Comparing Safety and Accuracy of Standardised Versus Subjective Triage Code Assignment by Nurses: A Multicenter Observational Simulated Study

Background: Standardised triage systems have been in place for decades with minor modifications, while nurses' skills and knowledge have significantly advanced.

Aim: To determine whether nurses' clinical expertise outperforms triage systems in simulated clinical cases.

Design: A multicenter simulated observational study.

Methods: The study was conducted from January 1, 2024 to March 31, 2024, in four Italian emergency departments, enrolling triage-performing nurses. Thirty clinical cases, based on real patients representing daily emergency department influx, were reconstructed. The primary outcome was the agreement between the triage code assigned by the Manchester Triage System and the code assigned based on clinical expertise. The secondary outcome compared the predictive ability of the codes assigned by nurses regarding clinical outcomes, such as death within 72 h, the need for hospitalisation, and the need for life-saving intervention. The study was reported in accordance with the STROBE statement.

Results: Seventy-seven triage nurses completed the 30 vignettes. The agreement between the MTS-assigned code and the clinical expertise triage reported a Cohen's kappa of 0.576 (95% CI: 0.564-0.598). For death within 72 h, the clinical expertise code reported better results than the Manchester Triage System. For life-saving interventions, the Manchester Triage System reported a lower performance than clinical expertise. The variability in triage code assignment was higher for clinical expertise compared to the Manchester Triage System.

Conclusions: Triage codes assigned by nurses based on clinical expertise perform better in terms of clinical outcomes, suggesting a need to update triage systems to incorporate nurses' knowledge and skills. However, standardised triage systems should be maintained to reduce variability and ensure consistent patient classification.

Reporting method: The study was conducted and reported according to the STROBE statement.

Patient or public contribution: No patient or public contribution.