Skip to main content

Reliability and validity of an Italian four-level emergency triage system


The goal of this study is to assess the reliability and validity of a four-level emergency triage system (Urgency Category (UC) 1 = immediate response; UC 2, 3 and 4 assessment within 20, 60 and 120 minutes respectively) used in an Italian large urban hospital with 60,000 emergency department (ED) visits annually.


Three triage nurses, using our triage system, independently assigned, at the same time, triage scores to each patient admitted to the ED from June to August 2011. We collected demographic and clinical characteristics, nurse triage category, resources used for each triage code (for example, laboratory tests, EKG, radiographs, procedures), admission status and site, nurse triage forms that included presenting complaint, vital signs, and pain score. For each scenario, the most frequent UC (the mode) has been considered as true triage. Weighted kappa (K) was used to calculate inter-rater reliability. Validity was evaluated by studying the relationships between the triage category assigned by the nurses and resource consumption.


A total of 315 patients admitted to the ED were included in the study randomly (35 were excluded for incomplete data). Mean age was 47 years. Five patients were admitted to the ICU, 48 to nonintensive units. Trauma was the most frequent symptom at triage (44%). The mean time of rating was 2 minutes. The UCs assigned were: 14% with UC 4, 60% UC 3, 25.7% UC 2, 0.3% UC 1. We found 2/315 (0.6%) cases with a marked discordance (2 or more points), 69/315 (21.9%) cases with partial agreement (2/3) and 244/315 (77.5%) cases with a complete agreement (5/5) among nurses who used the triage method. Interrater reliability among the three nurses was K = 0.71 (CI: 0.58 to 0.84). Hospital admission by our triage system was as follows: 1 (100%), 2 (30%), 3 (12%), 4 (2%). The mean of resources used for each triage code was: 4.5 (SD 2.2) for UC 2; 3.2 (SD = 1.67) for UC 3; 1.89 (SD 0.84) for UC 4.


Our triage system shows a good interrater reliability and validity in predicting resource consumption. To our knowledge, this is the first prospective Italian study that tests the relationships between the triage category assigned by the nurses (using a four-level triage method) and resource consumption.

Author information



Corresponding author

Correspondence to N Parenti.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Parenti, N., Rastelli, G., Ferri, C. et al. Reliability and validity of an Italian four-level emergency triage system. Crit Care 16, P482 (2012).

Download citation

  • Published:

  • DOI:


  • Emergency Department
  • Resource Consumption
  • Interrater Reliability
  • Weighted Kappa
  • Triage System