Physician gestalt for emergency department triage: A prospective videotaped study

Abstract

Objective: Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process. Methods:We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges.Results: In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system-and physicianbased triage in predicting hospital admission were similar (0.635 vs. 0.631, p = 0.896).Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R 2 ) in EDLOS and charges were similar between the two triage methods (R 2 = 3% for EDLOS, 7%-9% for charges).Conclusions: Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.

A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study

“…This was a geriatric sub-study of a prospective observational study [ 17 ] that was conducted in the ED of the National Taiwan University Hospital (NTUH) from May 2020 to March 2022. The NTUH is a tertiary academic medical center with approximately 2,400 beds and 100,000 ED visits annually.…”

“…There is no research on quick, observation-based frailty assessment at the ED triage that we are aware of. In our prior study, we developed and validated an observation-based (physician gestalt) triage method that performed similarly to computer algorithm-based triage [ 17 ]. This physician gestalt-based quick assessment may also be employed to assess frailty at ED triage to augment existing triage systems.…”

One size does not fit all: the complexities of addressing flow in contemporary EDs

“…Again, metrics are important; physician triage was associated with a decrease in left without being seen rates (to 2.5 from 4.5%) and fewer days requiring ambulance diversion, whereas the effect on overall ED length of stay was modest (a decrease of 11 min among non-admitted patients, and no difference among admitted patients). A senior physician with strong experience in the triage role to assess urgency and manage workflow as a "regulator" was important, a construct validated in another study from Taiwan wherein attending physicians tended to perform better than residents in predicting the need for hospital admission [3].…”