Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

Abstract

Introduction: The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED. Methods: We defined under-triage as patient visits with an Emergency Severity Index (ESI) score of 4 or 5 (ie, low acuity), and the patient was admitted to the hospital during the same visit. We defined mistriage, or medical error, when nurse-physician dyad reviewers determined that a different ESI level should have been assigned based on the information available at triage. A multidisciplinary team used nominal group technique to build consensus on key drivers and outcome metrics for this new trigger. We randomly selected 267 charts for review utilizing the under-triage trigger. Results: Of the 125,457 patients triaged as level 4 or 5 in 2019 and 2020, 1.1% (n = 1,423) were under-triaged. Of the 267 charts reviewed, 127 were categorized as mistriage, making the under-triage’s positive predictive value trigger 48%. Reviews took 2–10 minutes per chart. We identified 10 categories of under-triage. Nine themes emerged, with four specific and measurable action items mapped to process and outcome metrics. Conclusions: We identify a new, feasible ED trigger, under-triage, that identifies medical error with a high positive predictive value. We identify process and outcome metrics and interventions to improve triage for future patients.

Race and Ethnicity and Primary Language in Emergency Department Triage

“…24 Lower acuity scores can also lead to a mismatch in the degree of care patients need and are given in the ED, as patients with lower triage ESI scores are more likely to be placed in areas with higher patient-to-nurse ratios. 25,26 Racial and ethnic disparities in triage also cause immediate and delayed harms by undermining the trustworthiness of the ED and the health care system as a whole. Structural, institutional, and interpersonal racism, discrimination, and bias in health care-both historic and current-have undermined the trustworthiness of health care institutions for many communities primarily of minority racial and ethnic populations.…”

“…Undertriaging patients with acute, but not immediately life-threatening symptoms leads to longer wait times for physician evaluations, entailing delays in time-sensitive treatments, such as antibiotics in patients with sepsis, and for imaging in patients with fractures . Lower acuity scores can also lead to a mismatch in the degree of care patients need and are given in the ED, as patients with lower triage ESI scores are more likely to be placed in areas with higher patient-to-nurse ratios …”

Improving Wait Times for Children with Caregivers with Limited English Proficiency in the Emergency Department

“…Swarming with the interpreter creates a more efficient workflow for the interpreter, patient, and care delivery team. 10 …”

KUTS: A Foundational Triage System for Improving Accuracy in Mid-Level Emergency Classifications

“…And even nurses with years of experience can also develop triage fatigue [20]. Practical clinical work relies on junior doctors and nurses as well as their intuitive work experience [21] to accomplish some initial triage work, such as possible diagnosis and differential diagnosis of the patient, and to decide on the most important next step of life-saving treatments. Due to the inexperience and uneven level of junior doctors, on one hand, clear inquiries and enough attention to some key information related to the condition may fail to be acquired; on the other hand, juniors may be incapacitated to forecast the upcoming changes in the patient's condition or differentiate between patients with moderate severity of symptoms and give suitable grading.…”