Emergency Severity Index Category Research Articles

Patient sex, racial and ethnic disparities in emergency department triage: A multi-site retrospective study

ObjectivesThere is limited evidence on sex, racial, and ethnic disparities in Emergency Department (ED) triage across diverse settings. We evaluated differences in the assignment of Emergency Severity Index (ESI) by patient sex and race/ethnicity, accounting for age, clinical factors, and ED operating conditions. MethodsWe conducted a multi-site retrospective study of adult patients presenting to high-volume EDs from January 2019–February 2020. Patient-level data were obtained and analyzed from three EDs (academic, metropolitan community, and rural community) affiliated with a large health system in the Southeastern United States. For the study outcome, ESI levels were grouped into three categories: 1–2 (highest acuity), 3, and 4–5 (lowest acuity). Multinomial logistic regression was used to compare ESI categories by patient race/ethnicity and sex jointly (referent = White males), adjusted for patient age, insurance status, ED arrival mode, chief complaint category, comorbidity score, time of day, day of week, and average ED wait time. ResultsWe identified 186,840 eligible ED visits with 56,417 from the academic ED, 69,698 from the metropolitan community ED, and 60,725 from the rural community ED. Patient cohorts between EDs varied by patient age, race/ethnicity, and insurance status. The majority of patients were assigned ESI 3 in the academic and metropolitan community EDs (61% and 62%, respectively) whereas 47% were assigned ESI 3 in the rural community ED. In adjusted analyses, White females were less likely to be assigned ESI 1–2 compared to White males although both groups were roughly comparable in the assignment of ESI 4–5. Non-White and Hispanic females were generally least likely to be assigned ESI 1–2 in all EDs. Interactions between ED wait time and race/ethnicity-sex were not statistically significant. ConclusionsThis retrospective study of adult ED patients revealed sex and race/ethnicity-based differences in ESI assignment, after accounting for age, clinical factors, and ED operating conditions. These disparities persisted across three different large EDs, highlighting the need for ongoing research to address inequities in ED triage decision-making and associated patient-centered outcomes.

Evaluation of Emergency Department Surge Spaces During the COVID-19 Crisis

Background: In response to the surge of COVID-19 patients in March and April 2020, our emergency department in New York City implemented a novel triage screening process to identify low acuity patients who could be diverted from the emergency department to a surge space. Patients who were (1) ≤ 70 years old; (2) triaged as Emergency Severity Index category 4 or 5, and (3) not requiring use of a stretcher (4) displaying mild COVID-19 symptoms were diverted to one of two surge spaces [West Surge Space (WSS) or Ambulatory Clinic Surge Space (ACSS)], where a complete set of vital signs were taken and an exam by a medical provider was conducted. Methods: From March 12 to April 20, 2020, we analyzed the total volume of patients diverted to the surge space and their discharge disposition (i.e., admitted to hospital, transfer to main emergency department, left against medical advice, discharged from a surge space, or expired). A receiver operator curve (ROC) was calculated to predict discharge disposition based on triage diversion to either surge space. Results: There were 6,241 patients triaged during the study period, in which one-quarter [n = 1,753 (26%)] were diverted to a surge space. The average number of patients per day was 141.8 (standard deviation [SD] 54.5) in the main emergency department and 39.8 (SD 29.9) in the surge spaces. Of the patients triaged and diverted to a surge space, a large proportion were successfully discharged from those areas without entering the main emergency department (84%, n = 866 in WSS and 94%, n = 745 in ACSS). Very few signed out against medical advice (3%, n = 26 in WSS and 2%, n = 12 in ACSS), transferred to the main emergency department (1%, n = 8 in WSS and 0.4%, n = 3 in ACSS), or admitted (13%, n = 130 in WSS and 4%, n = 30 in ACSS]. No patients expired in either surge space. The ROC analysis showed that the model had excellent discrimination power, with an area under the curve of 0.97 for WSS and 0.96 for ACSS. Conclusion: A novel triage screening process successfully diverted 26% of low acuity patients with mild symptoms of COVID-19 to surge spaces. Nearly 92% of these patients were successfully discharged without entering the main emergency department footprint.

Patients treated by general practitioners in auniversity emergency department before and after implementation of atriage system

In auniversity emergency department (ED), patients with low treatment urgency and general medical complaints are assigned to general practitioners within the ED. The Emergency Severity Index (ESI) was implemented to determine the urgency of treatment. To investigate the impact of the ESI implementation on the patient population treated by general practitioners and to show the distribution of ESI categories among these patients. Comparison of emergency patients treated by general practitioners over 6months before (t0) and after (t1) ESI implementation using routine data and an evaluation form to be completed by the general practitioner. The analysis was carried out descriptively and using the Χ2test and t‑test. At t0, 615 treatment cases and at t1 751cases were analyzed. There were no significant differences in age, gender, the proportion of patients being referred to ED, or hospital admissions. The ESI classification was predominantly in the low urgency categories ESI5 (37%) and ESI4 (46%), with 8% of patients in ESI3 or2. The predicted resource needs matched for 76% of patients in ESI5, for 36% in ESI4, and for 44% of patients in ESI3. Hospital admission was required for 3% of ESI 5patients and 7% of ESI 4patients. Even for patients with low treatment urgency, hospital admission may be indicated. In addition, differences from the predicted resource requirements indicate triaging problems in the patient population studied. Thus, the ESI assessment does not seem suitable to redirect patients to non-ED-based outpatient care.

Accuracy of Emergency Severity Index in older adults.

Background and importanceEmergency Severity Index is a five-level triage tool in the emergency department that predicts the need for emergency department resources and the degree of emergency. However, it is unknown whether this is valid in patients aged greater than or equal to 65 years.ObjectiveThe aim of the study was to compare the accuracy of the Emergency Severity Index triage system between emergency department patients aged 18–64 and greater than or equal to 65 years.Design, settings, and participantsThis was a retrospective observational cohort study of adults who presented to a Finnish emergency department between 1 February 2018 and 28 February 2018. All data were collected from electronic health records.Outcome measures and analysisThe primary outcome was 3-day mortality. The secondary outcomes were 30-day mortality, hospital admission, high dependency unit or ICU admission, and emergency department length of stay. The area under the receiver operating characteristic curve and cutoff performances were used to investigate significant associations between triage categories and outcomes. The results of the two age groups were compared.Main resultsThere were 3141 emergency department patients aged 18–64 years and 2370 patients aged greater than or equal to 65 years. The 3-day mortality area under the curve in patients aged greater than or equal to 65 years was greater than that in patients aged 18–64 years. The Emergency Severity Index was associated with high dependency unit/ICU admissions in both groups, with moderate sensitivity [18–64 years: 61.8% (50.9–71.9%); greater than or equal to 65 years: 73.3% (63.5–81.6%)] and high specificity [18–64 years: 93.0% (92.0–93.8%); greater than or equal to 65 years: 90.9% (90.0–92.1%)]. The sensitivity was high and specificity was low for 30-day mortality and hospital admission in both age groups. The emergency department length of stay was the longest in Emergency Severity Index category 3 for both age groups. There was no significant difference in accuracy between age groups for any outcome.ConclusionEmergency Severity Index performed well in predicting high dependency unit/ICU admission rates for both 18–64 years and greater than or equal to 65-year-old patients. It predicted the 3-day mortality for patients aged greater than or equal to 65 years with high accuracy. It was inaccurate in predicting 30-day mortality and hospital admission for both age groups.

Patient Characteristics and Clinical Process Predictors of Patients Leaving Without Being Seen from the Emergency Department.

IntroductionDelays in patient flow in the emergency department (ED) result in patients leaving without being seen (LWBS). This compromises patient experience and quality of care. Our primary goal was to develop a predictive model by evaluating associations between patients LWBS and ED process measures and patient characteristics.MethodsThis was a cross-sectional study in a 95,000 annual visit adult ED comparing patients LWBS, with controls. Data were drawn from four seasonally adjusted four-week periods (30,679 total visits). Process measures included 1) arrivals per hour; 2) “door-to-provider” time; and the numbers of 3) patients in the waiting room; 4) boarding ED patients waiting for an inpatient bed; 5) providers and nurses (RN); and 6) patients per RN. Patient characteristics collected included 1) age; 2) gender; 3) race/ethnicity; 4) arrival mode (walk-in or via emergency medical services [EMS]); and 5) acuity based on Emergency Severity Index (ESI). Univariable analyses included t-tests and Pearson’s chi-square tests. We split the data randomly into derivation and validation cohorts. We used backward selection to develop the final derivation model, and factors with a p-value ≤ 0.05 were retained. Estimates were applied to the validation cohort and measures of discrimination (receiver operating characteristic) and model fit were assessed.ResultsIn the final model, the odds of LWBS increased with the number of patients in the waiting room (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.03 to 1.06); number of boarding patients (OR 1.02; 95% CI, 1.01 to 1.03); arrival rate (OR 1.04; 95% CI, 1.02 to 1.05) and longer “door-to-provider” times (test of linear trend in the adjusted OR was p = 0.002). Patient characteristics associated with LWBS included younger age (OR 0.98; 95% CI, 0.98 to 0.99), and lower acuity (higher ESI category) (OR 2.01; 95% CI, 1.84 to 2.20). Arrival by EMS was inversely associated with LWBS (OR 0.29; 0.23 to 0.36). The area under the curve for the final model in the validation cohort was 0.85 (95% CI, 0.84 to 0.86). There was good agreement between the observed and predicted risk.ConclusionArrival rate, “door-to-provider time,” and the numbers of patients in the waiting room and ED boarders are all associated with patients LWBS.

Comparing Expert and Non-Expert Assessment of Patients Presenting with Neurological Symptoms to the Emergency Department: A Retrospective Observational Study.

ObjectiveReferrals to neurology in emergency departments (ED) are continuously increasing, currently representing 15% of all admissions. Existing triage systems were developed for general medical populations and have not been validated for patients with neurological symptoms.MethodsTo characterize neurological emergencies, we first retrospectively analyzed symptoms, service times and resources of the cohort of neurological referrals to a German interdisciplinary ED (IED) during 2017 according to urgency determined by final IED diagnosis. In a second step, we performed a retrospective assignment of consecutive patients presenting in April 2017 according to internal guidelines as either acute (requiring diagnostic/therapeutic procedures within 24 hrs) or non-acute neurological conditions as well as a retrospective classification according to the Emergency Severity Index (ESI). Both assessments were compared with the urgency according to the final ER diagnosis.ResultsIn a 12-month period, 36.4% of 5340 patients were rated as having an urgent neurological condition; this correlated with age, door-to-doctor time, imaging resource use and admission (p < 0.001, respectively). In a subset of 275 patients, 59% were retrospectively triaged as acute according to neurological expertise and 48% according to ESI categories 1 and 2. Neurological triage identified urgency with a significantly higher sensitivity (94.8, p < 0.01) but showed a significantly lower specificity (55.1, p < 0.05) when compared to ESI (80.5 and 65.2, respectively).ConclusionThe ESI may not take specific aspects of neurological emergency (eg, time-sensitivity) sufficiently into account. Refinements of existing systems or supplementation with dedicated neurological triage tools based on neurological expertise and experience may improve the triage of patients with neurological symptoms.

Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management.

Few studies have evaluated impact of emergency department (ED) management on delayed transfers to the pediatric intensive care unit (PICU). Our study objectives were to describe patient characteristics of PICU transfers less than or equal to 12 hours of admission and determine the reason for transfer. We conducted a retrospective chart review of patients transferred to PICU less than or equal to 12 hours of admission. We extracted patient demographics, emergency severity index category, ED, floor and PICU length of stay (LOS), and PICU "significant" interventions. Charts were reviewed independently by the study principal investigator and a PICU attending who classified transfers as secondary to progression of disease or error in ED management. Furthermore, errors were classified as diagnostic, management, or disposition errors. A total of 164 patients met inclusion criteria. Most were male (86/164, 52.4%), with emergency severity index category 2 (116/164, 70.7%) and respiratory diagnosis (98/164, 59.8%). Most transfers (136/164, 82.9%) resulted from progression of illness. No significant interventions were performed in 48.8% (80/164) of patients. Of 164 transfers, 28 (17.1%) resulted from ED error, and half of these were management errors. Compared with disease progression, the ED error group had a significantly shorter median floor LOS {3.45 [interquartile range (IQR): 2.15, 7.56] vs 6.58 (IQR: 3.70, 9.20); P = 0.005}, more PICU interventions [1.5 (IQR: 0, 4) vs 0 (IQR: 0, 2); P = 0.006], and longer PICU LOS [2.50 (IQR: 1.09, 4.25) vs 1.36 (IQR: 0.80, 2.50); P = 0.013]. Most PICU transfers less than or equal to 12 hours after admission result from illness progression. Half of these do not require significant interventions. The PICU transfers after ED management error had significantly shorter floor LOS, longer PICU LOS, and more interventions.

Exploring the Frequency of Blood Pressure Documentation in Emergency Departments

One of the most commonly performed task in the emergency department (ED) is reported as the monitoring of vital signs, yet there are no published standards of care that provide guidelines for the frequency of obtaining vital signs in the ED. The purpose of this exploratory study was to determine the frequency of documentation of vital signs recorded during ED visits across Veterans Health Administration (VHA) facilities. Deidentified patient level data from the VHA electronic health record (EHR) were abstracted for emergency department visits for 12 randomly selected days in calendar year 2011. The dataset included vital signs data, associated time stamps, facility, length of stay, triage category based on the Emergency Severity Index (ESI), and patient disposition for all patients. Descriptive statistics were used to describe the frequency of the specific vital sign measures, and parametric and nonparametric tests were used to examine study variables by ESI. The sample consisted of over 43,232 unique patient visits to 94 VHA EDs with a median length of stay of 173.3 min (interquartile range [IQR], 96.1-286.9). The mean number of times that blood pressure (BP) was recorded per visit was 1.23 (SD 1.175). For the entire sample, median time between blood pressure measurements was 139.7 min (IQR, 81.6-230.1). There was a significant difference in median length of stay and median time between blood pressure by ESI category. In this dataset, median time between documentation of BP in the ED was every 2.3 hr for all patients. While the median time was statistically significant between ESI categories, these times may not be clinically relevant. More important was the inconsistent documentation of vital signs of ED patients in the designated fields in the EHR. Most facilities (84.1%) documented BP for >75% of patient visits. However, eight facilities (9.1%) had BP documented in <50% of patient visits. It seems unlikely that vital signs are not monitored in the ED; nurses anecdotally report that vital signs are recorded on a paper chart and later scanned as an image into the EHR. However, lack of consistent process in documentation of vital signs may decrease the care team's ability to note early warning signs of physiological instability or deterioration.

Application of the emergency severity index in pediatric emergency department

Objective Demonstrate the implication of Emergency Severity Index (ESI) in pediatric emergency room (ER). Method ESI categories of 21 904 visitors to ER of Beijing Children's Hospital's international department were reviewed. SPSS statistic software was employed to compare the results of ESI categories by doctors and nurses separately using x2 analysis. Results There are highly consistency in ESI categories by doctors and nurses. ESI is an easy-learned and effective triage method. Conclusions ESI is capable in pediatric emergency room regarding recognizing serious cases and saving clinical resources. Key words: Pediatric; Emergency department; Triage; Categories; Severity; The Emergency severity index; Visit capacity; Clinical resources

Transporting Clinical Tools to New Settings: Cultural Adaptation and Validation of the Emergency Severity Index in German

To date, no German triage tool with proven reliability and validity exists. The goal of this project is to translate and culturally adapt the Emergency Severity Index (ESI) and to assess reliability and validity of the German version. The ESI was translated following principles recommended for the translation and cultural adaptation of instruments. We performed a prospective, single-center cohort study. Reliability was assessed by calculating Cohen's weighted κ for agreement of 2 experts who reviewed the triage nurses' notes. To assess validity, associations of the number of resources, hospitalization, admission to intensive care, length of stay, and mortality with the assigned ESI level were investigated. Only small cultural adaptations had to be made during the translation process. Interrater agreement was high (κ(w) = 0.985) in a sample of 125 patients. For the assessment of validity, a sample of 2,114 patients was used. Spearman's rank correlation coefficient between ESI category and number of resources was ρ = -0.567. The association (Kendall's τ) between ESI category and disposition, and hospitalization was τ = -0.429 and τ = -0.453, respectively. The areas under the curves for the predictive ability of the ESI for hospitalization in general and hospitalization to an ICU were 0.788 and 0.856, respectively. The association between emergency department length of stay and ESI category was also significant (Kruskal-Wallis χ² = 450.8; df = 4; P < .001). Furthermore, the association between ESI category and survival probability was significant (log-rank χ² = 36.06; df = 3; P < .001). Translation of the ESI following guidelines was feasible and resulted in a reliable and valid German version.

82: The Use of an Accelerated Triage and Treatment Protocol Decreases Left Without Being Seen Rates and Wait Times in Emergency Severity Index Category 3 Patients

82: The Use of an Accelerated Triage and Treatment Protocol Decreases Left Without Being Seen Rates and Wait Times in Emergency Severity Index Category 3 Patients

Reliability and validity of the emergency severity index triage algorithm in a pediatric population

Study objectives: As demand for emergency services has continued to outpace available allocated resources in recent years, emergency department (ED) triage systems have faced increasing scrutiny. Longer queues for care make the use of a reliable, valid triage system imperative to patient safety. Little is known about the reliability and validity of triage systems in children. The purpose of this study is to evaluate the reliability and validity of the Emergency Severity Index (ESI) triage algorithm in a pediatric population. Methods: This 2-phase investigation used a methodologic design. In the first phase, interrater reliability was evaluated using ED triage scenarios, as well as in a prospective cohort of ED patients presenting to triage. ED triage nurses and nurse and physician investigators performed retrospective blinded triages using only the original triage note to assess reproducibility. In phase 2, validity was assessed using a retrospective analysis of observed resource use, ED length of stay, and hospitalization compared with resource utilization estimated at triage by the ESI. Results: During the validity phase, 510 patients were included in the final data analysis. Hospitalization, ED length of stay, and resource utilization were strongly associated with ESI category. In the reliability phase, weighted κ for ED nurse triage of standard scenarios ranged from 0.84 to 1.00, representing excellent agreement. Twenty ED pediatric patients were triaged simultaneously by an ED triage nurse and the nurse investigator. Weighted κ was 0.82 (95% confidence interval 0.66 to 0.98), also representing strong agreement between raters. Conclusion: When used to triage pediatric patients, the ESI triage algorithm demonstrated both reliability and validity in this tertiary care pediatric population.

Association of emergency severity index versus three triage category with emergency department charges in a pediatric population

Study objectives: The objective of this study is to determine the association between Emergency Severity Index (ESI) versus 2 triage assignment and emergency department (ED) charges in an ED pediatric population. Methods: This retrospective health records survey was approved by the hospital institutional review board. All pediatric patients, defined as those younger than 14 years, presenting to the hospital ED during a 1-month period in 2003, were considered for inclusion. Patients who left without being seen by a physician, left before their evaluation could be completed, whose ED record n was unavailable were excluded from analysis. Demographic and billing information, including professional and facility fees, and disposition were assessed through structured medical rewas missing, or whose billing informatiocord abstraction performed in a defined sequence by trained reviewers. Data were analyzed using SPSS for Windows version 11.0 statistical software. Results: Five hundred two patients were identified for inclusion during the study period. Twenty-seven patients were excluded for missing billing data, left without being seen, left before completion of evaluation, being registered in error, missing ESI categories, or being billed at a separate campus, leaving 475 patients for final data analysis. Mean ED charges for the 14 ESI-1 patients were $1,256 (95% confidence interval [CI] $969 to $1,544); for the 84 ESI-2 patients were $589 (95% CI $474 to $704); for the 168 ESI-3 patients were $367 (95% CI $326 to $409); for the 176 ESI-4 patients were $305 (95% CI $281 to $330); and for the 33 ESI-5 patients were $247 (95% CI $210 to $285). Conclusion: ESI triage assignment was associated with ED charges in this pediatric population. Additional analysis is warranted to determine the association between ESI category and actual nursing, physician, and direct costs of caring for this patient population.