Effects of a triage process conversion on the triage of high-risk presentations

Effect of Emergency Severity Index Annual Competency Assessment on Mistriage

BACKGROUND

There is limited evidence identifying best practices to promote competency of accurate assignment of the Emergency Severity Index (ESI) acuity level to patients who present to the emergency department (ED) triage.

LOCAL PROBLEM

Triage-trained nurses do not receive competency training in an ESI triage tool.

METHODS

A retrospective chart review of 150 patients was completed to evaluate mistriage rates before and after triage-trained nurses completed an ESI competency assessment.

RESULTS

The retrospective chart review showed no statistically significant difference in mistriage from pre- to postintervention (P = .8535).

CONCLUSIONS

Implementation of an ESI annual competency assessment aligns well with an emerging theme in the literature that ED nurses should be provided with ongoing education that reinforces knowledge and implementation of ESI triaging.

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department

OBJECTIVES

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.

METHODS

Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.

RESULTS

There was a higher level of agreement (κ  =  0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ  =  0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ  =  0.80; 95% CI 0.76-0.84).

CONCLUSION

The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

Racial disparity in emergency department triage

BACKGROUND

Previous reports of lower triage acuity scores and longer Emergency Department (ED) wait times for African Americans compared to Caucasians had insufficient information to determine if this was due to bias or appropriately based on medical history and clinical presentation.

OBJECTIVE

(1) Determine if African Americans are assigned lower triage acuity scores (TAS) after adjusting for a number of demographic and clinical variables likely to affect triage scores. (2) Determine if lower TAS translate into clinically significant longer wait times to assignment to a treatment area.

METHODS

This was a retrospective matched cohort design analysis of de-identified data extracted from the ED electronic medical record system, which included demographic and clinical information, as well as TAS, and ED process times. Triage scores were assigned using a 5-point scale (ESI), with 1 being most urgent and 5 being least urgent. Mean TAS and wait times to a treatment area for specific chief complaints were compared by race; after adjusting for age, gender, insurance status, time of day, day of week, presence of co-morbidities, and abnormal vital signs using a 1:1 matched case analysis.

RESULTS

The overall mean TAS for African Americans was 2.97 vs. 2.81 for Caucasians (difference of 0.18; p<0.001), translating to a lower acuity rating. African Americans had a significantly longer wait time to a treatment area compared to case-matched Caucasians (10.9min; p<0.001), with much larger differences in wait times noted within certain specific chief complaint categories.

CONCLUSION

Our current study supports the hypothesis that racial bias may influence the triage process.

The influence of emergency medical services transport on Emergency Severity Index triage level for patients with abdominal pain

OBJECTIVES

The Emergency Severity Index (ESI) is a prospectively validated, five-level emergency department (ED) triage system designed to match triage acuity to both patient acuity and appropriate resource allocation. The study hypothesis was that, in practice, there exists an inappropriate bias toward triaging patients with abdominal pain to a higher ESI level based solely upon their mode of arrival to the ED.

METHODS

The authors performed a retrospective case-control study of patients presenting with abdominal pain. Patients were matched on sex, age (± 5 years), and date of arrival. Cases were those patients triaged to a Level 2, and controls were those triaged as Level 3. Conditional multiple variable logistic regression was used to evaluate the effect of the following variables on the odds of being triaged as Level 2: mode of arrival, systolic blood pressure (<90 mm Hg; normal, >140 mm Hg), heart rate, severe pain score (≥ 8 of 10), fever, race, history of cancer, and previous abdominal surgery. Age was also included in the regression modeling to confirm that matching was adequate. One-hundred cases and 100 controls were necessary to provide adequate sample size. A backward modeling technique was used, requiring a p < 0.05 for retention.

RESULTS

Of the 200 subjects, 52 arrived by emergency medical services (EMS) and 148 walked in. After matching for sex, age, and date of arrival, and after adjusting for heart rate, cancer diagnosis, and severe pain, the odds ratio (OR) for being triaged ESI Level 2 was 7.19 (95% confidence interval [CI] = 2.75 to 18.8, p < 0.0001) for EMS patients compared to walk-in patients. The admission rate for Level 2 patients was not different from that of Level 3 patients (49% vs. 35% of Level 3 patients, p = 0.06), but EMS patients were more likely to be admitted, regardless of ESI level assignment (65% vs. 34%, p < 0.001).

CONCLUSIONS

After adjusting for covariates, EMS patients with abdominal pain were more likely to be triaged to a higher acuity level. Triage level was not associated with admission, but patients arriving by EMS were more likely to be admitted. This may indicate that the effect of EMS arrival on triage level assignment is actually appropriate. Further research is necessary to validate whether mode of arrival should be incorporated in the initial ESI triage acuity assignment.

Validation of an algorithm for categorizing the severity of hospital emergency department visits

BACKGROUND

Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated.

OBJECTIVE

To assess the validity of the NYU algorithm.

RESEARCH DESIGN

A longitudinal study in a single integrated delivery system from January 1999 to December 2001.

SUBJECTS

A total of 2,257,445 commercial and 261,091 Medicare members of an integrated delivery system.

MEASURES

ED visits were classified as emergent, nonemergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation approach.

RESULTS

Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within 1-day (odds ratio = 3.37, 95% CI: 3.31-3.44) or death within 30-days (odds ratio = 2.81, 95% CI: 2.62-3.00) than visits categorized as nonemergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for nonemergent conditions was not related to socio-economic status or insurance type.

CONCLUSIONS

The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for nonemergencies.