Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients

Introduction:Under-triage increases patients’ risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. This study aimed to determine the rates as well as associated factors of under-triage and over-triage in emergency department (ED), based on Emergency Severity Index (ESI) triage system.Methods:In this retrospective cross-sectional study, triage level of ED patients based on the ESI version 4, was studied during a 9-month period in 2019. Patients’ ESI level, which were examined by triage nurses were reevaluated by 3 emergency physicians and the rate of correct, under-, and over-triage as well as their associated factors were analyzed. Results:1000 cases of triage were evaluated. Triage was correct in 69.1% of cases. The rate of under-triage was 4.9%, and that of over-triage was 26.0%. Over-triage was significantly more common among patients aged 18–30 years than for those aged ≥65 years (adjusted odds ratio [OR] = 1.73; 95% confidence interval [CI]: 1.07–2.81; p = 0.026); those with traumatic injuries (adjusted OR = 1.80; 95% CI: 1.29–2.52; p = 0.001); those arriving at the hospital during the evening shift (adjusted OR = 1.42; 95% CI: 1.01–2.0; p = 0.046); patients who were hospitalized (adjusted OR = 0.35; 95% CI: 0.22–0.54; p < 0.001); and those with severe pain (adjusted OR = 0.28; 95% CI: 0.10–0.84; p = 0.023). Younger age was also significantly associated with under-triage. Patients aged 18–30 years were under-triaged more often than those aged ≥65 years (adjusted OR = 3.05; 95% CI: 1.16–8.00; p = 0.023).Conclusions: Over-triage was substantially more common than under-triage in Vajira Hospital. Factors associated with over-triage were younger age, traumatic injury, arrival time, hospital admission, and severe pain. Younger age was the only factor related to under-triage.

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

Assessment of Pre-LVAD Hemodynamics to Predict Post LVAD Early RV Failure

Effective triage in the emergency department (ED) is crucial for ensuring timely and appropriate care. The Emergency Severity Index (ESI) is a widely used triage system with strong predictive value for clinical outcomes. However, its performance in middle-income countries remains understudied, particularly in settings with variable resource availability, diverse patient populations, and inconsistent triage practices. This study aimed to assess in-hospital mortality across ESI levels and evaluate the ESI's diagnostic performance in predicting mortality among ED patients in a middle-income country. We conducted a retrospective cohort study at a tertiary care hospital in Thailand, including 331,182 ED patients from January 2016 to December 2021. Data on demographics, ESI level, comorbidities, and outcomes (mortality, ICU admission, and length of stay) were analyzed. The primary outcome was in-hospital mortality across ESI levels 1–5, while secondary outcomes included ICU admission, hospital length of stay, and ED resource utilization. The overall in-hospital mortality rate was 0.6%. However, mortality was significantly higher among patients triaged as ESI level 1 (17%), compared with those at levels 2 (1.7%), 3 (0.3%), 4 (<0.1%), and 5 (0%). ICU admission rates were highest among ESI level 1 patients (35%), followed by those at level 2 (9.8%), with rates declining as triage acuity decreased. ESI levels 1 and 2 demonstrated strong predictive performance for mortality, with a sensitivity of 82.1% and a negative predictive value of 99.9%. Patients classified as ESI level 1 had the highest utilization of diagnostic and therapeutic interventions, including blood tests (93%), supplemental low-flow oxygen (36%), and mechanical ventilation (30%). ESI level 1 was associated with significantly higher in-hospital mortality, ICU admissions, and resource utilization compared with other levels. These findings support the continued use of the ESI for ED triage, especially in middle-income settings.

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.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study

Background and Purpose: The emergency severity index (ESI) triage system has been recommended by the Ministry of Health to classify patients at emergency departments. This study aimed to assess the validity of ESI system (version 4) in the emergency department of a teaching hospital. Outcome measures were hospitalization, emergency department (ED) length of stay, resource consumption, in-hospital mortality, and patient service costs. Methods: In this retrospective cross-sectional study, medical records of 562 ED patients were reviewed to determine the ESI level and outcome measures in April 2013. Possible correlations were assessed using Phi and Cramer's V and Spearman's Rho. Data analysis was performed in SPSS V.16, and P value of 0.05 was considered significant. Results: In this study, frequency of five ESI levels (1-5) was 24, 14, 365, 158 and 0, respectively. In addition, Phi and Cramer's V for hospitalization and mortality were 0.350 (P<0.001) and 0.345 (P<0.001), respectively. Spearman's Rho for patient service costs, ED length of stay, and resource consumption were -0.434 (P<0.001), -0.015 (P=0.362), and -0.411 (P<0.001), respectively. According to our findings, the association between triage levels and resource consumption was more significant compared to other outcome measures. Conclusion: According to the results of this study, ESI triage ratings could successfully predict patient outcomes in terms of hospitalization, in-hospital mortality, resource consumption, and patient service costs. Therefore, use of this valid triage system is recommended for the arrangement of human and physical resources at emergency departments.

The accurate triage of arriving emergency department (ED) patients is a key component of emergency nursing practice. Overtriage assignment of patients misallocates scarce resources in a time of department overcrowding, whereas patient undertriage can create risks for negative patient outcomes secondary to care delays. Limited evidence is available regarding ED triage accuracy. It is estimated that appropriate adherence to the Emergency Severity Index (ESI) triage tool and assigning triage categories could be as low as 60% (McFarlane, 2019a, 2019b). The purpose of this retrospective observational study was to examine the 2019 triage distribution of 954,847 ED encounters at 25 hospitals. Comparisons were then made with the spreads identified in the ESI Implementation Handbook (Gilboy, Tanabe, Travers, & Rosenau, 2020). Study results reflect the presence of wide variations in distribution when compared with the expected spread published by Gilboy et al. (2020). These variations illustrate the need for further facility-level evaluation. ESI Level 2 percentages varied from as little as 2.6% to as high as 69% of each facility's ED visit population. Examining an individual facility's annualized triage distribution may serve as a swift method in determining whether additional investigation into triage accuracy is warranted. EDs must implement and sustain an ongoing quality control program to achieve and maintain triage inter- and intrarater reliability. Further research is needed on the value of triage inaccuracy with real-time feedback on nurses' clinical decision-making and patient outcomes. It is also imperative that the expected and observed ESI triage distribution in U.S. EDs is updated when established accuracy quality control programs are present.

The aim of the study was to investigate the association between primary language and length of stay (LOS) in the pediatric emergency department (ED) within the context of known disparities impacting healthcare experiences and outcomes for patients with language barriers. We conducted a retrospective cohort study of consecutive encounters of patients presenting to, and discharged from, an urban pediatric ED from May 2015 through April 2018. Encounters were grouped into English primary language (EPL), Spanish (SPL), and other (OPL). Mean LOS comparisons were stratified by Emergency Severity Index (ESI). Bivariate and multivariate analyses were used to examine the relationship between LOS and variables, including age, sex, race/ethnicity, insurance, and time of presentation. A total of 139,163 encounters were included. A higher proportion of SPL and OPL encounters were characterized as lower ESI acuity compared with EPL. Significantly longer LOS for SPL and OPL encounters was observed in the 2 lower acuity strata. The ESI 4-5 stratum demonstrated the greatest LOS disparity between EPL, SPL, and OPL (94 vs 103 vs 103 minutes, respectively, P < 0.001). In the highest acuity stratum, ESI 1-2, there was a nonsignificant trend toward longer LOS among EPL encounters (P = 0.08). The multivariate model accounted for 24% of LOS variance, but effect sizes were small for all variables except for ESI and age. Patients with Spanish or other non-EPL who were triaged to lower acuity ESI levels experienced longer LOS in the pediatric ED than English-speaking counterparts. They also used the ED more frequently for low acuity issues, possibly reflecting disparities in access to primary care.

OBJECTIVE: The aim of this study was to examine the chief complaints and clinical characteristics, outcomes, and associated factors of pediatric cancer patients who present at the emergency department (ED).METHODS: A retrospective, single-center study was conducted on children less than 18 years old with active cancer treatment at the Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand from January 2017 to September 2023. The chief complaints, and clinical characteristics of ED encounter were captured. The outcomes of the patients were categorized into those from admitted patients and those from the discharged group, before the potential risk factors were analyzed.RESULTS: A total of 91 ED encounters were documented among fifty cancer patients, representing 0.2% of total pediatric ED visits. Sixty-three (69.2%) ED visits met the inclusion criteria. The most common cancer was acute lymphoblastic leukemia. The common ED chief complaints were fever, gastrointestinal complaints, and respiratory complaints. Our results show that most pediatric cancer patients presenting at the ED were hospitalized (84.1%). There were no deaths at ED, and no patient died within 48 hours of ED visits. Seventy-seven percent of patients sought care within one day of developing emergency conditions. Fever as a chief complaint (p = 0.016), and levels 1 and 2 of emergency severity index (ESI) were the risk factors associated with cancer ED visits resulting in hospitalization (odds ratio = 5.64; 95% confidence intervals 1.09-29.14).CONCLUSION: ED visits were common among children with cancer. The most frequent chief complaints were fever, gastrointestinal complaints, and respiratory complaints. Approximately 80% of ED visits resulted in hospitalization. Having fever as the chief compliant, especially in patients with high body temperature, and levels 1 and 2 of ESI, were associated with an increased likelihood of admission. This study provides valuable baseline information to enhanced the quality of emergency care for pediatric cancer patients.

Comparison between Emergency Severity Index plus peak flow meter and Emergency Severity Index in the dyspneic patients with chronic obstructive pulmonary disease: A randomized clinical trial

Introduction:An effective triage needs to consider many factors, such as good triage protocol, experienced triage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage (SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associated with triage appropriateness. Methods:This study was done in two phases. In the first phase, a team of emergency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT model by considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), Pediatric Canadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of the hospital as the core concept. In the second phase, a prospective observational study was conducted in the ED of Songklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to October 2019 to evaluate the accuracy of the developed triage model. Results: A total of 520 pediatric patients met the inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%, respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction of death, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triage were 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage were underlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75‒9.23), fever (OR = 0.60, 95%CI: 0.41‒0.88), dyspnea (OR: 6.38, 95%CI: 2.51‒16.22), diarrhea (OR = 0.26, 95%CI: 0.09‒0.73), oxygen saturation <95% (OR = 3.18, 95%CI: 1.09‒9.27), accessory muscle use during breathing (OR = 3.67, 95%CI: 1.09‒12.41), and wheezing or rhonchi (OR = 6.96, 95%CI: 3.14‒15.43). Conclusion:SPT showed good correlation of hospital admission rates and resource utilization with pediatric triage level of urgency. However, further efforts are needed to decrease the rates of over- and under-triage.

Patients triaged in category 5 of the Emergency Severity Index (ESI) do not need any resources before discharge from the emergency department (ED). We studied the characteristics of these patients and focused on those who were admitted or sent to the outpatient department after their ED visit. A retrospective observational study was conducted on 117 740 patient presentations. Patients were included in the study when they were triaged with the ESI and presented to one of the two EDs under study between 1 September 2004 and 1 June 2006. Overall, 22.2% of the patients were triaged in ESI 5. Patients aged less than 40 years, women, and self-referred patients were most likely triaged in ESI 5, as well as patients presenting with complaints such as 'checkup appointments at the ED' and 'complaints of the skin'. Patients triaged in ESI 5 who were admitted or sent to the outpatient department were most likely elderly (aged above 65 years) and referred patients. They were also more likely to present with complaints such as 'postoperative complications, wound care problems, and plaster problems' and 'complaints of the genitourinary system'. Although younger patients and women were more likely triaged in ESI 5, patients within this category who were admitted or sent to the outpatient department were more likely elderly and referred patients. Being admitted or sent to the outpatient department and triaged in ESI 5 indicates undertriage. Revision of the system is required to properly account for these patient groups.

Objective:To evaluate the validity, reliability, sensitivity, and specificity of the Emergency Severity Index (ESI) and Australasian Triage System (ATS) for children visiting admitted to the emergency department (ED). Methods: This was a prospective study occurred in the Mofid children's Hospital in Iran from August 2017 to November 2018 and children had aged ≤14 years and presented at the ED with a medical symptom were considered eligible for participation. This study was divided into two phases: in the first phase, we determined the inter-rater reliability of ESI version 4 and ATS by triage nurses and pediatric residents. In the second phase, to analyze the validity, sensitivity, and specificity of each triage system. Reliability and agreement rates were measured using kappa statistics. Results:ESI showed inter-rater reliability with kappa of 0.65–0.92 (P<0.001) and ATS showed inter-rater reliability with kappa of 0.51–0.87 ESI had sensitivity ranged from 81% to 95% and specificity ranged from 73% to 86%. In addition, sensitivity ranged of the ATS were 80% to 95% and specificity ranged from 74% to 87%. Under triage and over triage occurred in 12% and 15% of patients respectively in ESI and 13% and 15% of patients respectively in ATS.Conclusion:The ESI and ATS both valid to triage children in the ED section of Mofid children's Hospital paediatric. Reliability of the ESI is good, moderate to good for the ATS.