Disagreement among health care professionals about the urgent care needs of emergency department patients

Study objective: To assess agreement among health professionals with regard to the need for urgent care among emergency department patients. Methods: We conducted a chart review of 266 ED patients in an urban teaching hospital. Eight health professionals (four emergency nurses, two emergency physicians, two family physicians) used identical criteria to retrospectively rate urgency. Agreement was measured for all reviewers, as well as among health professionals of the same specialty. Agreement was also measured between one ED nurse's retrospective assessment and the prospective assessments of the triage nurses who had seen the patients on presentation. Results: The percentage of patients rated as needing urgent care by the retrospective reviewers ranged from 11% to 63%. Agreement. among the retrospective reviewers was fair (kappa=.38; 95% confidence interval, .30 to .46) and was no better among reviewers of the same specially. We found only slight agreement between the nurse reviewer's retrospective assessment and the triage nurses' prospective assessments (kappa=.19; 95% confidence interval, .07 to .31). Conclusion: Even when using the same criteria, health professionals frequently disagree about the urgency of care in ED patients. When retrospective reviewers disagree with a prospective assessment of urgency, the potential exists for denial of payment or even lawsuits. Because the subjectivity of urgency definitions may increase disagreement, the development of more objective and uniform definitions may help improve agreement.