Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis

Abstract

BackgroundEmergency department (ED) triage is performed to prioritize care for patients with critical and time-sensitive illness. Triage errors create opportunity for increased morbidity and mortality. Here, we sought to measure the frequency of under- and over-triage of patients by nurses using the Emergency Severity Index (ESI) in Brazil and to identify factors independently associated with each.MethodsThis was a single-center retrospective cohort study. The accuracy of initial ESI score assignment was determined by comparison with a score entered at the close of each ED encounter by treating physicians with full knowledge of actual resource utilization, disposition, and acute outcomes. Chi-square analysis was used to validate this surrogate gold standard, via comparison of associations with disposition and clinical outcomes. Independent predictors of under- and over-triage were identified by multivariate logistic regression.ResultsInitial ESI-determined triage score was classified as inaccurate for 16,426 of 96,071 patient encounters. Under-triage was associated with a significantly higher rate of admission and critical outcome, while over-triage was associated with a lower rate of both. A number of factors identifiable at time of presentation including advanced age, bradycardia, tachycardia, hypoxia, hyperthermia, and several specific chief complaints (i.e., neurologic complaints, chest pain, shortness of breath) were identified as independent predictors of under-triage, while other chief complaints (i.e., hypertension and allergic complaints) were independent predictors of over-triage.ConclusionsDespite rigorous and ongoing training of ESI users, a large number of patients in this cohort were under- or over-triaged. Advanced age, vital sign derangements, and specific chief complaints—all subject to limited guidance by the ESI algorithm—were particularly under-appreciated.

Physicians’ Disease Severity Ratings are Non-Inferior to the Emergency Severity Index

“…Due to the fact that about half of all patients are triaged as moderate acuity [17][18][19][20] and that upgrading the ESI is suggested in the case of "clinical suspicion" [21], we assessed the ESI's predictive validity with and without information gained by PDSR (ESI sub-stratified by addition of PDSR 5 ("patient looks extremely ill"), see Table 4). Surprisingly, substantial differences were found in all ESI categories with relevant mortality.…”

Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen

“…Application to modern civilian use has not been standardized nor validated . Modern civilian triage assessment is a poor or inconsistent tool in the reliable prediction of illness severity . This is related to intra‐ and inter‐observer variation in initial assessment of ED patients, including surgical abdomens .…”

Risk of mortality and cardiopulmonary arrest in critical patients presenting to the emergency department using machine learning and natural language processing

“…According to studies [2][3][4][5], under-triage contributes to delays in time-sensitive interventions, morbidity, and mortality. Over-triage, may have indirect but equally harmful effects [6], resulting in diversion of limited time and resources from more urgent patients and inappropriate allocation to less severe patients. In a study [2], the clinical severity of under-triage in the MTS was assessed for a cohort of pediatric patients.…”

“…It was concluded that although infrequent, under-triage could have serious clinical consequences. In another study [6], the frequency of under-and over-triaged patients was measured by nurses using the Emergency Severity Index (ESI). Initial ESI-determined triage priority was classified as inaccurate for 16426 of 96071 patients.…”