306 Assessment of Emergency Department Anaphylaxis Patient Triage Based on the Emergency Severity Index

Abstract

Early recognition and treatment of anaphylaxis is crucial. Delayed epinephrine administration for anaphylaxis allows progression of symptoms and has been associated with worse outcomes and increased mortality. Emergency department (ED) triage is a crucial step in management and ensures rapid assessment and resource allocation to the most critical patients. The Emergency Severity Index (ESI) is a common ED triage assessment tool that categorizes patients into one of five levels. Patients with the highest acuity are triaged as levels 1 and 2 while patients in levels 3, 4, and 5 are categorized based on expected resource utilization. The study objective was to assess ED triage of anaphylaxis patients and determine characteristics associated with higher versus (vs) lower triage levels. A cohort study including prospectively and retrospectively enrolled patients was conducted between 2010 and 2018 at a quaternary care academic ED with 77,000 annual patient visits. Patients were included if they met anaphylaxis diagnostic criteria for anaphylaxis. Patient health records were reviewed to evaluate patient demographics, inciting trigger, ESI triage level, out-of-hospital management, presenting signs and symptoms, ED management, and disposition. Prospectively enrolled patients and their ED providers also completed questionnaires regarding reaction characteristics and out-of-hospital treatment. Logistic regression analysis was performed to compare patient characteristics and management between patients triaged as ESI levels 1 or 2 vs levels 3 or 4. Data are summarized with descriptive statistics and corresponding odds ratios (ORs) with 95% confidence intervals (CIs). A total of 1104 patients met anaphylaxis diagnostic criteria and were eligible for study inclusion, of which 71% were enrolled retrospectively and 29% prospectively. The mean patient age was 34 years, 28% of patients were children (under 18 years of age), and 57% were female. Overall, 72% of patients received epinephrine (either prior to or after ED arrival). ESI triage levels of 1, 2, 3, 4, and 5 were assigned in 26 (2%), 517 (47%), 499 (45%), 62 (6%), and 0 (0%) of visits, respectively. There was no significant difference in ESI level assignment between prospectively and retrospectively enrolled patients. Patients assigned an ESI level of 3 or 4, compared to those with an ESI level of 1 or 2, had a longer median time from ED arrival to epinephrine administration (31 minutes [IQR 16-57] vs 13 minutes [IQR 7-13], [p < 0.01]), were more likely to be children (32% vs 24%; OR 1.50, 95% CI [1.15-1.96]), less likely to receive epinephrine in the ED (41% vs 53%; OR 0.62, 95% CI [0.49-0.78]), more likely to have an unidentified trigger (25% vs 18%; OR 1.45, 95% CI [1.08-1.93]), less likely to have angioedema (55% vs 63%; OR 0.74, 95% CI [0.58-0.94]) and less likely to report dyspnea (59% vs 66%; OR 0.74; 95% CI [0.58-0.94]), or throat tightness (45% vs 54%; OR 0.71; 95% CI [0.56-0.89]). An ESI triage level of 3 or 4 was associated with an increased time to epinephrine administration in patients presenting to the ED with anaphylaxis. Forty-one percent of patients triaged as ESI level 3 or 4 received epinephrine in the ED suggesting undertriage of a substantial proportion of anaphylaxis patients. Children and patients with an unidentified allergic trigger were more likely to be triaged as level 3 or 4.