Impact of the referral letter on triage decisions in adult patients admitted to the emergency room

Introduction: We conducted a two-month prospective study (8,171 admissions) in the Angers university hospital emergency room to analyse the impact of the referral letter on the initial triage of patients admitted to the emergency room performed by the reception and triage nurse. Methods: We analysed the level of priority of the CIMU triage scale (nurse's classification of emergency room patients), the presenting complaint, and the need for an urgent procedure before and after reading the referral letter and examined the nurse's comments for explanations concerning any triage changes. Results: 1,516 patients arriving with a referral letter (18.5% of admissions) were included and interpretable data were available for 756 of these cases. After reading the referral letter, nurses modified the CIMU triage level for 34 (4.5%) patients, the presenting complaint for 50 (6.6%) patients and eliminated the need for an urgent procedure for 70 (9.3%) patients. No significant difference was observed concerning the choice of the CIMU triage level (p = 0.908). However, changes in triage level were significantly more frequently towards a more urgent category (p = 0.005). Analysis of the nurse's comments showed that these results can be explained by the signs of severity indicated in the referral letter. Certain histories and/or diagnostic hypotheses appeared to lead nurses to eliminate the need for an urgent procedure. Conclusion: In this study, the referring physician's letter had a limited impact on the choice of triage level defined by the nurse on admission to the emergency room except for patients in whom the referral letter mentioned signs of severity, not observed at reception, led the nurse to apply a more urgent triage level. It would be interesting to study the information contained in the referral letter, useful for triage of patients admitted to the emergency room, in order to improve the impact of the referral letter on the quality of triage.