Emergency Severity Index Level Research Articles

Optimizing Triage: Assessing Shock Index, Pediatric Age-Adjusted as an Adjunct to Improve Emergency Severity Index Mistriage.

We investigated the diagnostic value of shock index, pediatric age-adjusted (SIPA) in predicting Emergency Severity Index level 3 patients' outcomes. Secondary objectives included exploring the impact of fever and participant variables on SIPA's predictive ability. A retrospective chart review identified children aged 1 to 15 years triaged as a level 3 in the emergency department between January 2018 and December 2021. Shock index, pediatric age-adjusted thresholds based on age, 1 to 6 years (>1.2), 7 to 12 years (>1.0), and 13 to 17 years (>0.9), were used. We assessed elevated SIPA and SIPA corrected for fever to evaluate associations with outcomes and interventions. Our findings, involving 192 patients, revealed that elevated SIPA demonstrated enhanced discrimination relative to nonelevated SIPA. Patients with elevated SIPA had more average interventions: 1.14 versus 0.74, P < 0.016; average interventions using SIPA corrected for fever: 1.14 versus 0.77, P < 0.006; average interventions controlling for race and sex: 1.15 versus 0.71, P < 0.001; hospital admission: 64.4% versus 42.9%, P = 0.004; hospital length of stay (LOS): 3.06 days (SE, 0.42) versus 1.46 days (SE, 0.23); hospital LOS using SIPA corrected for fever: 2.75 days (SE, 0.44) versus 1.72 days (SE, 0.24); ventilatory support: 16.44% versus 3.36%, P < 0.002; fluid bolus: 28.77% versus 14.29%, P < 0.015; intravenous medications (antibiotics, antiepileptics, immune globulin, albumin): 45.21% versus 30.25%, P < 0.036. There was no difference between other interventions, pediatric intensive care admission, and LOS between the 2 groups. Importantly, SIPA was unaffected by fever, race, or sex. Shock index, pediatric age-adjusted identifies level 3 Emergency Severity Index pediatric patients more likely to require hospital admission, longer LOS, and a lifesaving intervention especially ventilatory support, intravenous fluids, or specific intravenous medications. Shock index, pediatric age-adjusted's predictive ability remained unaffected by fever, race, or sex, making it a valuable tool in preventing mistriage and justifying inclusion in the Emergency Severity Index danger zone vitals criteria for up-triage.

Low-Acuity Pediatric Emergency Department Utilization: Caregiver Motivations.

Proper emergency department (ED) utilization is a hallmark of population health. Emergency department overcrowding due to nonurgent visits causes increased stress to healthcare staff, higher costs, and longer wait times for more urgent cases. This study sought to better understand post pandemic reasons caregivers have when bringing in their children for nonurgent visits and devise effective interventions to improve caregiver choice for non-ED care for nonurgent conditions. Surveys were conducted at an urban pediatric hospital for Emergency Severity Index (ESI) level 3 to 5 visits. A total of 602 surveys were completed with 8 being excluded from analysis. Survey responses and anonymized demographic information were collected. Responses were compared between surveys grouped by respondent age category, relation to child, child's race, insurance type, and ESI levels. Primary reasons given for nonurgent ED visits were perceived urgency (74.2%, n = 441), ED superiority to other locations (23.9%, n = 142), and referral to the ED by a third party (17.7%, n = 105). Of those who cited perceived urgency as a reason, 80.5% (n = 355) wanted to lessen their child's pain/discomfort as soon as possible, but only 13.6% said that their child was too ill to be seen anywhere else (n = 60). Demographic differences occurred in the proportions of respondents citing some of the primary and secondary reasons for bringing their child to the ED. This study highlights 3 key findings. An immediate desire for care plays a key role in caregiver decision making for low-acuity visits. There is potential socioeconomic and racial bias in where care is recommended that needs to be further explored in this region. Cross community interventions that target key reasons for seeking low-acuity care have the highest likelihood of impacting the use of the ED for low-acuity conditions.

Triage Accuracy in Pediatrics Using the Emergency Severity Index

IntroductionAlthough the Emergency Severity Index is the most widely used tool in the United States to prioritize care for patients who seek emergency care, including children, there are significant deficiencies in the tool’s performance. Inaccurate triage has been associated with delayed treatment, unnecessary diagnostic testing, and bias in clinical care. We evaluated the accuracy of the Emergency Severity Index to stratify patient priority based on predicted resource utilization in pediatric emergency department patients and identified covariates influencing performance. MethodsThis cross-sectional, retrospective study used a data platform that links clinical and research data sets from a single freestanding pediatric hospital in the United States. Chi-square analysis was used to describes rates of over- and undertriage. Mixed effects ordinal logistic regression identified associations between Emergency Severity Index categories assigned at triage and key emergency department resources using discrete data elements and natural language processing of text notes. ResultsWe analyzed 304,422 emergency department visits by 153,984 unique individuals in the final analysis; 80% of visits were triaged as lower acuity Emergency Severity Index levels 3 to 5, with the most common level being Emergency Severity Index 4 (43%). Emergency department visits scored Emergency Severity Index levels 3 and 4 were triaged accurately 46% and 38%, respectively. We noted racial differences in overall triage accuracy. DiscussionAlthough the plurality of patients was scored as Emergency Severity Index 4, 50% were mistriaged, and there were disparities based on race indicating Emergency Severity Index mistriages pediatric patients. Further study is needed to elucidate the application of the Emergency Severity Indices in pediatrics using a multicenter emergency department population with diverse clinical and demographic characteristics.

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.

Elimination of Emergency Department Ambulance Divert during the COVID-19 Pandemic Was Not Associated with an Increase in the Average Number of Ambulance Arrivals Per Day

: Introduction During the COVID-19 pandemic, ambulance divert in our EMS system reached critical levels. We hypothesized that eliminating ambulance divert would not be associated with an increase in the average number of daily ambulance arrivals. Our study objective was to quantify the EMS and emergency department (ED) effects of eliminating ambulance divert during the COVID-19 pandemic. Methods Regional hospital divert data were obtained for the 10-county Twin Cities metro from MNTrac, a state-supported online system designed to allow hospitals to indicate their divert status to EMS. ED metrics are reported for a single Level I trauma center and were obtained by a deidentified data pull from our electronic medical record covering the 12 months prior to the elimination of divert (2021) and the 12 months after divert elimination (2022). The decision to eliminate divert occurred in November 2021, based on data available through October, with an implementation date of January 2022. The primary study outcome was to quantify the effect of the elimination of divert on the number of ambulances arriving per day at the study hospital. Results Regional utilization of ambulance divert increased steadily by 859% from January to October 2021 when 355 individual divert events occurred, totaling 809 hours (34 days). There was no significant difference in the number of ambulances that arrived to the study hospital in 2021 (30,774) vs 2022 (30,421) p = 0.15. As compared to 2021, in 2022 there was no significant increase in mean ambulance arrivals per day (84/day vs 83/day, p = 0.08), time to room Emergency Severity Index level 2 (ESI) patients (28 min vs 28 min, p = 0.90), or time to obtain emergent head CT in acute “code stroke” patients (12 min vs 12 min). Ambulance turnaround interval in the ED did not appreciably increase (16 min vs 17 min, p = 0.15). Conclusion Elimination of ambulance divert was not associated with increases in the number of mean daily ambulance arrivals or EMS turnaround intervals, delays in ESI 2 patients being placed in beds, or prolonged time to head CT in stroke code patients.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BackgroundThe end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. ObjectiveThis study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. MethodsThe study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. ResultsThe study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1–46.3%; p < 0.001) and 22.1% (95% CI 19.3–26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1–3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. ConclusionsTotal adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Factors Associated with Overutilization of Computed Tomography of the Cervical Spine.

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model. Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule. Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture. Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.

Cognitive biases regarding utilization of emergency severity index among emergency nurses

AimThe study aimed to measure emergency nurses' prevalence of cognitive biases when utilizing Emergency Severity Index (ESI). Moreover, the study aimed to measure the differences between cognitive biases and demographic variables. BackgroundNurses use Emergency Severity Index (ESI) to prioritize the patients. Cognitive biases could compromise the clinical decisions of nurses in triage. Consequently, this hinders the delivery of safe and quality patient care. MethodsA cross-sectional analytical approach invited 208 emergency nurses from four tertiary care hospitals. Institutional review board approval and permission from institutional heads were obtained. Informed consent was attained before data collection. Data was collected through a structured scenario-based questionnaire to measure cognitive biases at five levels of ESI. Descriptive and inferential statistics were obtained through v25.0 of SPSS. ResultsAmong the 86.6% response rate, 56.2% of nurses were male. 62.90% had nursing diplomas. Cognitive biases were present at all ESI levels one to five, in order 51%, 45%, 90%, 89%, and 91% among nurses. Premature closure 22%, tolerance to risk 12%, satisfying bias 25%, framing effect 22%, and blind obedience 34% from level one to five consecutively. Demographic variables, including males, experience between 2 and 5 years, general nursing as qualification, and without emergency severity index certification, were identified to encounter more cognitive biases when making triage decisions. ConclusionNumerous cognitive biases are considerably existing among emergency nurses when prioritizing patients. Cognitive de-biasing measures can improve triage decisions among nurses that could enhance quality care and patient safety.

Both acuity and long term prognosis are important Emergency Department metrics: comparison of mobility assessment with the Emergency Severity Index

Objective: To compare the SUHB mobility scale (i.e., stable(S), unstable gait(U), needing help to walk(H), or bedridden(B)) and the Emergency Severity Index (ESI) associations with admission and mortality outcomes. Design: Post-hoc analysis of a prospective observational study including all consenting presenting to the ED over a period of 3 weeks. Odd ratios and AUCs were calculated to assess predictive performance of SUHB and compared with ESI. Results: Out of 2422 patients, 65% presented with a stable gait, 45% with an ESI level 3. With increasing mobility impairment on the SUHB scale, the probability for admission and mortality increased. SUHB had a higher AUC than ESI for 1-year mortality. Conclusion: SUHB was a better predictor than ESI of long-term mortality. The scale, which is rapid, requires little additional training, and no extra costs, could be used as a useful supplement to the triage process.

A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients

BackgroundPalliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED).MethodsThis prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1–3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan–Meier and log-rank tests.ResultsA total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16–8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 − 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03–19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84–3.77.ConclusionsAmong older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.

Emergency Severity Index (ESI) algorithm in trauma patients: The impact of age during the pandemic

ObjectiveThe ESI algorithm is widely used to triage patients in the emergency room. However, few studies have assessed the reliability of ESI to accurately triage trauma patients. The aim of this study was to compare vital signs, resource utilization, and patient outcomes among trauma patients during the pandemic in 2020 vs. the previous year prior to the pandemic. MethodsThis retrospective study was conducted over a 24-month period at an urban adult level one trauma center. Demographic and clinical characteristics, resource utilization, and patient outcomes were extracted from the electronic medical records and trauma registry. Trauma patients assigned ESI level 2 were stratified by age (<65 years and ≥ 65 years) and year (2019 vs. 2020) for data analysis. ResultsA total of 3,788 trauma patients were included in the study. Males represented 68.4% (2,591) of patients and the median age was 50 years (IQR: 31, 69). The majority of patients were assigned ESI level 2 (2,162, 57.1%) and had a blunt mechanism of injury (3,122, 82.4%). In 2020, patients <65 years of age utilized less resources compared to 2019 (p < 0.001). Likewise, patients >65 years of age required less lab tests [OR: 0.1, 95% CI: (0.05 – 0.4)], IV fluids [OR: 0.2, 95% CI: (0.2 -0.3)], IV medications [OR: 0.6, 95% CI: (0.4 - 0.7)], and specialty consultations [OR: 0.4, 95% CI: (0.3 -0.5)] compared to 2019 (p < 0.0001). Within 2020, vital signs and resources utilized between younger and elderly patients varied significantly (p < 0.01). Correspondingly, the clinical outcomes between younger and elderly patients within 2020, differed significantly (p < 0.01). ConclusionsThe COVID-19 pandemic affected the triage of trauma patients. During 2020, patients utilized less resources compared to the previous year. Additionally, younger and elderly patients had different vital signs, resource utilization, and clinical outcomes although both being assigned ESI level 2. Younger trauma patients may have been over-triaged in 2020 due to the COVID-19 pandemic.

Using Model Classification to detect Bias in Hospital Triaging

Background: In light of the COVID-19 pandemic and the health crisis left in its wake, our goal is to develop extensive machine-learning techniques to provide a clear picture of the treatment, and possible mistreatment, of specific patient demographics during hospital triaging. Objective: We aim to reveal whether a patient’s treatment and hospital disposition is related to the following attributes - Emergency Severity Index (ESI), gender, employment status, insurance status, race, or ethnicity which our 100 MB dataset included. Materials and methods: Our work is separated into two parts - the classification task and data analysis. As part of the classification task, we used the k-Nearest-Neighbor classifier, the F1-score, and a random forest. We then analyze the data using SHapley Additive exPlanations (SHAP) values to determine the importance of each attribute. Results: Our findings show that significance varies for each attribute. Notably, we found that patients with private insurance programs receive better treatment compared to patients with federal-run healthcare programs (e.g. Medicaid, Medicare). Furthermore, a patient’s ethnicity has a greater impact on treatment for patients under 40 years of age for any given ESI level. Surprisingly, our findings show language is not a barrier during treatment. Discussion and conclusion: We, therefore, conclude that although hospitals may not be doing so intentionally, there is a systemic bias in hospital triaging for specific patient demographics. For future works, we hope to aggregate additional patient data from hospitals to find whether specific demographics of patients receive better healthcare in different parts of the United States.

Undertriage for Children With Caregivers Preferring Languages Other Than English.

Undertriage, the underestimation of acuity, can result in delayed care and potential morbidity in the emergency department (ED). Although inequities in ED care based on language preference have been noted, little is known about its association with undertriage. We evaluated for differences in undertriage based on caregiver language preference. This was a retrospective cross-sectional study of patients aged younger than 21 years, triaged as Emergency Severity Index (ESI) level 4 or 5 (nonurgent), to the pediatric ED from January 1, 2019, through January 31, 2021. Indicators of undertriage were defined as hospital admission, significant ED resource use, or return visits with admission. We used logistic regression with generalized estimating equations to measure the association of preferred language with undertriage. Of 114 266 ED visits included in the study, 22 525 (19.8%) represented patients with caregivers preferring languages other than English. These children were more likely to experience undertriage compared with those with caregivers preferring English (3.7% [English] versus 4.6% [Spanish] versus 5.9% [other languages]; Spanish versus English: odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.4] and other languages versus English: OR, 1.6; 95% CI, 1.2-2.2). Differences remained after adjusting for sex, insurance, mode of arrival, and clustering by triage nurse (Spanish versus English: adjusted OR, 1.3; 95% CI, 1.3-1.5) and other languages versus English: adjusted OR, 1.6; 95% CI, 1.2-2.2). Children accompanied by caregivers preferring languages other than English are more likely to be undertriaged in the pediatric ED. Efforts to improve the triage process are needed to promote equitable care for this population.

Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage

Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI). To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage. This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022. Assigned ESI level. Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage. A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]). In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.

Associated Factors of Under and Over-Triage Based on The Emergency Severity Index; a Retrospective Cross-Sectional Study.

Under-triage increases patients' risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. This study aimed to determine the rates as well as associated factors of under-triage and over-triage in emergency department (ED), based on Emergency Severity Index (ESI) triage system. In this retrospective cross-sectional study, triage level of ED patients based on the ESI version 4, was studied during a 9-month period in 2019. Patients' ESI level, which were examined by triage nurses were reevaluated by 3 emergency physicians and the rate of correct, under-, and over-triage as well as their associated factors were analyzed. 1000 cases of triage were evaluated. Triage was correct in 69.1% of cases. The rate of under-triage was 4.9%, and that of over-triage was 26.0%. Over-triage was significantly more common among patients aged 18-30 years than for those aged ≥65 years (adjusted odds ratio [OR] = 1.73; 95% confidence interval [CI]: 1.07-2.81; p = 0.026); those with traumatic injuries (adjusted OR = 1.80; 95% CI: 1.29-2.52; p = 0.001); those arriving at the hospital during the evening shift (adjusted OR = 1.42; 95% CI: 1.01-2.0; p = 0.046); patients who were hospitalized (adjusted OR = 0.35; 95% CI: 0.22-0.54; p < 0.001); and those with severe pain (adjusted OR = 0.28; 95% CI: 0.10-0.84; p = 0.023). Younger age was also significantly associated with under-triage. Patients aged 18-30 years were under-triaged more often than those aged ≥65 years (adjusted OR = 3.05; 95% CI: 1.16-8.00; p = 0.023). Over-triage was substantially more common than under-triage in Vajira Hospital. Factors associated with over-triage were younger age, traumatic injury, arrival time, hospital admission, and severe pain. Younger age was the only factor related to under-triage.

Implementation of Vertical Split Flow Model for Patient Throughput at a Community Hospital Emergency Department

BackgroundHospitals have implemented innovative strategies to address overcrowding by optimizing patient flow through the emergency department (ED). Vertical split flow refers to the concept of assigning patients to vertical chairs instead of horizontal beds based on patient acuity. ObjectiveEvaluate the impact of vertical split flow implementation on ED Emergency Severity Index (ESI) level 3, patient length of stay, and throughput at a community hospital. MethodsRetrospective cohort study of all ESI level 3 patients presenting to a community hospital ED over a 3-month period prior to and after vertical split flow implementation between 2018 and 2019. ResultsIn total, data were collected from 10,638 patient visits: 5262 and 5376 patient visits pre- and postintervention, respectively. There was a significant reduction in mean overall length of stay when ESI-3 patients were triaged with vertical split flow (251 min vs 283 min, p < 0.001). ConclusionsCommunity hospital ED implementation of vertical split flow for ESI level 3 patients was associated with a significant reduction in overall length of stay and improved throughput. This model provides a solution to increase the number of patients that can be simultaneously cared for in the ED without increasing staffing or physical space.

320 Trends in Acute Care of Vaso-Occlusive Episodes in the Emergency Department Following the 2014 National Heart Lung Blood Institute Guidelines

Patients presenting to the Emergency Department (ED) with sickle cell disease (SCD) vaso-occlusive episodes (VOE) encounter variability in triage acuity level designation and pain management practices. Our study aims to describe national trends in Emergency Severity Index (ESI) level designation and the rate of narcotic administration for ED patients with SCD VOE. We additionally compare both of these variables before and after publication of the 2014 National Heart Lymph Blood Institute (NHLBI) guidelines for the management of patients with VOE.

133 Rates and Predictors of Emergency Department Mis-Triage: A Multiyear, Multicenter Study

The five level Emergency Severity Index (ESI) is used in over 70% of emergency departments (ED) across the U.S. to sort patients based on predicted acuity and resource needs. Most studies assessing the validity of the ESI are based on expert opinion through chart review or case simulations with highly variable performance. We developed objective measures to define under- and over-triage for each ESI level, to estimate the frequency of mis-triage, and assess patient and visit characteristics associated with mis-triage in a multi-center practice setting.

Race and Other Disparate Demographic Variables Identified Among Emergency Department Boarders.

IntroductionEmergency department (ED) boarding, the process of holding patients in the ED due to a lack of inpatient beds after the decision is made to admit, has profound consequences. Increased ED boarding times are associated with adverse patient outcomes, including increased mortality. While previous studies have demonstrated racial disparities with regard to ED boarding, current literature lacks insight into discrepancies that may exist among other demographic groups as it pertains to ED boarding. We sought to review ED boarding times differentiated by demographic characteristics.MethodsWe conducted a retrospective review of all ED admissions from an academic ED in the Southeast from April–September 2019. The primary outcome assessed was boarding time, defined as time from decision to admit to ED departure. Patient demographic data including race, gender, and age were collected and analyzed. We performed descriptive statistics and chi-square analyses.ResultsThe study population included 17,606 patients with a mean age of 56.3. Nearly half (49.8%) of the patients were female. Additionally, 43.8% of patients were Black and 48.6% White. For all admissions, there was no difference in mean boarding time among Black and White patients (5.2 ± 8.8 vs 5.2 ± 8.2 hours, P = 0.11). Among Emergency Severity Index (ESI) level I admissions, Black patients boarded longer than White patients (4.1 ± 0.3 vs 2.7 ± 0.3 hours, P = 0.009). Black patients also boarded significantly longer than White patients for psychiatric admissions (22.7 ± 23.7 vs 18.5 ± 19.4 hours, P <0.05). For all admissions, males boarded longer than females (5.5 ± 8.5 vs 4.9 ± 8.2 hours, P <.0001). Patients older than 75 boarded for less time (3.8 ± 6.2 hours) compared to younger groups (15–24: 6.4 ± 10.8 hours; 25–44: 6.6 ± 10.8; 45–64: 5.0 ± 7.6; and 64–75: 4.7 ± 6.7; all P <.05).ConclusionThis analysis demonstrated significant differences in ED boarding times between races among psychiatric and ESI I admissions, gender, and age. This data provides insight into differences in ED boarding times among demographic groups and provides a focal point for examining possible factors contributing to the observed differences.

Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department.

Introduction:The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED.Methods:We defined under-triage as patient visits with an Emergency Severity Index (ESI) score of 4 or 5 (ie, low acuity), and the patient was admitted to the hospital during the same visit. We defined mistriage, or medical error, when nurse-physician dyad reviewers determined that a different ESI level should have been assigned based on the information available at triage. A multidisciplinary team used nominal group technique to build consensus on key drivers and outcome metrics for this new trigger. We randomly selected 267 charts for review utilizing the under-triage trigger.Results:Of the 125,457 patients triaged as level 4 or 5 in 2019 and 2020, 1.1% (n = 1,423) were under-triaged. Of the 267 charts reviewed, 127 were categorized as mistriage, making the under-triage’s positive predictive value trigger 48%. Reviews took 2–10 minutes per chart. We identified 10 categories of under-triage. Nine themes emerged, with four specific and measurable action items mapped to process and outcome metrics.Conclusions:We identify a new, feasible ED trigger, under-triage, that identifies medical error with a high positive predictive value. We identify process and outcome metrics and interventions to improve triage for future patients.