- Email: [email protected]
The effectiveness of nurse-led outpatient referral triage decision making in pediatric otolaryngology
International Journal of Pediatric Otorhinolaryngology 79 (2015) 576–578
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The effectiveness of nurse-led outpatient referral triage decision making in pediatric otolaryngology§ Paul Hong a,b,*, Krista Ritchie a, Cathy Beaton-Campbell a, Lynn Cavanagh a, James Belyea a, Gerard Corsten a a b
IWK Health Centre, Department of Surgery, Dalhousie University, Halifax, NS, Canada School of Human Communication Disorders, Dalhousie University, Halifax, NS, Canada
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 December 2014 Received in revised form 27 January 2015 Accepted 29 January 2015 Available online 7 February 2015
Objectives: To assess the effectiveness of nurse-led triage of outpatient referrals in an academic pediatric otolaryngology practice. Methods: Three hundred consecutive outpatient referrals were reviewed and triaged by two otolaryngology registered nurses and two attending pediatric otolaryngologists. The nurses received triage training. The referrals were triaged as ‘routine’ (to be seen within 2–3 months), ‘semi-urgent’ (to be seen within 6 weeks), or ‘urgent’ (to be seen within 2 weeks). Weighted Kappa statistics (correcting for chance agreement) were performed to assess for the degree of agreement. After the consultation visits, patient records were reviewed to determine whether any referrals had been inappropriately triaged by the nurses. Results: Overall, there was substantial agreement between all raters. Specifically, weighted Kappa statistics were as follows: surgeon 1, nurse 1: 0.708; surgeon 1, nurse 2: 0.670; surgeon 2, nurse 1: 0.762; surgeon 2, nurse 2: 0.647; nurse 1, nurse 2: 0.756; and surgeon 1, surgeon 2: 0.784. Review of patient charts after consultation showed that no referrals were deemed to be inappropriately triaged and no urgent cases had been missed. Conclusions: Our model of nurse-led triage of outpatient referrals was found to be effective and safe. Similar systems may be considered in other areas of medicine as a viable and acceptable alternative to the traditional physician-led triage practice. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nurse triage Nurse-led triage Outpatient referrals Surgical referrals Pediatric otolaryngology
1. Introduction Over the last decade, demand on the healthcare systems in the Unites States and Canada has changed significantly due to the aging population, rising costs, and physician shortages. To this end, nurses have been providing more advanced and independent care, thereby replacing some roles traditionally performed by physicians [1,2]. These adjunctive roles provided by nurses can be costeffective and may have the advantage of improving patient access and wait-times, as well as promoting physician productivity. One example of an expanded nursing role involves triaging of patient referrals. Specifically, nurse-led triage has been reported to
§
This study was presented at The Society for Ear, Nose and Throat Advances in Children Scientific Meeting in St. Louis, MO. * Corresponding author at: IWK Health Centre, 5850/5980 University Avenue, PO Box 9700, Halifax, NS, Canada B3K 6R8. Tel.: +1 902 470 0841; fax: +1 902 470 8929. E-mail address: [email protected] (P. Hong). http://dx.doi.org/10.1016/j.ijporl.2015.01.031 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
be safe and effective in primary care [3], acute medical admissions [4], and in some surgical specialities [5,6]. Many different triaging systems have been reported in the literature. It is a practice that has changed over time and many modifications have been instituted to increase the efficiency of the triage process. Some of these include telephone triage [3], computer-aided triage [7], and internet based e-mail triage services [8]. Yet, most subspecialty surgical centers still use the traditional triage system where the consulting physicians perform the triage duties [6]. The current study was conducted to assess the effectiveness and safety of nurse-led triage of outpatient referrals in an academic pediatric otolaryngology clinic.
2. Methods Three hundred consecutive outpatient referrals sent to our pediatric otolaryngology clinic were photocopied and distributed to the following raters: (1) two clinic nurses and (2) two staff
P. Hong et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 576–578
physicians (fellowship-trained pediatric otolaryngologists). Those referrals with additional information provided to one or more raters were excluded. For instance, referrals accompanied by a phone-call to one of the raters from the referring healthcare provider were deemed to be biased and thus not included in the study. Only the information on the referral document was used to triage patients. The two registered nurses who participated in this study are experienced in pediatric otolaryngology and also received triage training. Briefly, the training involved an informal session with one of the attending physicians (G.C.), followed by the two nurses reviewing referral letters, discussing each case and obtaining clarification from the physician if any issues arose. Soon afterwards, the two nurses started performing the primary triage duties independently. Specifically, the nurses collected the incoming referrals throughout the day from the clinic fax machine and triaged them accordingly. All referrals letters were triaged as ‘routine’ (to be seen within 2–3 months), ‘semi-urgent’ (to be seen within 6 weeks), or ‘urgent’ (to be seen within 2 weeks). During the study period, all four participants independently graded each referral letter as urgent, semi-urgent, or routine. Interobserver (for all combinations between raters, including nurse 1 vs. nurse 2, nurse 1 vs. surgeon 1, nurse 1 vs. surgeon 2, nurse 2 vs. surgeon 1, nurse 2 vs. surgeon 2, surgeon 1 vs. surgeon 2) agreement were then determined by calculating Kappa statistics. Specifically, weighted Kappa statistics between each rater for the three-level interval data (urgent, semi-urgent, routine) with 95% confidence intervals were calculated [9]. Standard one-tailed hypothesis testing only tests whether Kappa is significantly different than zero. We tested for significance with a two-tailed test, in order to see if agreement was significantly different than a predefined value of clinical importance. Because a Kappa of 0.4 is interpreted as moderate agreement [10], we set our null hypothesis to test that there is no difference between estimated Kappa and 0.4. An ‘‘almost perfect’’ Kappa estimate is conventionally defined as any agreement between 0.81 and 1.0 [10]. We aimed to have the lower bound of our 95% confidence interval remain within this almost perfect range. With this criterion, we would be 95% confident that the true level of agreement was within the almost perfect range. When too few ratings are performed, the confidence interval widens and commonly results in under-powered studies and lower than acceptable lower bound estimates on confidence intervals. For this reason, we used a large sample size of 300 consecutive referrals to calculate the Kappa statistics. After the consultation visits were completed on all 300 patients, their records were reviewed to ascertain whether any referrals were inappropriately triaged by the nurses and whether any truly urgent cases had been missed. Local Institutional Review Board approval was obtained for this study. 3. Results Six referrals were excluded due to more information about the referrals being available to one of the raters. Therefore to reach our sample size, a total of 306 consecutive outpatient referrals were included in the study. The referrals were collected during a 2month period in the pediatric otolaryngology clinic. Of the 300 referrals, 217 (72.3%) were from primary care physicians, 67 (22.3%) were from non-otolaryngology specialists (e.g., pediatricians, allergists), 13 (4.3%) were from otolaryngologists, and 3 (1%) were from audiologists or speech-language pathologists. Most referrals were triaged to be routine by all raters (Table 1). Specifically, of the 1200 triages performed in this
577
Table 1 Number of referrals triaged in each category by different raters. Raters
Routine
Semi-urgent
Urgent
Physician 1 Physician 2 Nurse 1 Nurse 2
248 239 234 237
50 60 63 60
2 1 3 3
study (300 triages by each of the four raters), 958 (79.8%) were considered to be routine. This was followed by 233 (19.4%) referrals being triaged as semi-urgent, and nine (0.8%) referrals being triaged as urgent. Regarding weighted Kappa statistics, the following criteria was used to evaluate the level of agreement: <0, none; 0–0.20, slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, substantial; and 0.81–1.0, almost perfect [10]. Overall, there was substantial agreements (0.647 to 0.784) between all rater combinations. Specifically, weighted Kappa statistics and the corresponding standard error (in parentheses) were as follows: surgeon 1 and nurse 1: 0.708 (0.050); surgeon 1 and nurse 2: 0.670 (0.054); surgeon 2 and nurse 1: 0.762 (0.045); surgeon 2 and nurse 2: 0.647 (0.053); nurse 1 and nurse 2: 0.756 (0.046); and surgeon 1 and surgeon 2: 0.784 (0.045). A retrospective review of the 300 patient records following their actual clinic appointments did not reveal any cases that had been deemed to be inappropriately triaged by the clinic nurses. Furthermore, no cases which should have been urgent were missed or under-triaged. 4. Discussion Over time, nurses have engaged in positions with more independence and responsibility [11]. This is demonstrated, for instance, by the expansion of the number of nurse practitioners in North America [1]. Furthermore, nurses have assumed leadership roles [12] and have taken over duties traditionally performed by physicians [2,6]. One such role is the triaging of outpatient referrals in healthcare settings. Specifically, nurse-led triage systems have become an established practice in many areas of medicine [3–5]. However, there remains a lack of formal evaluation of such models of care. Thus, more studies to ensure patient safety and efficiency of the nurse-led triage practice are required. To the best of our knowledge, the current study is the first one conducted in North America that assessed the triage role of outpatient referrals by nurses in a pediatric surgical setting. Overall, the findings showed that nurses and physicians had high degree of agreement when triaging outpatient referrals. This suggests that our nurses were able to demonstrate expert decisionmaking abilities even though physicians are considered the ‘goldstandard’ experts in performing triaging duties. Furthermore, no referrals were deemed to be mismanaged or inappropriately triaged by the nurses. That is, no truly urgent referrals were overlooked by the nurses, which verifies the safety of nurse-led triage system utilized in this study. Although the level of agreement between the nurses and the physicians was considered ‘substantial’ (weighted Kappa > 0.6), there was some variability noted between all rater combinations. Yet, the degree of variability was considered very minor in terms of weighted Kappa statistics [9]. Moreover, the level of agreement observed in the current study was better than previous studies in primary care and in the adult surgical setting, where inter-rater agreement was mostly considered ‘fair’ to ‘moderate’ [3,6]. Small variability also existed between the two physicians in our study (0.784), which was in keeping with previous studies [6]. This is
578
P. Hong et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 576–578
unsurprising since the triage process will always contain an element of subjectivity, and as such, it cannot be completely standardized [3]. In other words, there will always be some degree of inconsistency but the observed variability in our study was considered to be clinically insignificant. The outpatient referrals which led to disagreement between surgeons and nurses involved young children with otitis media and hearing/speech concerns and neck masses without systemic clinical features, such as weight loss or night sweats. Some of the raters triaged these children as semi-urgent, while others triaged them as routine. Interestingly, there was no consistent trend of either the nurses or surgeons triaging more conservatively or aggressively. Again, the rationale for this difference is most likely due to the subjective nature of the triaging process. There are many potential benefits of instituting a nurse-led outpatient referral triage system. Dedicated clinic nurses are usually present and available to receive and field referrals in the clinic, while the surgeon may be in the operating room or performing academic duties, such as teaching or research. Subsequently, physician-led triage process may occur on an adhoc basis, while the nurses can act in a more timely manner. In turn, such a system may reduce the workload of physicians, potentially allowing them to devote more time to performing other clinical or academic duties [6]. As well, there may be cost containment and improved efficiency since physician time is more costly to the healthcare system than that of nurses. A limitation of the present study is determining whether our results are generalizable to other clinical settings. It is unclear whether nurses in other pediatric otolaryngology clinics or other medical specialities will perform to the same degree. However, previous studies have demonstrated the effectiveness and safety of nurse-led triage practice in many other settings [3–6]. Therefore, we believe the current results may be valid outside of our clinic. Although we are confident in our nurse-led triage system, we make the following recommendations. First, the nurses should be non-casual employees who have had exposure to the specific area of medicine or healthcare. They should have appropriate triage training and also have a senior healthcare provider available to review any questionable referrals. For medicolegal purposes, this will usually be an attending physician. For referrals with high level of uncertainty, the nurses should be trained to error on the side of caution, as well as to discuss any concerns with the attending
physician. Finally, the triage practice should undergo regular audit or review to ensure that it continues to be safe and effective. 5. Conclusion Overall, there was substantial agreement between the nurses and the physicians when triaging outpatient referrals in our pediatric otolaryngology clinic. Furthermore, no referrals were deemed to be inappropriately triaged by the nurses. This indicates that nurse-led triage of outpatient referrals by experienced and trained nurses in our setting was found to be safe and effective. Similar models should be considered in other areas of medicine as a viable and acceptable alternative to the traditional physician-led triage practice. Funding There is no funding for this study. References [1] S.A. Weiland, Reflections on independence in nurse practitioner practice, J. Am. Acad. Nurse Pract. 20 (2008) 345–352. [2] A.P. Susilo, J. van Dalen, M.N. Chenault, A. Scherpbier, Informed consent and nurses’ roles: a survey of Indonesian practitioners, Nurs. Ethics 21 (2014) 684– 694 (2014). [3] J. Dale, R. Croutch, D. Lloyd, Primary care: nurse-led telephone triage and advice out-of-hours, Nurs. Stand. 12 (1998) 41–45. [4] N. Wennike, E. Williams, S. Frost, M. Masding, Nurse-led triage of acute medical admissions: accurate and time-efficient, Br. J. Nurs. 16 (2007) 824–827. [5] J. Rendell, Implementing a nurse-led telephone advice system in ophthalmology, Insight 24 (1999) 112–119. [6] I.F. Hathorn, M.L. Barnes, R.E. Moutain, Nurse-led triage of otolaryngology out-patient referrals: an acceptable alternative, J. Laryngol. Otol. 123 (2009) 1160–1162. [7] G.N. Rajkumar, D.R. Small, I.G. Conn, Computerised triage in a prostate assessment clinic, Prostate Cancer Prostatic Dis. 7 (2004) 118–121. [8] V. Patterson, J. Humphreys, R. Chua, Email triage of new neurological outpatient referrals from general practice, J. Neurol. Neurosurg. Psychiatry 75 (2004) 617–620. [9] J. Sim, C.C. Wright, The kappa statistic in reliability studies: use interpretation, and sample size requirements, Phys. Ther. 85 (2005) 257–268. [10] J.R. Landis, G.G. Koch, The measurement of observer agreement for categorical data, Biometrics 33 (1977) 671–679. [11] K.R. Robinson, Nurse-managed primary care delivery clinics, Nurs. Clin. North Am. 35 (2000) 471–479. [12] H. Franks, The contribution of nurse consultants in England to the public health leadership agenda, J. Clin. Nurs.. 23 (2014) 3424–3448.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The effectiveness of nurse-led outpatient referral triage decision making in pediatric otolaryngology§ Paul Hong a,b,*, Krista Ritchie a, Cathy Beaton-Campbell a, Lynn Cavanagh a, James Belyea a, Gerard Corsten a a b
IWK Health Centre, Department of Surgery, Dalhousie University, Halifax, NS, Canada School of Human Communication Disorders, Dalhousie University, Halifax, NS, Canada
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 December 2014 Received in revised form 27 January 2015 Accepted 29 January 2015 Available online 7 February 2015
Objectives: To assess the effectiveness of nurse-led triage of outpatient referrals in an academic pediatric otolaryngology practice. Methods: Three hundred consecutive outpatient referrals were reviewed and triaged by two otolaryngology registered nurses and two attending pediatric otolaryngologists. The nurses received triage training. The referrals were triaged as ‘routine’ (to be seen within 2–3 months), ‘semi-urgent’ (to be seen within 6 weeks), or ‘urgent’ (to be seen within 2 weeks). Weighted Kappa statistics (correcting for chance agreement) were performed to assess for the degree of agreement. After the consultation visits, patient records were reviewed to determine whether any referrals had been inappropriately triaged by the nurses. Results: Overall, there was substantial agreement between all raters. Specifically, weighted Kappa statistics were as follows: surgeon 1, nurse 1: 0.708; surgeon 1, nurse 2: 0.670; surgeon 2, nurse 1: 0.762; surgeon 2, nurse 2: 0.647; nurse 1, nurse 2: 0.756; and surgeon 1, surgeon 2: 0.784. Review of patient charts after consultation showed that no referrals were deemed to be inappropriately triaged and no urgent cases had been missed. Conclusions: Our model of nurse-led triage of outpatient referrals was found to be effective and safe. Similar systems may be considered in other areas of medicine as a viable and acceptable alternative to the traditional physician-led triage practice. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nurse triage Nurse-led triage Outpatient referrals Surgical referrals Pediatric otolaryngology
1. Introduction Over the last decade, demand on the healthcare systems in the Unites States and Canada has changed significantly due to the aging population, rising costs, and physician shortages. To this end, nurses have been providing more advanced and independent care, thereby replacing some roles traditionally performed by physicians [1,2]. These adjunctive roles provided by nurses can be costeffective and may have the advantage of improving patient access and wait-times, as well as promoting physician productivity. One example of an expanded nursing role involves triaging of patient referrals. Specifically, nurse-led triage has been reported to
§
This study was presented at The Society for Ear, Nose and Throat Advances in Children Scientific Meeting in St. Louis, MO. * Corresponding author at: IWK Health Centre, 5850/5980 University Avenue, PO Box 9700, Halifax, NS, Canada B3K 6R8. Tel.: +1 902 470 0841; fax: +1 902 470 8929. E-mail address: [email protected] (P. Hong). http://dx.doi.org/10.1016/j.ijporl.2015.01.031 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
be safe and effective in primary care [3], acute medical admissions [4], and in some surgical specialities [5,6]. Many different triaging systems have been reported in the literature. It is a practice that has changed over time and many modifications have been instituted to increase the efficiency of the triage process. Some of these include telephone triage [3], computer-aided triage [7], and internet based e-mail triage services [8]. Yet, most subspecialty surgical centers still use the traditional triage system where the consulting physicians perform the triage duties [6]. The current study was conducted to assess the effectiveness and safety of nurse-led triage of outpatient referrals in an academic pediatric otolaryngology clinic.
2. Methods Three hundred consecutive outpatient referrals sent to our pediatric otolaryngology clinic were photocopied and distributed to the following raters: (1) two clinic nurses and (2) two staff
P. Hong et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 576–578
physicians (fellowship-trained pediatric otolaryngologists). Those referrals with additional information provided to one or more raters were excluded. For instance, referrals accompanied by a phone-call to one of the raters from the referring healthcare provider were deemed to be biased and thus not included in the study. Only the information on the referral document was used to triage patients. The two registered nurses who participated in this study are experienced in pediatric otolaryngology and also received triage training. Briefly, the training involved an informal session with one of the attending physicians (G.C.), followed by the two nurses reviewing referral letters, discussing each case and obtaining clarification from the physician if any issues arose. Soon afterwards, the two nurses started performing the primary triage duties independently. Specifically, the nurses collected the incoming referrals throughout the day from the clinic fax machine and triaged them accordingly. All referrals letters were triaged as ‘routine’ (to be seen within 2–3 months), ‘semi-urgent’ (to be seen within 6 weeks), or ‘urgent’ (to be seen within 2 weeks). During the study period, all four participants independently graded each referral letter as urgent, semi-urgent, or routine. Interobserver (for all combinations between raters, including nurse 1 vs. nurse 2, nurse 1 vs. surgeon 1, nurse 1 vs. surgeon 2, nurse 2 vs. surgeon 1, nurse 2 vs. surgeon 2, surgeon 1 vs. surgeon 2) agreement were then determined by calculating Kappa statistics. Specifically, weighted Kappa statistics between each rater for the three-level interval data (urgent, semi-urgent, routine) with 95% confidence intervals were calculated [9]. Standard one-tailed hypothesis testing only tests whether Kappa is significantly different than zero. We tested for significance with a two-tailed test, in order to see if agreement was significantly different than a predefined value of clinical importance. Because a Kappa of 0.4 is interpreted as moderate agreement [10], we set our null hypothesis to test that there is no difference between estimated Kappa and 0.4. An ‘‘almost perfect’’ Kappa estimate is conventionally defined as any agreement between 0.81 and 1.0 [10]. We aimed to have the lower bound of our 95% confidence interval remain within this almost perfect range. With this criterion, we would be 95% confident that the true level of agreement was within the almost perfect range. When too few ratings are performed, the confidence interval widens and commonly results in under-powered studies and lower than acceptable lower bound estimates on confidence intervals. For this reason, we used a large sample size of 300 consecutive referrals to calculate the Kappa statistics. After the consultation visits were completed on all 300 patients, their records were reviewed to ascertain whether any referrals were inappropriately triaged by the nurses and whether any truly urgent cases had been missed. Local Institutional Review Board approval was obtained for this study. 3. Results Six referrals were excluded due to more information about the referrals being available to one of the raters. Therefore to reach our sample size, a total of 306 consecutive outpatient referrals were included in the study. The referrals were collected during a 2month period in the pediatric otolaryngology clinic. Of the 300 referrals, 217 (72.3%) were from primary care physicians, 67 (22.3%) were from non-otolaryngology specialists (e.g., pediatricians, allergists), 13 (4.3%) were from otolaryngologists, and 3 (1%) were from audiologists or speech-language pathologists. Most referrals were triaged to be routine by all raters (Table 1). Specifically, of the 1200 triages performed in this
577
Table 1 Number of referrals triaged in each category by different raters. Raters
Routine
Semi-urgent
Urgent
Physician 1 Physician 2 Nurse 1 Nurse 2
248 239 234 237
50 60 63 60
2 1 3 3
study (300 triages by each of the four raters), 958 (79.8%) were considered to be routine. This was followed by 233 (19.4%) referrals being triaged as semi-urgent, and nine (0.8%) referrals being triaged as urgent. Regarding weighted Kappa statistics, the following criteria was used to evaluate the level of agreement: <0, none; 0–0.20, slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, substantial; and 0.81–1.0, almost perfect [10]. Overall, there was substantial agreements (0.647 to 0.784) between all rater combinations. Specifically, weighted Kappa statistics and the corresponding standard error (in parentheses) were as follows: surgeon 1 and nurse 1: 0.708 (0.050); surgeon 1 and nurse 2: 0.670 (0.054); surgeon 2 and nurse 1: 0.762 (0.045); surgeon 2 and nurse 2: 0.647 (0.053); nurse 1 and nurse 2: 0.756 (0.046); and surgeon 1 and surgeon 2: 0.784 (0.045). A retrospective review of the 300 patient records following their actual clinic appointments did not reveal any cases that had been deemed to be inappropriately triaged by the clinic nurses. Furthermore, no cases which should have been urgent were missed or under-triaged. 4. Discussion Over time, nurses have engaged in positions with more independence and responsibility [11]. This is demonstrated, for instance, by the expansion of the number of nurse practitioners in North America [1]. Furthermore, nurses have assumed leadership roles [12] and have taken over duties traditionally performed by physicians [2,6]. One such role is the triaging of outpatient referrals in healthcare settings. Specifically, nurse-led triage systems have become an established practice in many areas of medicine [3–5]. However, there remains a lack of formal evaluation of such models of care. Thus, more studies to ensure patient safety and efficiency of the nurse-led triage practice are required. To the best of our knowledge, the current study is the first one conducted in North America that assessed the triage role of outpatient referrals by nurses in a pediatric surgical setting. Overall, the findings showed that nurses and physicians had high degree of agreement when triaging outpatient referrals. This suggests that our nurses were able to demonstrate expert decisionmaking abilities even though physicians are considered the ‘goldstandard’ experts in performing triaging duties. Furthermore, no referrals were deemed to be mismanaged or inappropriately triaged by the nurses. That is, no truly urgent referrals were overlooked by the nurses, which verifies the safety of nurse-led triage system utilized in this study. Although the level of agreement between the nurses and the physicians was considered ‘substantial’ (weighted Kappa > 0.6), there was some variability noted between all rater combinations. Yet, the degree of variability was considered very minor in terms of weighted Kappa statistics [9]. Moreover, the level of agreement observed in the current study was better than previous studies in primary care and in the adult surgical setting, where inter-rater agreement was mostly considered ‘fair’ to ‘moderate’ [3,6]. Small variability also existed between the two physicians in our study (0.784), which was in keeping with previous studies [6]. This is
578
P. Hong et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 576–578
unsurprising since the triage process will always contain an element of subjectivity, and as such, it cannot be completely standardized [3]. In other words, there will always be some degree of inconsistency but the observed variability in our study was considered to be clinically insignificant. The outpatient referrals which led to disagreement between surgeons and nurses involved young children with otitis media and hearing/speech concerns and neck masses without systemic clinical features, such as weight loss or night sweats. Some of the raters triaged these children as semi-urgent, while others triaged them as routine. Interestingly, there was no consistent trend of either the nurses or surgeons triaging more conservatively or aggressively. Again, the rationale for this difference is most likely due to the subjective nature of the triaging process. There are many potential benefits of instituting a nurse-led outpatient referral triage system. Dedicated clinic nurses are usually present and available to receive and field referrals in the clinic, while the surgeon may be in the operating room or performing academic duties, such as teaching or research. Subsequently, physician-led triage process may occur on an adhoc basis, while the nurses can act in a more timely manner. In turn, such a system may reduce the workload of physicians, potentially allowing them to devote more time to performing other clinical or academic duties [6]. As well, there may be cost containment and improved efficiency since physician time is more costly to the healthcare system than that of nurses. A limitation of the present study is determining whether our results are generalizable to other clinical settings. It is unclear whether nurses in other pediatric otolaryngology clinics or other medical specialities will perform to the same degree. However, previous studies have demonstrated the effectiveness and safety of nurse-led triage practice in many other settings [3–6]. Therefore, we believe the current results may be valid outside of our clinic. Although we are confident in our nurse-led triage system, we make the following recommendations. First, the nurses should be non-casual employees who have had exposure to the specific area of medicine or healthcare. They should have appropriate triage training and also have a senior healthcare provider available to review any questionable referrals. For medicolegal purposes, this will usually be an attending physician. For referrals with high level of uncertainty, the nurses should be trained to error on the side of caution, as well as to discuss any concerns with the attending
physician. Finally, the triage practice should undergo regular audit or review to ensure that it continues to be safe and effective. 5. Conclusion Overall, there was substantial agreement between the nurses and the physicians when triaging outpatient referrals in our pediatric otolaryngology clinic. Furthermore, no referrals were deemed to be inappropriately triaged by the nurses. This indicates that nurse-led triage of outpatient referrals by experienced and trained nurses in our setting was found to be safe and effective. Similar models should be considered in other areas of medicine as a viable and acceptable alternative to the traditional physician-led triage practice. Funding There is no funding for this study. References [1] S.A. Weiland, Reflections on independence in nurse practitioner practice, J. Am. Acad. Nurse Pract. 20 (2008) 345–352. [2] A.P. Susilo, J. van Dalen, M.N. Chenault, A. Scherpbier, Informed consent and nurses’ roles: a survey of Indonesian practitioners, Nurs. Ethics 21 (2014) 684– 694 (2014). [3] J. Dale, R. Croutch, D. Lloyd, Primary care: nurse-led telephone triage and advice out-of-hours, Nurs. Stand. 12 (1998) 41–45. [4] N. Wennike, E. Williams, S. Frost, M. Masding, Nurse-led triage of acute medical admissions: accurate and time-efficient, Br. J. Nurs. 16 (2007) 824–827. [5] J. Rendell, Implementing a nurse-led telephone advice system in ophthalmology, Insight 24 (1999) 112–119. [6] I.F. Hathorn, M.L. Barnes, R.E. Moutain, Nurse-led triage of otolaryngology out-patient referrals: an acceptable alternative, J. Laryngol. Otol. 123 (2009) 1160–1162. [7] G.N. Rajkumar, D.R. Small, I.G. Conn, Computerised triage in a prostate assessment clinic, Prostate Cancer Prostatic Dis. 7 (2004) 118–121. [8] V. Patterson, J. Humphreys, R. Chua, Email triage of new neurological outpatient referrals from general practice, J. Neurol. Neurosurg. Psychiatry 75 (2004) 617–620. [9] J. Sim, C.C. Wright, The kappa statistic in reliability studies: use interpretation, and sample size requirements, Phys. Ther. 85 (2005) 257–268. [10] J.R. Landis, G.G. Koch, The measurement of observer agreement for categorical data, Biometrics 33 (1977) 671–679. [11] K.R. Robinson, Nurse-managed primary care delivery clinics, Nurs. Clin. North Am. 35 (2000) 471–479. [12] H. Franks, The contribution of nurse consultants in England to the public health leadership agenda, J. Clin. Nurs.. 23 (2014) 3424–3448.