Emergency Severity Index Triage Level Research Articles

Association between patient-reported onset-to-door time and mortality in patients hospitalized with COVID-19 disease

IntroductionTimely hospital presentation and treatment are critical for recovery from coronavirus disease (COVID-19). However, the relationship between symptom onset-to-door time and key clinical outcomes, such as inpatient mortality, has been poorly understood due to the difficulty of retrospectively measuring symptom onset in observational data. This study examines the association between patient-reported symptom onset-to-door time (ODT) and mortality among patients hospitalized and treated for COVID-19 disease. MethodsWe conducted a retrospective cohort study of emergency department (ED) encounters of patients with COVID-19 disease who were hospitalized and received remdesivir and/or dexamethasone between March 1, 2020, and March 1, 2022. The exposure was patient-reported ODT in days. The outcome of interest was inpatient mortality, including referral to hospice care. We used multivariable logistic regression to examine the association between ODT and mortality while adjusting for patient characteristics, hospital sites, and seasonality. We tested whether severe illness on hospital presentation modified the association between ODT and mortality. Severe illness was defined by Emergency Severity Index triage level 1 or 2 and hypoxia (SpO2 < 94%). ResultsOf the 3451 ED hospitalizations included, 439 (12.7%) resulted in mortality, and 1693 (49.1%) involved patients with severe illness on hospital presentation. Greater ODT was significantly associated with lower odds of inpatient mortality (adjusted odds ratio (AOR) = 0.96, 95% CI = 0.93–1.00, P = 0.023). There was a statistically significant interaction between ODT and severe illness at hospital arrival on mortality, suggesting the negative association between ODT and mortality specifically pertained to patients who were not severely ill upon ED presentation (AOR = 0.93, 95% CI = 0.87–1.00, P = 0.035). The adjusted probability of mortality was significantly lower for non-severely ill, hospitalized patients who presented on days 8–14 (5.2%–3.3%) versus days 0–3 (9.4%–7.5%) after symptom onset. ConclusionMore days between symptom onset and hospital arrival were associated with lower mortality among hospitalized patients treated for COVID-19 disease, particularly if they did not have severe illness at ED presentation. However, onset-to-door time was not associated with mortality among hospitalized patients with severe illness at ED presentation. Collectively, these results suggest that non-severely ill COVID-19 patients who require hospitalization are less likely to decompensate with each passing day without severe illness. These findings may continue to guide clinical care delivery for hospitalized COVID-19 patients.

Association of delirium with increased short-term mortality among older emergency department patients: A cohort study

Study objectiveTo evaluate the association between delirium and subsequent short-term mortality in geriatric patients presenting to the emergency department (ED). MethodsThis was an observational cohort study of adults age ≥75 years who presented to an academic ED and were screened for delirium during their ED visit. The Delirium Triage Screen followed by the Brief Confusion Assessment Method were used to ascertain the presence of delirium. In-hospital, 7-day, and 30-day mortality were compared between patients with and without ED delirium. Odds ratios with 95% confidence intervals (CIs) were calculated through logistic regression after adjusting for confounders including age, sex, history of dementia, ED disposition, and acuity. ResultsA total of 967 ED visits were included for analysis among which delirium was detected in 107 (11.1%). The median age of the cohort was 83 years (IQR 79, 88), 526 (54.4%) were female, 285 (29.5%) had documented dementia, and 171 (17.7%) had a high acuity Emergency Severity Index triage level 1 or 2. During the hospitalization, 5/107 (4.7%) of those with delirium and 4/860 (0.5%) of those without delirium died. Within 7 days of ED departure, 6/107 (5.6%) of those with delirium and 6/860 (0.7%) of those without delirium died (unadjusted OR 8.46, 95% CI 2.68–26.71). Within 30 days, 18/107 (16.8%) of those with delirium and 37/860 (4.3%) of those without delirium died (unadjusted OR 4.50, 95% CI 2.46–8.23). ED delirium remained associated with higher 7-day (adjusted OR 5.23, 95% CI 1.44–19.05, p = 0.008) and 30-day mortality (adjusted OR 2.82, 95% CI 1.45–5.46, p = 0.002). ConclusionDelirium is an important prognostic factor that ED clinicians and nurses must be aware of to optimize delirium prevention, management, disposition, and communication with patients and families.

Changes in Emergency Department Volumes at the Largest U.S. Military Hospital During the COVID-19 Pandemic.

The coronavirus-2019 (COVID-19) pandemic has significantly impacted global healthcare delivery. Brooke Army Medical Center (BAMC) is the DoD's largest hospital and a critical platform for maintaining a ready medical force. We compare temporal trends in patient volumes and characteristics in the BAMC emergency department (ED) before versus during the pandemic. We abstracted data on patient visits from the BAMC ED electronic medical record system. Data included patient demographics, visit dates, emergency severity index triage level, and disposition. We visually compared the data from January 1, 2019 to November 30, 2019 versus January 1, 2020 to November 30, 2020 to assess the period with the most apparent differences. We then used descriptive statistics to characterize the pre-pandemic control period (1 March-November 30, 2019) versus the pandemic period (1 March-November 30, 2020). Overall, when comparing the pre-pandemic and pandemic periods, the median number of visits per day was 232 (Interquartile Range (IQR) 214-250, range 145-293) versus 165 (144-193, range 89-308, P < .0001). Specific to pediatric visits, we found the median number of visits per day was 39 (IQR 33-46, range 15-72) versus 18 (IQR 14-22, range 5-61, P < .001). When comparing the median number of visits by month, the volumes were lower during the pandemic for all months, all of which were strongly significant (P < .001 for all). The BAMC ED experienced a significant decrease in patient volume during the COVID-19 pandemic starting in March 2020. This may have significant implications for the capacity of this facility to maintain a medically ready force.

Clinical Predictors of Emergency Department Revisits within 48 Hours of Discharge; a Case Control Study

Introduction:Emergency department (ED) revisits increase overcrowding and predicting which patients may need to revisit could increase patient safety. This study aimed to identify clinical variables that could be used to predict the probability of revisiting ED within 48 hours of discharge. Methods:A retrospective case-control study was conducted between July 2018 and January 2019 at the Emergency Medicine Department in Ramathibodi Hospital, Bangkok, Thailand. Patients who revisited the ED within 48 hours of discharge (case group) and patients who did not (control group) participated. The predictive factors for ED revisit were identified through multivariate logistic regression analysis. Results:The case group consisted of 372 patients, who revisited the ED within 48 hours, and the control group consisted of 1488 patients. The most common reason for revisiting the ED was recurring gastrointestinal illness, in 107 patients (28.76%). According to the multivariate data analysis , five factors influenced the probability of revisiting the ED: age of more than 60 years (p < 0.001, OR = 2.04, 95%CI: 1.51-2.77), initial Emergency Severity Index (ESI) triage level of 2 (p = 0.007, OR = 1.20, 95%CI: 0.93-1.56), ED stay duration of 4 hours or longer (p = 0.013, OR = 1.12, 95%CI: 0.87-1.44), body temperature of ≥37.5ºC on discharge (p = 0.034, OR = 1.34, 95%CI: 1.00-1.80), and pulse rate of less than 60 (OR = 1.55, 95%CI: 0.87-2.77) or more than 100 beats/minute (OR = 1.53, 95%CI: 1.10-2.11) (p = 0.011).Conclusion:According to the findings, the most important and independent predictive factor of ED revisit within 48 hours of discharge were, age ≥ 60 years, ESI triage level 2, ED length of stay ≥ 4 hours, temperature ≥ 37.5 C, and 60 > pulse rate ≥ 100 beats/minute.

Assessment of ED triage of anaphylaxis patients based on the Emergency Severity Index

To describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4). We conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines. A total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28min compared to 13min, p<.001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20-4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31-0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38-0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38-0.82]), hypoxemia (OR, 0.34 [0.18-0.64]), or increased heart (OR 0.83 [0.73-0.95]) or respiratory (OR 0.70 [0.60-0.82]) rates. Patients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage.

A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department.

Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine. Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition. Twenty-five EM residents evaluated 17,642 patients (median= 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median= 22) medical resuscitations and 483 (median= 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses. Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

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

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.

Evaluating the accuracy of emergency nurses in correct triage using emergency severity index triage in Sina hospital of Tabriz: a cross-sectional analysis

Objective: Triage refers to the evaluation and categorization of patients for better management to deliver services. A good triage system should be able to accurately specify the patients who require urgent care. Thus, this study aimed to evaluate the accuracy of emergency nurses in correct triage using Emergency Severity Index (ESI) triage. Methods: In this descriptive cross-sectional study 750 patients, who referred to the emergency department (ED) of Sina teaching hospital, participated from 23 July to 22 August in 2015. Participants were selected using convenience sampling method. The patients’ triage level was determined by physicians and nurses separately and the results were compared. To define the level of agreement between two groups (inter-rater agreement), the kappa index was evaluated. Data were analyzed using SPSS version 17. Results: Among 750 patients, 577 patients (76.9%) were classified in correct triage group, 90 patients (12%) in undertriage group and 83 patients (11.1%) in overtriage group. Kappa agreement coefficient between the ESI triage level of physicians and nurses was 0.659 (95% CI: 0.646-0.667). There was statistically significant difference between the triage level of physicians and nurses (P < 0.001). Conclusion: This study showed that there was moderate agreement between the triages of physicians and nurses. It seems that improving nurses’ skills and knowledge might increase the accuracy of emergency nurses in patients’ correct triage. Therefore, planning programs based on training correct triage for emergency nurses is strongly suggested.

Sex differences in STEMI activation for patients presenting to the ED 1939

ObjectiveThe objective was to determine whether sex was independently associated with door to ST-elevation myocardial infarction (STEMI) activation time. We hypothesized that women are more likely to experience longer delays to STEMI activation than men. MethodsWe conducted a retrospective cohort study of adults ≥18 years who underwent STEMI activation at 3 urban emergency departments between 2010 and 2014. The Wilcoxon rank sum test and logistic regression were used to compare men and women regarding time to activation and proportion with times <15 minutes, respectively. ResultsOf 400 eligible patients, we excluded 61 (15%) with prehospital activations, 44 (11%) arrests, and 3 (1%) transfers. Of the remaining 292 patients, mean age was 61±13 years, 64% were men, 57% were black, and 37% arrived by ambulance. Median door to STEMI activation time was 7.0 minutes longer for women than for men (25.5 vs 18.5 minutes, P=.028). In addition, men were more likely than women to have a door to STEMI activation time <15 minutes (45% vs 28%, P=.006). After adjusting for race, hospital site, Emergency Severity Index triage level, arrival mode, and chief concern of chest pain, the odds of men having STEMI activation times <15 minutes were 1.9 times more likely than women. ConclusionsWomen have longer median door to STEMI activation times than men. A significantly lower proportion of women (28% vs 45%) are treated per American Heart Association guidelines of door to STEMI activation <15 minutes when compared with men, adjusting for confounders. Further investigation may identify possible etiology of bias and potential areas for intervention.

201 Predictive Validity of Emergency Department Crowding Measures for Inpatient Mortality

Study Objectives: Emergency department (ED) crowding is prevalent, and existing research suggests that ED crowding is associated with increased patient mortality. However, prior studies are limited by small hospital samples, inclusion of specific patient subgroups, and inadequate case mix adjustment; furthermore, studies are not directly comparable because of different measures of ED crowding. As a result, the external validity and causal mechanisms of ED crowding measures are unclear. Identification of valid metrics is critical for the proper design of public reporting and pay-for-performance initiatives. Our aim was to assess the predictive validity of multiple ED crowding measures for inpatient mortality. Methods: We performed a retrospective cohort study using data from a regional, integrated health system (Kaiser Permanente Southern California- KPSC). We included ED visits from 2008 to 2010 occurring at 13 KPSC hospitals which resulted in hospital admission. All hospitals had implemented a systemwide, electronic medical records system during the study period. Exclusion criteria included age<18 years, visits by non-members, transfers to other hospitals, discharges from the ED, and patients receiving observation status care. The outcome was inpatient mortality. The unit of analysis was an ED visit. We assessed system- and visit-level measures of ED crowding. System metrics included exposures to ED occupancy and external length of stay, both at ED arrival and averaged over an index visitor's length of stay (LOS). Visit metrics included waiting, evaluation, and boarding time, as well as total LOS, experienced by an index visitor. To assess for non-linear effects, all ED crowding measures were categorized into quintiles. Hierarchical logistic regression models accounted for visit clustering by hospital and person. Covariates included demographic characteristics, 29 pre-existing co-morbidities noted from health service records in the preceding year, Emergency Severity Index triage level, triage vital signs, primary hospital diagnosis, time variables for year, month, day, and shift, and ED site. Results: The study cohort included 326,487 ED visits resulting in hospitalization by 201,036 unique patients. Prior to covariate adjustment, all system metrics, boarding time, and total LOS were predictive of inpatient mortality (p<0.05). In adjusted analyses, boarding time was strongly predictive of mortality, with a threshold effect seen at 1.6 hours (1.7-2.8 hours, OR: 1.1, 95%CI: 1.02, 1.2; >2.9 hours, OR: 1.2, 95%CI: 1.1, 1.3). None of the other system or person-level metrics predicted inpatient mortality after covariate adjustment (p>0.3). Conclusion: Surprisingly, system measures of ED crowding and most visit-level time intervals were poorly predictive of mortality, suggesting that threats to patient safety is driven by the experience of boarding rather than general exposure to ED crowding. Our findings suggest that measurement efforts and patient safety interventions should focus on boarding time. Other potential measures may be confounded by patient case mix or hospital level factors.

Use of a Comprehensive Metabolic Panel Point-of-Care Test to Reduce Length of Stay in the Emergency Department: A Randomized Controlled Trial

Awaiting results from laboratory testing may sometimes be a rate-limiting step in emergency department (ED) throughput prolonging length of stay and contributing to crowding. We determine whether introduction of a comprehensive metabolic panel point-of-care test can reduce ED length of stay compared with traditional central laboratory testing. We performed a randomized, controlled trial among 10,244 noncritically ill ED patients aged 15 years and older whose physicians ordered a comprehensive metabolic panel at a single, large, academic, urban medical center. Participants were randomly assigned to performance of a comprehensive metabolic panel by a point-of-care test (n=5,154) or central laboratory testing (n=5,090). The primary outcome was length of stay in the ED. A point-of-care test reduced median ED length of stay among all study patients by 22 minutes (median 350 minutes [interquartile range 206 to 1,002 minutes] with point-of-care test versus median 372 minutes [interquartile range 217 to 1,150 minutes] with central laboratory testing; median difference 22 minutes; 95% confidence interval [CI] 4 to 40 minutes). A point-of-care test also reduced ED length of stay in patients discharged to home (256 versus 268 minutes; median difference 12 minutes; 95% CI 2 to 22 minutes) and with an Emergency Severity Index triage level of 3 (333 versus 355 minutes; median difference 22 minutes; 95% CI 4 to 40 minutes). Use of a point-of-care test for a comprehensive metabolic panel reduced ED length of stay compared with central laboratory testing in the adult ED of a single academic center.

The Influence of Emergency Medical Services Transport on Emergency Severity Index Triage Level for Patients With Abdominal Pain

The Emergency Severity Index (ESI) is a prospectively validated, five-level emergency department (ED) triage system designed to match triage acuity to both patient acuity and appropriate resource allocation. The study hypothesis was that, in practice, there exists an inappropriate bias toward triaging patients with abdominal pain to a higher ESI level based solely upon their mode of arrival to the ED. The authors performed a retrospective case-control study of patients presenting with abdominal pain. Patients were matched on sex, age (± 5 years), and date of arrival. Cases were those patients triaged to a Level 2, and controls were those triaged as Level 3. Conditional multiple variable logistic regression was used to evaluate the effect of the following variables on the odds of being triaged as Level 2: mode of arrival, systolic blood pressure (<90 mm Hg; normal, >140 mm Hg), heart rate, severe pain score (≥ 8 of 10), fever, race, history of cancer, and previous abdominal surgery. Age was also included in the regression modeling to confirm that matching was adequate. One-hundred cases and 100 controls were necessary to provide adequate sample size. A backward modeling technique was used, requiring a p < 0.05 for retention. Of the 200 subjects, 52 arrived by emergency medical services (EMS) and 148 walked in. After matching for sex, age, and date of arrival, and after adjusting for heart rate, cancer diagnosis, and severe pain, the odds ratio (OR) for being triaged ESI Level 2 was 7.19 (95% confidence interval [CI] = 2.75 to 18.8, p < 0.0001) for EMS patients compared to walk-in patients. The admission rate for Level 2 patients was not different from that of Level 3 patients (49% vs. 35% of Level 3 patients, p = 0.06), but EMS patients were more likely to be admitted, regardless of ESI level assignment (65% vs. 34%, p < 0.001). After adjusting for covariates, EMS patients with abdominal pain were more likely to be triaged to a higher acuity level. Triage level was not associated with admission, but patients arriving by EMS were more likely to be admitted. This may indicate that the effect of EMS arrival on triage level assignment is actually appropriate. Further research is necessary to validate whether mode of arrival should be incorporated in the initial ESI triage acuity assignment.

Accuracy of the Emergency Severity Index Triage Instrument for Identifying Elder Emergency Department Patients Receiving an Immediate Life‐saving Intervention

The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life-saving intervention in the emergency department (ED). The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1-month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life-saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review. Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI]=23.3% to 61.3%); the specificity was 99.2% (95% CI=98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients). The ESI triage instrument identified fewer than half of elder patients receiving an immediate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage.

Comparison of the Emergency Severity Index (ESI) and the Taiwan Triage System in Predicting Resource Utilization

The importance of accurate triage in Taiwan is becoming more apparent with the increasing number of emergency department (ED) patients, and resources for the National Health Insurance becoming constrained. This study compared the ability of the Taiwan triage system (TTS) and the standardized 5-level Emergency Severity Index (ESI) triage system to predict ED resource utilization. Patients arriving at the ED were triaged by both TTS and by using a two-page checklist of ESI criteria during the 3-month study period. The ESI triage level was calculated independently to avoid bias. Disease category (trauma vs. nontrauma), length of stay (LOS) and hospitalization data were evaluated. A total of 3172 patients with both ESI and TWN evaluation were included. The distributions of ESI ratings within TTS level 1 were: ESI 1, 21.1%; ESI 2, 68.1%; ESI 3, 7.4%; ESI 4, 3.4%; ESI 5, 0%. For TTS level 3, they were: ESI 1, 0.1%; ESI 2, 26.2%; ESI 3, 39.5%; ESI 4, 27.5%; ESI 5, 6.8%. Hospitalization rates were 74.5%, 40.9% and 22.2% in TTS levels 1, 2 and 3, respectively; and were 96.2%, 47.0%, 30.9%, 6.7%and 6.6% in ESI levels 1, 2, 3, 4 and 5, respectively. TTS triaged more trauma patients as life-threatening/emergent condition than nontrauma patients (68.8% vs. 48.4%, p < 0.001). Triage by ESI, however, showed no significant difference in the percentage of trauma and nontrauma patients with highly acute conditions (44.2% vs. 46.6%, p = 0.230). Patients with ESI level 4 or 5 have significantly shorter ED LOS than those with ESI level 3. ESI produces more accurate discriminating patient acuity, ED LOS and hospitalization rate than TTS. Adopting a standardized 5-level triage tool might improve resource utilization planning of ED practice.

The Emergency Severity Index (version 3) 5-Level Triage System Scores Predict ED Resource Consumption

ObjectivesThe Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument that is gaining in popularity. A unique component of the ESI algorithm is prediction of resource consumption. Our objective was to validate the ESI version 3 triage algorithm in a clinical setting for the following outcome measures: actual resource consumption and patient length of stay in the emergency department and hospital. MethodsWe conducted a retrospective, descriptive study of 403 ED patients who presented to a large academic medical center. The following dependant variables were abstracted from the ED record: number of ED resources used and emergency department and hospital length of stay. The relationship between ESI level and each of the dependent variables was determined. ResultsMean resource use decreased monotonically as a function of ESI level 1 (5), 2 (3.89), 3 (3.3), 4 (1.2) and 5 (0.2). The ED average length of stay (minutes) per ESI level was as follows: 1 (195), 2 (255), 3 (304), 4 (193), and 5 (98). ESI triage level did not predict hospital length of stay. ConclusionsThe ESI algorithm accurately predicted ED resource intensity and gives administrators the opportunity to benchmark ED length of stay according to triage acuity level.

The Emergency Severity Index Triage Algorithm Version 2 Is Reliable and Valid

AbstractObjectives:Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three‐level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states.Methods:In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60‐day all‐cause mortality.Results:Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n= 3,289) and 0.69 to 0.87 for patient triages (n= 386). Outcomes for the validity cohort (n= 1,042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty‐day all‐cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%.Conclusions:ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.

The emergency severity index triage algorithm version 2 is reliable and valid.

Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n = 3289) and 0.69 to 0.87 for patient triages (n = 386). Outcomes for the validity cohort (n = 1042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.

Emergency severity index triage category is associated with six-month survival. ESI Triage Study Group.

The Emergency Severity Index (ESI) is a new five-level triage instrument. The objective of this study was to determine whether there is an association between ESI triage status and short-term survival. This was a survival analysis for a population-based, stratified random sample of patients over the age of 14 years who visited an urban, university-affiliated hospital emergency department (ED). Measures included ESI triage category (1 through 5), vital status obtained from the Social Security Administration, date of death (if applicable), and survival time in days. Data were analyzed with Kaplan-Meier survival analysis. Eighty-seven percent (202/232) of a random sample of patients appeared in the Social Security vital status registry. During the 252-day follow-up period, 19 patients (9%) died, 161 (80%) lived, and 22 (11%) had an unknown vital status. The ESI triage level was strongly associated with vital status at six months (Kaplan-Meier chi-square 25.9, p<0.0001). No patient in triage categories 4 and 5 died (lower limits of the 95% confidence interval for survival, 92% and 93%, respectively); whereas survival in triage category 1 was 68%, and in categories 2 and 3 it was 86% and 83%, respectively. Most of the deaths occurred within 60 days after the index ED visit. Sensitivity analyses biased against the instrument continued to demonstrate the association between triage status and survival. The ESI triage status is associated with six-month survival. Patients with the highest three triage groups experienced decreased survival during the follow-up period, whereas all patients in the two lowest triage strata survived at least six months.