It is clear that effective triage results in identification of the more severely ill child so that he is not ignored in crowded hospital waiting rooms.6 Little has been reported, however, on the comparative abilities of different health professionals to perform effec¬ tive triage.7 It is entirely possible that nurses, nurse practitioners, and others can perform effective triage. The necessity to conserve valuable Received for publication June 7,1974; accepted 25. From Kings County Hospital-Downstate Medical Center, Brooklyn, NY.
Sept
Reprint requests
to
Kings County Hospital\x=req-\
Downstate Medical Center, 451 Clarkson Ave, Brooklyn, NY 11203 (Dr. Russo).
Performance of the above six functions measured to compare the efficacy of pediatricians and PNPs in performing was
physician time in an era of contin¬ uing physician shortages mandates an investigation of this kind. In the present study, the ability of pediatrie nurse practitioners (PNPs) to per¬ form medical triage in a large pediat¬ rie ambulatory service was compared with that of a group of pediatricians. The Pediatrie Ambulatory Service at Kings County Hospital Center was chosen as the study site. An orga¬ nized triage system has been devel¬ oped at this institution and has been in operation for eight years.7 Six PNPs and six pediatricians who have been engaged in performing all tri¬ age functions at the hospital for at least one year comprise the group of triage officers. Patients arrive at the triage area steadily throughout the day. The ma¬ jority of them have no appointment and are acutely ill. Because of the large number of arriving patients, a child may have to wait a long time to be examined by a clinic pediatrician. In this study, references to the clinic pediatrician indicate a pediatrician who is not involved in the triage pro¬ cess but who ultimately examines and treats the patient. Triage officers are used to identify the sicker children and provide them with immediate services while they are waiting to be examined by the clinic pediatrician. They are responsible for providing the following services: 1. Identification of the child's basic
problem(s)
2. Classification of the children
dis¬
MATERIALS AND METHODS
Raymond M. Russo, MD; Vymutt J. Gururaj, MD; Alicia S. Bunye, MD; Yong H. Kim, MD; Sania Ner, MD The ability of pediatric
the
ac-
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/05/2015
triage.
The six pediatricians performing triage all Board-qualified or Board-certified pediatricians who had completed at least two years of experience in the outpatient department prior to the study period. The six PNPs had been trained previ¬ ously in the Kings County Hospital Pediat¬ rie Outpatient Department's pediatrie nurse practitioner program and had suc¬ cessfully completed all course require¬ ments. (This program has been designed to conform with the American Academy of Pediatrics and the American Nursing As¬ sociation's Guidelines for Training Pediat¬ rie Nurse Practitioners.) The PNPs receive a one-year course of training in the Pediat¬ rie Outpatient Department. Six months of this training consists of didactic sessions were
involving physical diagnosis, history-tak¬ ing techniques, and a review of common pediatrie illnesses. The remaining six
months are devoted to the actual eval¬ uation and management of the conditions of acutely ill, pediatrie, walk-in patients under the direct supervision of a full-time staff pediatrician. Much of this latter expe¬ rience takes place in the triage area. Edu¬ cation in the triage function is included in this six months as well. Each of the six PNPs who participated in the study had at least nine additional months of experience in performing triage functions after the formal training period ended. All six pediatricians and all six PNPs participated in the study in order to mea¬ sure the average performance of both groups, and to avoid, as far as possible, the bias of measuring either extremely good or extremely bad individual performances. The study group was assembled by se¬ lecting every fourth family reporting to the outpatient department on five consecu¬ tive mornings (Oct 29 to Nov 2, 1973). Study patients were distributed equally
between the six pairs of triage officers, each pair consisting of one pediatrician and one PNP. Each pair examined 19 pa¬ tients, with the exception of one group who examined 18 patients. The children were examined first by a PNP and then separately and indepen¬ dently by the triage pediatrician. Each evaluation was monitored and the eval¬ uation form collected by a single author (A.S.B.) who observed all the interviews to minimize observer differences. Both eval¬ uations were then subsequently compared. If the author monitoring the dual eval¬ uation thought the parent's description of the child's problem was influenced by the previous evaluation, she was to eliminate the family from the study. When dis¬ crepancies existed, the opinion of the clinic pediatrician who ultimately examined the child was used to substantiate the eval¬ uation of either the triaging pediatrician or the PNP. The authors' opinion was not used to decide which of the two was correct.
At the conclusion of the study, all dis¬ between pediatrician and PNP evaluations were tabulated by the authors, the charts were reviewed, and, where nec¬ essary, the clinic pediatrician who ulti¬ mately performed the definitive examina¬ tion was interviewed. No attempt was made to substantiate the correctness or lack of correctness of the PNP and pediatrician when they both agreed. The purpose of this study was to measure the difference in their perform¬ ance rather than to assess the accuracy of triage officers in general, since this had al¬ ready been reported.7
crepancies
RESULTS The study group was composed of 113 children ranging in age from 5 weeks to 12 years 9 months, with 65 boys and 48 girls included. Perform¬ ance of the aforementioned six func¬ tions was measured for each of the 113 children. The maximum number of discrepancies possible was, there¬ fore, 678. The number of overall dis¬ crepancies in the evaluations of pe¬ diatricians and PNPs was 110, and the discrepancy rate was 16% (110/ 678). Identical evaluations were made 84% of the time. The evaluations were then compared for discrepancies in each of the following six categories: No. (%) of Discrepancies
Identification of problem Classification of severity
Initiating therapy
35 22 4
(32) (20) (4)
Ordering diagnostic procedures Ordering body temperature measurements
Disposition Total
14
23 12 110
it; this is reflected in the figures listed
(12)
in Table 1.
Classification by Severity of Illness
(21)
(11) (100)
Identifying the Patient's Problem The largest number of discrep¬
ancies were found in performance of this function. Thirty-five instances were discovered in which the eval¬ uations either did not list the pa¬ tient's basic problem(s) or identified different problems. This represents 32% of the total number of discrep¬ ancies found. The PNPs were far more diligent in recording patient problems: 73 pa¬ tients (65%) examined by the PNP had an adequate note regarding their basic problem, compared to 52 (46%) of the pediatrician's patients
(P < .01).
In only two instances did the two examiners identify completely differ¬ ent patient problems, the pediatrician being judged correct both times. In the remaining 33 instances, dis¬ crepancies occurred because of a fail¬ ure on the part of an examiner to record the patient's basic problem. In discussing this aspect with the triage pediatrician or PNP at the conclusion of the study, it was clear that this oc¬ curred in those patients returning for a follow-up visit, where the nature of the patient's problem was already well known to the clinic physician and where the triage officer thought there was no need for further com¬
mentary. When the patient's basic problem had not been described, however, the correct evaluator was considered to be the one who listed the problem rather than the one who failed to list
The
triage officer is expected to ap¬ three-point classification to es¬ timate the severity of illness in all incoming patients. This system has ply
a
been described elsewhere.7 Accord¬ ingly, the large number of children with mild illness or nonacute prob¬ lems are classified as nonemergencies. Those patients who are more severely ill or should not be kept wait¬ ing in a crowded area are given a pri¬ ority rating. Finally, the very few patients with potentially life-threat¬ ening conditions are classified as
emergencies.
The number of discrepancies found in classifying patients was 22. The PNP was found to be correct in her classification as often as the pediatri¬ cian (Table 1). A total of 45 patients received a priority classification, 39 by the pe¬ diatrician and 34 by the PNP. Of these, 28 (62%) were so classified by both the pediatrician and the PNP. Of the remaining 17 patients, 11 were given a priority classification by the pediatrician alone and 6 by the PNP alone. The number of correct and in¬ correct priority classifications made is shown in Table 2.
Initiating Required Therapy The triage officer is expected to ini¬ tiate medical treatment when a pa¬ tient can be made more comfortable while waiting to see the clinic physi¬ cian or when the patient has returned specifically for therapy. Thus, chil¬ dren suffering an acute asthmatic at¬ tack receive an injection of epinephrine at triage and those with fever
Table 1.·—PNP and Pediatrician Decisions
Upheld by Clinic
No.
By Identification of problem Classification of severity Initiation of therapy
Ordering diagnostic procedures Ordering body temperature measurements Disposition Total
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/05/2015
PNP
(74) 7(32)
26
4(29) 8 1 46
(35) (8) (42)
Pediatrician
(%) of Correct Decisions By Pediatrician 8(23) 8(36) 3(75) 8(57) 12
(52)
~2 (17) 41 (37)
By Either 1 (3) 7(32) 1(25) 2(14) 3 03) 9(75) 23 (21)
2.—Priority Classifications Upheld by Clinic Pediatrician
Table
No. of Classifications _A_
By PNP
By Pediatrician
Considered correct Considered
Findings
inconclusive
antipyretic.
In only four patients (4%) did the PNP and the pe¬ diatrician differ in this function, and the pediatrician was considered cor¬ rect in his judgment in three of the an
four instances (Table 1).
quickly. Body temperatures
are
measured only if the triage officer thinks it is indicated. The pediatri¬ cian ordered the temperature to be measured for 54 children (48%), while the PNP ordered it to be measured for 63 patients (56%). Both the pedia¬ trician and the PNP tended to order roentgenographic or laboratory pro¬ cedures to the same degree, the pe¬ diatrician ordering tests in six pa¬ tients (5%) and the PNP in ten
patients (9%). There
23 (21%) instances in evaluator ordered the body temperature to be measured while the other did not. For roentgenographic and laboratory procedures, the dis¬ crepancy rate was somewhat less (14 instances or 12%). The pediatrician was more often correct both in ordering measurement of body temperature or roentgen¬ ographic or laboratory study to be un¬ dertaken (Table 1). These differences
which
are
pital. Discrepancies in patient disposition
occurred 12 times for a rate of 11%. There was no essential difference found between PNP and pediatrician in the accuracy of dispositions made
(Table 1).
Ordering Preliminary Diagnostic Procedures and Body Temperature Measurements After having taken a brief medical history and performed a limited phys¬ ical examination, the triage officer is expected to initiate required proce¬ dures and investigations when indi¬ cated, ie, body temperature measure¬ ment, complete blood cell count, roentgenography, etc. This allows better utilization of patient waiting time and permits the clinic physician to evaluate the patient's condition more
tients may receive their definitive evaluation and therapy at triage; (2) they may be referred to a specialty
area, eg, operating room; (3) they may be assigned to a clinic pediatri¬ cian or returned to a physician who has seen them previously; or (4) they may be admitted directly to the hos¬
incorrect
receive
Triage Disposition Several possible dispositions may be made by the triage officer: (1) pa¬
were
one
statistically significant (P < .05).
COMMENT
Of the six categories in which per¬ formance was measured, there were a significant number of discrepancies in pediatrician and PNP evaluation in three: identifying the patient's prob¬ lem, classifying the severity of his ill¬ ness, and ordering measurement of the body temperature. The dis¬ crepancy rate in the other three cate¬ gories was below 15%. The PNP proved to be more faith¬ ful in recording patient problems than the pediatrician, giving her a large performance edge in this cate¬ gory. It is important to remember that 78 of the 113 children had identi¬ cal evaluations by both PNP and pe¬ diatrician in this category, and in only two instances was there serious disagreement between them. In the vitally important function of classifying the severity of a child's ill¬ ness, there was no clear superiority on the part of either pediatrician or PNP. The ability of the PNP to iden¬ tify the child who deserves a priority classification was at least as good as that of the pediatrician. The perform¬ ance of this function is critical to suc¬ cessful triage, and failure to perform well would seriously compromise the use of PNPs in triage. The only significant performance difference occurred in ordering mea¬ surement of body temperature and other diagnostic procedures. Pediatri¬ cians were superior to PNPs in this regard. This is a relatively less impor¬ tant triage function, however, and
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/05/2015
does not constitute a strong reason for precluding the use of PNPs in per¬
forming triage. The discrepancies existing in initi¬ ating therapy and arriving at a dis¬ position were very few, and while the pediatrician was considered correct in three of four instances, no definitive
conclusion can be drawn on the basis of this small sample. The use of health professionals other than the pediatrician or the PNP to perform emergency room tri¬ age remains an area for further study. Certainly nurses who do not have PNP training have performed triage functions in many hospitals. It is conceivable that the ability of an
experienced emergency room nurse to identify a patient's problem, classify the severity of his illness, and make an appropriate disposition can also be shown to equal that of a pediatrician
PNP. In conclusion, the triage PNP is at least equally able to identify patient problems, judge the severity of their illnesses, initiate immediate therapy, and arrive at a correct disposition as is a pediatrician. The use of PNPs to perform triage would appear to be de¬ sirable from the standpoint of con¬ serving valuable physician time with¬ out adversely affecting the quality of or
triage performance.
References 1. Weinerman
ER, Edwards HR: Triage
system shows promise in management of emergency
department
load.
Hospitals
38:55-62, 1964. 2. Torrens PR, Yedvab DG: Income and residence are keys to E.R. usage pattern. Mod Hosp 108 (2):113-116, 1967. 3. Goss MEW, Reed JL, Reader GG: Time spent by patients in emergency room. NY State J Med 71:1243-1246, 1971. 4. Weinerman ER, Rutzen SR, Pearson
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