The comparability of emergency department waiting time performance data

TO THE EDITOR: In their recent article on emergency department (ED) waiting time performance data, Greene and Hall1 proposed that “assigning patients to a less urgent triage category than is appropriate” is a possible explanation for observed variations in waiting time performance. In Australia, triage decisions are made on the basis of clinical urgency. The Australasian Triage Scale is underpinned by a robust body of research and a national triage education program.2 Applying the scale supports clinical processes in the ED, ensures equity of access to health care resources on the basis of urgency and optimises the efficient delivery of ED services. Importantly, organisational imperatives and ED performance targets have no place in triage decision making. Undertriage places patients at increased clinical risk and places triage clinicians at medicolegal risk, so is an undesirable and uncommon decision outcome. The only Australian study that has compared independent triage nurse categorisations made during real triage episodes showed that overall agreement was 60.1% (among 939 patients) and that patients were more often overtriaged (31.2%) than undertriaged (8.7%).3 Greene and Hall’s claim that “there has been documented gaming of other hospital performance indicators in Australia, and of ED performance overseas”, referenced to articles by Curtis and colleagues4 and the British Medical Association,5 is unsubstantiated. Neither of these source articles provides any objective research evidence of undertriaging to meet ED performance targets.