Outcomes for Emergency Severity Index Triage Implementation in the Emergency Department

Abstract

IntrOductIOnHospital triage in the emergency department (ED) is defined as allocating priority for the provision of care and cure for the patients in the emergency department [1]. In response to overcrowding in emergency departments and in order to ensure critically-ill patients receive services in a timely manner, so hospital triage is developed by using reliable and valid guidelines in order to improve effectiveness [2]. Since the triage decision making process has been introduced as a context-dependent process which is affected by significant internal and external factors [3][4][5][6][7][8], so the complexity of triage decision making has resulted in special attention to the validity and reliability while using triage scales in the emergency departments [6][7][8][9][10][11].The reliability of the Emergency severity index (ESI) triage has been assessed using inter-rater agreement mainly and test-retest among nurses and physicians [2,[12][13][14][15]. The validity of triage has been assessed by key indicators such as emergency department admission [13][14][15][16][17][18][19][20][21] or ICU admission [13,14,19], length of ED [16,19] or hospital stay [13,22], mortality [17,19,20], Hospital discharge [13,14] or left without being seen [16][17][18][19] and resource utilization [13,20,22].Being simple and objective has made the ESI triage system reasonable to be accepted worldwide. The reliability and validity of the ESI has been approved in U.S. [23][24][25] but in the other countries need more investigation and verification. Kyranou in Greece [16] demonstrated that the establishment of the ESI in the ED had good reliability and validity but improvement of nurses` experience and long-term follow-up are necessary to succeed. Grossmann in Switzerland [13] revealed that using the ESI in the ED of an urban tertiary care center is valid, reliable and culturally adapted. Chi in Taiwan [19] found that the ESI produces more accurate discrimination on the basis of patient acuity than the Taiwan triage system. Elshove-Bolk in Norway [21] showed that the ESI triage reliably predicts patient acuity in a population of self-referred patients. Selman [26] revealed that the ESI triage system assists the practitioner in identifying the priorities of care and has the potential for significantly improve patient outcomes. But there are serious concerns about using the ESI in emergency departments of other countries because there are significant differences in the structure of their health care system and culture of care comparing to U.S. Therefore, it is essential to consider the compliance of the triage process in emergency departments with the ESI The ESI has been shown to have good reliability and validity in EDs of many developed countries [12,13,16,19,21]. The importance of applying valid and reliable scales in EDs has been recommended [27,28] however, little information on the ESI reliability and validity in emergency departments of Iran is available [29]. In early 2011, there were only a few emergency departments which used...

Emergency severity index version 4 during the first year of implementation at an academic institution

“…[33] Many studies used weighted kappa values that may over estimate the reliability. [19,24] For the six studies in the meta analysis on reliability of ESI, the overall agreement rate was 78.5%. [19] We theorize that an acceptable level may be 70% agreement, especially since the ESI v4 training manual states that nurses using the ESI system were able to predict how may resources the ED patient required 70% of the time.…”

“…[18] There is a wide range of results regarding reliability (from fair to very good) and validity of triage systems in the literature; with ESI and CTAS having the highest reported reliability. [12,23,24] However, a systematic review of different triage systems suggests there is limited and insufficient evidence for assessing validity and reliability in many triage scales, with variability in the methods and measurements (kappa, weighted kappa, Pearson). [22,23] Validity is difficult to assess for triage acuity, as there is no true gold standard upon which to measure.…”

“…[3,13] Garbez et al argued that this may not be specific enough for less experienced nurses. [24,30] Several studies showed that the ESI system has a tendency to allocate patients to ESI level 2. [19,24] Singer et al also noted that some respondents were misclassifying by using their perception of what tests the emergency physician may order or their own perception of the patient's condition, instead of using the exact ESI algorithm.…”

“…[24,30] Several studies showed that the ESI system has a tendency to allocate patients to ESI level 2. [19,24] Singer et al also noted that some respondents were misclassifying by using their perception of what tests the emergency physician may order or their own perception of the patient's condition, instead of using the exact ESI algorithm. [29] While it is interesting to note that these nurse respondents thought the ESI triage system was helpful for less experienced nurses, the original intent is that this triage system is for experienced nurses.…”

The reliability of the Australasian Triage Scale: a meta-analysis

“…[1] The Australasian Triage Scale (ATS) is a five-level emergency department triage algorithm that has been continuously developed in Australia and subjected to several studies. [2][3][4][5][6][7] The ATS, a 5-point triage scale, has been endorsed by the Australasian College for Emergency Medicine and adopted in performance indicators by the Australian Council on Healthcare Standards.…”