Current recommended treatment for middle-third clavicle fractures is limited to the use of ice, analgesics, a sling, and rest. Radiography for these fractures would be superfluous if physicians could accurately identify them by clinical examination alone. The primary purpose of this study was to determine whether emergency physicians can accurately diagnose clavicle fractures, and whether they can differentiate middle-third fractures from medial- or lateral-third fractures by clinical assessment alone.

We enrolled a convenience sample of patients who presented to our rural emergency department with possible clavicle fracture between Nov. 1, 2001, and Apr. 30, 2002. Prior to viewing radiographs, physicians scored their clinical certainty of diagnosis on a 10-cm visual analogue scale. When certain of fracture, physicians determined the location of the fracture, the nature of the fracture and their hypothetical comfort in treating the injury without radiography.

In 51 of 77 enrolled patients (66%; 95% confidence interval [CI], 54.6%–76.6%), treating physicians were certain of the diagnosis of clavicle fracture prior to radiography. In these 51 cases, radiography revealed a fracture in 50 cases (98.0%; 95%CI, 89.6%–99.9%). The physicians were 100% accurate for 4 fractures clinically identified as lateral-third fractures (95% CI, 39.7%–100%) and for 41 fractures identified as middle-third fractures (95% CI, 91.4%–100%). They were correct on only 1 of 5 injuries (20%; 95% CI: 1%–72%) they clinically identified as medial-third fractures. Despite high clinical accuracy with middle-third fractures, they stated in 27 of 42 cases (64%; 95%CI, 48.0%–78.5%) that they would have been uncomfortable treating the patient without a radiograph.

This study provides evidence that experienced emergency physicians are highly accurate when they are clinically certain of clavicle fracture. Further, when emergency physicians do clinically diagnose clavicle fracture, they can accurately identify the patient subgroup that will be responsive to conservative treatment. Routine radiography of obvious middle-third clavicle fractures does not appear to improve diagnostic accuracy or treatment decisions.

To assess the performance of the newly implemented Canadian Emergency Department Triage and Acuity Scale (CTAS) triage system in a redesigned 200-bed community hospital emergency department (ED) and to evaluate the predictive validity of CTAS in this setting.

Triage system performance was analyzed on the basis of 4 quality indicators: time to triage; triage duration; proportion of patients who left without being seen by a physician; and waiting time to nurse and physician, stratified by triage level and reported as fractile response rates. The predictive validity of CTAS was evaluated by investigating the relationship between CTAS level, hospitalization index, ED length of stay (LOS) and diagnostic test utilization.

During the study period, 32 574 patients were triaged and 32 261 were eligible for study. Eighty-five percent were triaged within 10 minutes, and 98% had a triage duration of ≤5 minutes. Waiting times to nurse and physician were within CTAS time objectives in 96.3% and 92.3% of cases respectively. The left without being seen (LWBS) rate was 0.96%. Hospitalization rates were compatible with CTAS standards for adults in Levels I, II, III and V and for children in Level V. Median LOS and laboratory test utilization were highly correlated with CTAS Levels II to V (p < 0.01), and similar correlation between triage acuity and imaging utilization was noted in adult patients with non-traumatic non-musculoskeletal complaints (p < 0.01).

The CTAS is adaptable to countries beyond Canada and its operating objectives are achievable. Time to triage and fractile response rates can be considered indicators of triage quality and ED performance. CTAS is a valid instrument for predicting admission rates, hospital LOS and diagnostic utilization.

Triage reliability studies typically use hypothetical scenarios and weighted kappa scores where agreement within one level is considered satisfactory. But if triage category is used to help define ED case-mix groups for comparative or benchmarking processes, agreement on exact triage level and major system involved is important. Our hypothesis was that a computerized menu that links presenting complaints to preferred triage levels (PC-linked triage) would provide high triage reliability.

Our objective was to assess inter-rater reliability of PC-linked triage using the Canadian Emergency Department Triage and Acuity Scale (CTAS) in a real-time clinical setting, considering agreement on exact triage level and primary body system involved.

On duty triage nurses entered patient presenting complaint and PC-linked triage level as per standard procedure. In a convenience sample of patients, a second nurse, blinded to triage assignment, observed the triage interaction and independently entered presenting complaint and triage level on a dummy terminal.

During the study, 15 nurse pairs triaged 266 patients. Study patients matched actual emergency department case mix closely. Triage nurses agreed exactly in 74% of cases and within one level in 94% of cases. The unweighted kappa value was 0.66 (95% confidence interval [CI], 0.60–0.73) and the quadratic weighted kappa value was 0.75 (95% CI, 0.68–0.81). Kappa for agreement on major system involved was 0.80 (95% CI, 0.69–0.91).

PC-linked triage has high inter-rater reliability in a real-time clinical setting. PC-linked triage may be useful as one factor in defining case-mix groups for benchmarking and comparative purposes.