Abstract. Objectives: Triage is the initial clinical sorting process in hospital emergency departments (EDs). Because of poor reproducibility and validity of three-level triage, the authors developed and validated a new five-level triage instrument, the Emergency Severity Index (ESI). The study objectives were: 1) to validate the triage instrument against ED patients' clinical resource and hospitalization needs, and 2) to measure the interrater reliability (reproducibility) of the instrument. Methods: This was a prospective, observational cohort study of a population-based convenience sample of adult patients triaged during 100 hours at two urban referral hospitals. Validation by resource use and hospitalization (criterion standards) and reproducibility by blinded paired triage assignments compared with weighted kappa analysis were assessed. Results: Five hundred thirty-eight patients were enrolled; 45 were excluded due to incomplete evaluations. The resulting cohort of 493 patients was 52% female, was 26% nonwhite, and had a median age of 40 years (range 16-95); overall, 159 (32%) patients were hospitalized. Weighted kappa for triage assignment was 0.80 (95% CI = 0.76 to 0.84). Resource use and hospitalization rates were strongly associated with triage level. For patients in category 5, only one-fourth (17/67) required any diagnostic test or procedure, and none were hospitalized (upper confidence limit, 5%). Conversely, in category 1, one of twelve patients was discharged (upper confidence limit, 25%), and none required fewer than two resources. Conclusions: This five-level triage instrument was shown to be both valid and reliable in the authors' practice settings. It reproducibly triages patients into five distinct strata, from very high hospitalization/resource intensity to very low hospitalization/resource intensity. Keywords: triage; emergency service, hospital; clinical protocols; nursing assessment. ACADEMIC EMER-GENCY MEDICINE 2000; 7:236-242 T HERE were 95 million hospital emergency department (ED) visits in 1997.1 For more than 30 years, literature reports indicate that as many as one-half of ED visits are for minor health problems. [2][3][4][5][6][7][8] Triage is the preliminary clinical assessment process that sorts patients prior to full ED diagnosis and treatment, so that in the setting of resource constraints (i.e., limited beds, staff, and equipment), patients with the highest acuity are treated first. Most U.S. hospitals use three triage categories, 9 whereas five-level triage prevails in Canada, 10 and health insurers use triage data when reviewing the ''medical necessity'' of ED services for reimbursement purposes.14 Such decision making depends on reproducible and valid triage classifications. Unfortunately, existing ED triage methods are flawed, particularly for identification of nonurgent patients who may be referred for care elsewhere. 14-21Because of limitations in existing triage processes, we developed and validated a five-level triage instrument, based on an expanded conceptual model:...

Abstract. Objectives: To implement a new fivelevel emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures. Methods: The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed. Results: Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n = 62 nurses), and 0.73 for patient triages (n = 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 58/63 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. Conclusions: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes. Key words: triage; emergency service; hospital; clinical protocols; nursing assessment. ACADEMIC EMERGENCY MEDICINE 2001; 8:170-176 N EARLY all hospital emergency departments (EDs) use some form of triage, a focused clinical assessment usually performed by a professional nurse. The triage nurse aims to rapidly prioritize patients so that those with the greatest need are seen before those with less urgent conditions. Triage is conventionally thought to be better than a ''first come, first served'' entry policy because effective treatment for many emergencies is time-critical, 1,2 yet on the other hand, a substantial proportion of patients 3-5 have more minor emergencies that do not necessitate immediate intervention.In the United States, most EDs use three-level or four-level comprehensive triage.6 These comprehensive triage models of practice have been criticized 7 because of poor reproducibility [8][9][10][11][12] in acuity assignments, and because of lack of empiric validation 13 against clinical outcomes. In a preliminary study, 14 a new triage instrument, the Emergency Severity Index (ESI), demonstrated highly reproducible, clinically valid five-level triage stratification. The primary purposes of the current study were to ...

Abstract. Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High-fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high-fidelity medical simulators will be added to the hands-on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high-fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high-fidelity medical simulation; 2) to share the results of a proof-of-concept EM simulation workshop introducing multiple mannequin/ three-patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide-ranging discussion and handson exploration of these methods. Key words: patient safety; performance; teamwork; team training; emergency medicine; simulation. ACADEMIC EMER- GENCY MEDICINE 1999; 6:312 -323 T HE PRACTICE of emergency medicine (EM) presents many cognitive, social, and systems challenges to clinicians and administrators. Education of emergency physicians (EPs) must optimally include training to manage the self, team, and environment under difficult conditions. Naturalistic decision making (NDM) is a growing school of thought that has led to greater understanding of how skilled people solve complex problems in the actual contexts in which tasks must be carried out. Job performance in EM can be characterized as consisting of the eight task and setting factors that serve as a framework for the NDM movement (Table 1).