What is the critical review of Emergency Severity Index (ESI) Triage?

From the Guidelines

The Emergency Severity Index (ESI) triage system requires critical review due to several limitations in modern emergency department settings, and I recommend implementing regular validation studies and considering supplementary tools to address its shortcomings. The ESI is a five-level triage algorithm widely used in emergency departments that categorizes patients based on acuity and resource needs, with level 1 being most urgent and level 5 least urgent. While ESI provides a standardized approach to patient prioritization, it has notable weaknesses including inconsistent inter-rater reliability, particularly for ESI levels 2 and 3, inadequate sensitivity to certain vulnerable populations like elderly patients and those with psychiatric conditions, and limited incorporation of vital signs in decision-making 1.

Limitations of ESI Triage

Some of the key limitations of the ESI triage system include:

• Inconsistent inter-rater reliability, particularly for ESI levels 2 and 3
• Inadequate sensitivity to certain vulnerable populations like elderly patients and those with psychiatric conditions
• Limited incorporation of vital signs in decision-making
• Lack of dynamic reassessment protocols for patients whose conditions change while waiting

Recommendations for Improvement

To improve triage accuracy, emergency departments should:

• Provide regular staff training focused on challenging triage scenarios
• Implement quality improvement measures that track triage accuracy
• Consider modified ESI versions that address specific population needs
• Develop complementary assessment tools for special populations, such as the guidelines for field triage of injured patients recommended by the National Expert Panel on Field Triage 1

Importance of Accurate Triage

Accurate triage directly impacts patient outcomes by ensuring timely care for those most in need while appropriately managing department resources. The ESI triage system, despite its limitations, remains a widely used and essential tool in emergency departments. By acknowledging its shortcomings and working to address them, healthcare providers can improve the quality of care delivered to patients. The guidelines for field triage of injured patients, as outlined in the MMWR Recommendations and Reports 1, provide a framework for improving triage decisions and ensuring that patients receive the appropriate level of care.

From the Research

Critical Review of Emergency Severity Index (ESI) Triage

The Emergency Severity Index (ESI) triage system is a widely used tool in emergency departments to prioritize patients based on their medical care needs. The system categorizes patients into five levels of acuity, with ESI level 1 being the highest acuity and ESI level 5 being the lowest.

Limitations and Challenges

• The ESI system has been found to have limitations in accurately triaging patients with suspected acute coronary syndrome (ACS) 2.
• Studies have shown that the ESI system can result in undertriage and overtriage of patients, with significant variations in triage accuracy by facility and patient characteristics 3.
• The system has been found to be poorly associated with serious outcomes in patients with suspected ACS, and supplementing the ESI tool with other validated clinical tools can improve the accuracy of triage 2.
• Clinical experience has demonstrated two levels of ESI level 2 patients: those who require immediate intervention and those who are stable to wait for at least ten minutes 4.

Predictive Value and Outcomes

• The ESI triage system has been found to have predictive value in determining urgency and guiding subsequent clinical decisions 5.
• Outcome measurements, such as hospitalization, mode of admission, mortality, length of stay in ED, cost of ED stays, and resources utilized, are all dependent on the initial triage categorization 5.
• The ESI system has been found to be associated with significant associations between triage category and outcomes, including seizures/febrile fits and pediatric intensive care unit (PICU) admissions 5.

Areas for Improvement

• Revisions to the ESI level 1 criteria may be beneficial to improve the accuracy of triage 4.
• Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity 3.
• The ESI system should be supplemented with other validated clinical tools to improve the accuracy of triage, particularly for patients with suspected ACS 2.
• Further research is needed to evaluate the effectiveness of the ESI system in different patient populations and settings 6, 3.

Key Findings

• Mistriage with ESI was common, occurring in 32.2% of encounters, with 3.3% undertriaged and 28.9% overtriaged 3.
• Black patients had a greater relative risk of overtriage and undertriage compared to White patients, and Black male patients had a greater relative risk of overtriage and undertriage compared to White female patients 3.
• High relative risk of undertriage was found among patients taking high-risk medications, those with a greater comorbidity burden, and those with recent intensive care unit utilization 3.