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About two decades ago the Federal Circuit threw open the doors of the US Patent Office to business method patent applicants. State Street announced that methods that yield a useful, concrete, and tangible result would be eligible for patent protection.1 This decision roughly coincided with the birth of e-commerce and an explosion of business method patents in the USA. About a decade ago the Supreme Court stepped back from State Street by installing screens that blocked applicants from patenting business methods claimed as abstract ideas. Bilski2 characterized claims to a method of hedging against energy price fluctuation risk as abstract, and therefore not eligible for patent protection.3 All nine justices supported this result, but their opinions revealed a significant split on the question of whether any patents on business methods should be permitted. Three justices joined Justice Stevens who called for categorical exclusion of business methods from the patent system.4 Three other justices joined Justice Kennedy who praised business inventions from this new “Information Age” and fretted that overly strong screens to eligibility established during the “Industrial Age” were no longer appropriate.5 While recognizing the method at hand was claimed too abstractly to be patent eligible, these justices seemed confident that the future would bring forth many business method inventions deserving of patents.6 The ninth justice, Justice Scalia, found the middle ground; he did not join the portion of Kennedy’s opinion discussing the Information Age.7 Nor did he join Stevens by embracing a categorical exclusion of business methods.8
Emergency department (ED) triage prioritizes patients based on urgency of care, and the Canadian Triage and Acuity Scale (CTAS) is the national standard. We describe the inter-rater agreement and manual overrides of nurses using a CTAS-compliant web-based triage tool (eTRIAGE) for 2 different intensities of staff training.
Methods:
This prospective study was conducted in an urban tertiary care ED. In phase 1, eTRIAGE was deployed after a 3-hour training course for 24 triage nurses who were asked to share this knowledge during regular triage shifts with colleagues who had not received training (n = 77). In phase 2, a targeted group of 8 triage nurses underwent further training with eTRIAGE. In each phase, patients were assessed first by the duty triage nurse and then by a blinded independent study nurse, both using eTRIAGE. Inter-rater agreement was calculated using kappa (weighted κ) statistics.
Results:
In phase 1, 569 patients were enrolled with 513 (90.2%) complete records; 577 patients were enrolled in phase 2 with 555 (96.2%) complete records. Inter-rater agreement during phase 1 was moderate (weighted κ = 0.55; 95% confidence interval [CI] 0.49–0.62); agreement improved in phase 2 (weighted κ = 0.65; 95% CI 0.60–0.70). Manual overrides of eTRIAGE scores were infrequent (approximately 10%) during both periods.
Conclusions:
Agreement between study nurses and duty triage nurses, both using eTRIAGE, was moderate to good, with a trend toward improvement with additional training. Triage overrides were infrequent. Continued attempts to refine the triage process and training appear warranted.
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