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I have read the outstanding publication in the Rev Esc Enferm USP Journal from Silva et al. entitled “Triage in an adult emergency service: patient satisfaction”(1). The authors concluded that there was a high level of patient satisfaction. The patients being categorized in red and orange have been excluded from sampling, so it may result in undercoverage. Undercoverage occurs when all subgroups of the target population are not adequately represented in the sample. In Silva et al.’s study, only nonemergency patients (categories Yellow, Green and Blue) were included, so emergency patients (categories Red and Orange) were excluded from the study. The main focus of Emergency department (ED) is to provide emergency care to critically ill patients (Red and Orange cases) in a timely manner(2). Therefore it might be a major flaw in the research methodology to exclude emergency patients, especially Red and Orange cases, from the study. In fact, the undercoveraged target population may threaten the internal validity of the study of patient satisfaction in the ED. Therefore, it may be concluded that studies should not only include emergency patients but also should weigh the results based on patient acuity scores or triage categories. It is critical to interpret patient satisfaction results in regard to patient acuity. It would not be helpful if a patient with common cold is visited in less than 30 minutes, while it takes more than 10 minutes to perform an electrocardiogram for a patient with chest pain. Unfortunately, it`s not clear the association between waiting time and patient acuity with patient satisfaction in the current study. Often, there is a poor correlation between the results of the triage nurse’s evaluation and patients’ perception of their medical condition on the patient acuity level at the time of triage(3), so it is expected that nonemergency patients perceive dissatisfaction with waiting time in the ED. You may find even more exhausting to convince a patient with simple common cold to wait 240 minutes to see a physician. It is also worth mentioning that overcrowding might play a role as mediating variable and confounded the results. Finally, it is recommended that patient satisfaction be weighed by patient acuity in the emergency department in the future studies.

What if we miss the red and orange cases?