Emergency Severity Index Triage System Research Articles

Relationship of Hospital Mortality with Metabolic Acidosis Severity in Critically Ill Patients

Background: Metabolic acidosis (MA) is a common pathologic process with fatal consequences in critically ill (CI) patients. The more the severity of acidosis the more mortality rate is expected. To evaluate the relationship of hospital mortality with MA severity in CI patients admitted to emergency department (ED).
 Methods: In this prospective cohort study, we enrolled CI patients (based on physician clinical assumption), most at level 1 or 2 emergency severity index triage system. Patients were followed and evaluated in 2 parallel groups, one with and the other without MA. The severity of acidosis, chief complaints, final diagnosis, demographic data, acute physiologic assessment and chronic health evaluation II (APACHE II) score, serum lactate and bicarbonate level, need for intubation and mechanical ventilation, admission ward, hospital length of stay and in hospital mortality were compared between the 2 groups.
 Results: A total of 1811 CI patients including 60.2% males and 39.8% females with and without MA were evaluated. The most common age range was 65-55 years old (31.7%) with the meanSD of 61.348.23. The most common complaints and diagnoses were weakness (40.5%) and pneumosepsis (35.1%), respectively. Patients with severe acidosis had higher lactate level and APACHE II score (p<0.05). Mortality rate was 10.4%. Most of our cases had severe MA. Expired cases had higher lactate level and APACHE II score (p<0.05).
 Conclusion: Lactate level, bicarbonate level and APACHE II score were all significant independent predictors of hospital mortality in CI patients.

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.

Effectiveness of Implementing Emergency Severity Index Triage System in a Selected Primary Health Care Center in Oman: A Quasi-Experimental Study

BackgroundBecause most primary health care centers in Oman do not use a formal triage system, there are no available data on the effectiveness of implementing this system. PurposeTo assess the effectiveness of implementing an Emergency Severity Index triage system in primary health care centers in Oman. MethodsA pretest/posttest quasi-experimental design was used. The sample comprised 187 patients before Emergency Severity Index implementation and 102 patients after implementation. Waiting time, length of stay, patient satisfaction, and accuracy of classification were compared across the 2 groups. ResultsThe mean time (hour:minute) from registration to triage was reduced in the post-Emergency Severity Index group (mean = 0:18, SD = 0:14) compared with the pre-Emergency Severity Index group (mean = 0:23, SD = 0:19) (t = 2.59, P = 0.01). Furthermore, the mean length of stay was reduced in the post-Emergency Severity Index group (mean = 1:09, SD = 0:37) compared with that of the preimplementation group (mean = 1:24, SD = 0:41) (t = 3.10, P = 0.002). Patient satisfaction in the postimplementation group was improved (mean = 66.95, SD = 8.33) compared with that of the Emergency Severity Index group (mean = 65.01, SD = 8.73), but it did not reach statistical significance (t = −1.83, P = 0.07). The inter-rater agreement of triage level in post-Emergency Severity Index implementation markedly improved in the postimplementation group (Cohen’s kappa = 0.910, P < 0.001) compared with that of the preimplementation group (Cohen’s kappa = 0.082, P = 0.005). ConclusionsAlthough this is a single-setting study, the results have shown that the Emergency Severity Index system can contribute to a decrease in the negative crowding outcomes in primary health care centers in Oman.

Implementing the Emergency Severity Index Triage System in Jamaican Accident and Emergency Departments

Simone French is Consultant Physician at University of the West Indies, Jamaica, West Indies. Georgiana Gordon-Strachan is Professor at University of the West Indies, Jamaica, West Indies. Kevon Kerr is at University of the West Indies, Jamaica, West Indies. Jacquiline Bisasor-McKenzie is Emergency Physician, Disaster Management and Special Services Branch, Ministry of Health, Jamaica, West Indies. Lambert Innis is Emergency Physician, Disaster Management and Special Services Branch, Ministry of Health, Jamaica, West Indies. Paula Tanabe is Professor at Duke University School of Nursing, Durham, NC. Drs Tanabe and French were paid as consultants by the Ministry of Health for this project. Dr. Tanabe is a member of the ESI Triage Research Team LLC.

Assessment of Shift Programs of Emergency Department Health Personnel in Four Hospitals Providing Medical Training in Turkey and Iran, A Brief Report

Background: Emergency departments provide continuous 24 - h health services. The working shifts required for health workers to provide high - quality and continuous services are still the subject of debate. This descriptive study compares the emergency department working shifts in Turkey with the emergency department working shifts in Iran. Methods: This cross sectional descriptive study assesses numbers of paramedics, nurse, resident physicians, specialist physicians, faculty members, shift hours, numbers of patient admission per day, and compares the shift systems worked by emergency department staff in three hospitals providingmedical training in Turkey and emergency department staff from amedical faculty providing training in Iran. Results: The highest numbers of residents (N = 50) and members of teaching staff (N = 14) were observed in Tabriz - Iran Imam Reza Hospital. Resident physicians at Turkey’s Karadeniz technical University (KTU) Medical Faculty Emergency Department work 24 - h block shifts, while those in other centers work various shift patterns. The teaching staff at the Imam Reza Hospital work actively for 24 h, while those in hospitals in Turkey work actively in the daytime and are on standby in the evening. The Emergency Severity Index triage system is applied in the Imam Reza Hospital, while the three centers in Turkey use the yellow, red, and green triage coding system. Conclusions: Presentation of teaching a faculty member in 24 hours in shifts and using ESI triage system with divided shift times in a day can improve emergency management by decreasing personnel burnout and increasing care satisfaction in patients.

Effectiveness of Five-Level Emergency Severity Index Triage System Compared With Three-Level Spot Check: An Iranian Experience.

Background:Triage for patients’ prioritization in the emergency department is a suitable solution to decrease overcrowding. Different methods are used for prioritization that needs effectiveness evaluation.Objectives:The aim of this study was to assess the effectiveness of the emergency severity index (ESI) 5-level triage system in contrast with spot check triage.Patients and Methods:Data for this quasi-experimental study were extracted using a form to review 770 records of patients referred to emergency department of Imam Khomeini hospital (in Sari, north of Iran) during two separated periods each for four months; the first from 20th March to 19th July 2010 and the other from 21 March to 20 July 2011. The method used in the first time was spot check triage and the second one ESI triage. Data were processed with descriptive statistics and analyzed using independent samples t-test (CI = 95%).Results:Increase from 6.46 to 8.92 minutes in the average time from patient arrival to being visited by a physician (P < 0.001) and increase in average time from physician visit to receive the first nursing care from 7.68 to 15.89 minutes were significant (P < 0.001). The average waiting time for laboratory services was significantly decreased from 112.3 to 84.1 (P = 0.033). Increase in the average waiting time for radiology, decrease in average waiting time for sonography, average length of stay in the emergency department, and number of patients per emergency bed were not significant.Conclusions:Between the two systems of triage, ESI was more effective than the spot check and in the spatial and temporal domain of research, was a successful method in improving some indicators of emergency and improving the performance indices. Hospital managers by implementation of ESI system can take a step toward new health policies and improve the processes as key tools of continuous quality improvement system.

Emergency Severity Index Triage System Correlation with Emergency Department Evaluation and Management Billing Codes and Total Professional Charges

All services provided by physicians to patients during an emergency department (ED) visit, including procedures and "cognitive work," are described by common procedural terminology (CPT) codes that are translated by coders into total professional (physician) charges for the visit. These charges do not include the technical (facility) charges. The objectives of this study were to characterize associations between Emergency Severity Index (ESI) acuity level, ED Evaluation and Management (E&M) billing codes 99281-99285 and 99291, and total ED provider charges (sum of total procedure and E&M professional charges). Secondary objectives were to identify factors that might affect these associations and to evaluate the performance of ESI and identified variables to predict E&M code and average total professional charges. The authors reviewed 276,824 patient records for calendar year 2007, of which 193,952 adult ED visits from three different ED types (community, university-based academic, and non-university-based academic) met inclusion criteria. Correlations between 1) ESI level and E&M billing code per visit by institution and 2) ESI and total professional charges were analyzed using Spearman rank correlation. Linear regression analysis was performed to identify variables that significantly affected these correlations. ESI level and E&M codes were moderately correlated (Spearman r = 0.51). ESI levels corresponded proportionately to higher E&M codes. ESI 1, 2, and 3 most frequently corresponded with E&M level 5 (50, 62, and 45%, respectively), and ESI 4 and 5 most frequently corresponded with E&M level 3 (56 and 67%, respectively). Only age by decade significantly affected the association between ESI level and E&M billing code. The mean total professional charge for all patient encounters was $421 (SD ± $204) with increasing mean charges per patient by increasing ESI acuity. Race and E&M code significantly affected the relationship between ESI level and total ED professional charges per patient (adjusted r(2) = 0.66). A moderate, nonlinear correlation exists between ESI acuity levels and ED E&M billing codes. Increasing age affects this correlation. Race and E&M code affect the correlation between ESI level and total professional charges. As such, basic triage data can be used to estimate E&M code and total professional charges. Future studies are needed to validate these findings across other institutional settings.

Level 2 and Level 3 Patients in Emergency Severity Index Triage System

There is a lack of studies examining distinctions between patients assigned to Level 2 (high risk) and Level 3 (lower risk) in the 5-level ESI triage system. Describing patients assigned to Level 2 and Level 3 may identify unique characteristics related to chief complaint, interventions, and resource needs. A convenience sample of triage nurses was recruited from 2 emergency department (ED) sites. If, at the completion of the patient-nurse triage interaction, the nurse assigned the patient to either Level 2 or Level 3, additional clinical data related to that patient were collected from the ED medical record. Eighteen triage nurses participated in the study with 334 nurse-patient triage interactions collected. Patients presenting with a chief complaint of nausea and vomiting or having a medical history of renal insufficiency/failure were significantly more often assigned to Level 2 than to Level 3 (p = 0.036 and p = 0.013, respectively). Patients assigned to Level 2 were more likely to utilize cardiac monitoring, electrocardiogram, medications, and specialty consultation than patients assigned to Level 3. It is critical that nurses in the triage setting be aware of possible patient factors and resource needs that could influence assignment to specific triage levels.

174: Emergency Severity Index Triage System Correlation With Emergency Department Evaluation and Management Billing Codes

174: Emergency Severity Index Triage System Correlation With Emergency Department Evaluation and Management Billing Codes

The Emergency Severity Index 5-Level Triage System

The Emergency Severity Index triage system is a relatively new 5-level mode of operations created in the late 1990s. This system provides an operational model to meet the needs of all patients. This triage process segregates patients into 5 different treatment levels based on a variety of characteristics. This article discusses the Emergency Severity Index, how it works, its advantages and disadvantages, and implications for emergency department nurses.

The influence of triage systems and triage scores on timeliness of ED analgesic administration

Objectives The aim of the study was to examine the association between triage scoring systems and triage priority scores on time to initial emergency department (ED) analgesic administration. Methods An observational, multicenter, prospective, cohort study was conducted at 20 US and Canadian EDs. Centers from the United States used the Emergency Severity Index triage system or 1 of 3 unvalidated triage systems. Canadian centers used the Canadian Triage and Acuity Scale. Patients aged 8 years or older who presented to the ED with a chief complaint of moderate to severe pain (>3 on a 10-point numerical rating scale) and who were ultimately discharged home were eligible for study enrollment. Triage score, triage system, pain rating on arrival, and time of initial analgesic administration were recorded. Results Among 842 enrolled subjects, 506 (60%) received an analgesic while in the ED. Lower-acuity patients consistently waited longer for analgesics. On multivariate modeling, presenting pain intensity, total time spent in the ED, white ethnicity, and triage system were associated with time to initial analgesic administration. Emergency departments using the Canadian Triage and Acuity Scale triage system exhibited the lowest rates of analgesic use and displayed longer median times to initial analgesic administration. Conclusions Although there were some differences between triage systems, all sites and systems demonstrated unacceptably long times to analgesic provision. Many patients with moderate to severe pain received no analgesic during their ED stay. Future studies should examine whether ED overcrowding impacts timeliness of analgesic administration and identify specific strategies to improve pain management practices in this challenging environment.

Assessment of the applied emergency severity index triage system: quality index

Assessment of the applied emergency severity index triage system: quality index

Creation of a Validated Set of Pediatric Case Scenarios for the Emergency Severity Index Triage System

Creation of a Validated Set of Pediatric Case Scenarios for the Emergency Severity Index Triage System

Implementing the Emergency Severity Index Triage System in the Homeland of Hippocrates

Implementing the Emergency Severity Index Triage System in the Homeland of Hippocrates