Abstract
Our objective was to compare informal physicians’ disease severity ratings (PDSR) at presentation with the well-established Emergency Severity Index (ESI) in order to test for non-inferiority of the discriminatory ability regarding hospitalization, intensive care, and mortality. We made a prospective observational study with consecutive enrollment. At presentation, the PDSR and subsequently Emergency Severity Index (ESI) levels were recorded. The primary outcome was the non-inferiority of the discriminatory ability (PDSR versus ESI) regarding hospitalization, intensive care, and mortality. The secondary outcomes were the reliability, the predictive validity, and the safety of PDSR. We included 6859 patients. The median age was 51 years (interquartile range (IQR) = 33 to 72 years); 51.4% were males. There were 159 non-survivors (2.4%) at the 30 day follow-up. The PDSR’s discriminatory ability was non-inferior to the ESI’s discriminatory ability. The safety assessment showed mortality of <0.5% in low-acuity patients in both tools. The predictive validity increased by 3.5 to 7 times if adding high-acuity PDSR to ESI in all categories with mortality of >1%. Our data showed the non-inferiority of PDSR compared with ESI regarding discriminatory ability, a moderate reliability, and an acceptable safety of both tools.
Highlights
Out of the 7131 patients enrolled, we excluded 14 patients who were not undergoing formal Emergency Severity Index (ESI)-triage and 258 patients that were not rated by a physician, without physicians’ disease severity ratings (PDSR)
The main finding of this study is the non-inferiority of PDSR compared to ESI triage regarding predictive validity in an all-comer emergency departments (EDs) population
Both systems have weaknesses: In our cohort, partially due to system failures of ESI, mortality in “low-acuity” ESI 4 and 5 patients (0.2% in real life, 0.1% according to expert triage) was not completely excluded
Summary
The standardized use of formal triage is often unable to identify high-acuity patients within the recommended time-frame [1]. During times of crowding, waiting for triage hampers the timely identification of time-critical conditions, which is associated with adverse outcomes [2]. Crowding was shown to occur in up to 50% of all shifts in larger emergency departments (EDs) [3]. Crowding may have detrimental effects—e.g., on recommended door-to-balloon time in patients with ST-elevated myocardial infarction (STEMI) [4]. Possible solutions may be an increase of staff at triage, medical team evaluation [5], or accelerating the triage process
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