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

Jeremiah S Hinson, Diego A Martinez, Paulo S K Schmitz, Matthew Toerper, Danieli Radu, James Scheulen, Sarah A Stewart de Ramirez, Scott Levin, Jeremiah S Hinson, Diego A Martinez, Paulo S K Schmitz, Matthew Toerper, Danieli Radu, James Scheulen, Sarah A Stewart de Ramirez, Scott Levin

Abstract

Background: Emergency 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.

Methods: This 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.

Results: Initial 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.

Conclusions: Despite 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.

Keywords: Emergency department; Emergency severity index; Mistriage; Triage.

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the institutional review boards of all participating institutions.

Consent for publication

Not applicable.

Competing interests

SL is the founder and co-owner of a start-up company with a focus on data-driven improvement of emergency department and hospital operations. JH, DM, PS, MT, DR, JS, and SR have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Distribution of ED visits by initial ESI designation and classifications as accurate, over-triage, or under-triage. High acuity = ESI level 1 or 2; moderate acuity = ESI level 3; low acuity = ESI level 4 or 5. ED emergency department; ESI Emergency Severity Index
Fig. 2
Fig. 2
Associations between triage accuracy and clinical outcomes. a Under-triage to moderate- and low-acuity ESI triage levels is associated with a significantly increased prevalence of hospital admission and critical outcomes. b Over-triage to moderate- and high-acuity ESI triage levels is associated with a significantly decreased prevalence of hospital admission and critical outcomes

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