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Reliability and validity of the emergency severity index for pediatric triage
Debbie A Travers1, Anna E Waller, Jessica Katznelson
1School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. dtravers@email.unc.edu
Insights
The Emergency Severity Index (ESI) provides moderate reliability for pediatric triage, accurately stratifying patients by acuity. Further development of pediatric-specific educational materials is recommended to improve consistency.
Area of Science:
- Emergency Medicine
- Pediatric Triage
Background:
- The Emergency Severity Index (ESI) is a widely used 5-level triage tool for emergency departments.
- Its reliability and validity are established in general populations but less studied in pediatrics.
Purpose of the Study:
- To assess the reliability and validity of the ESI algorithm for pediatric triage across five different sites.
- To identify specific challenges in pediatric ESI triage.
Main Methods:
- Interrater reliability was measured using weighted kappa on written pediatric case scenarios and actual patient triages.
- Validity was assessed by comparing ESI ratings with patient outcomes like admission rates and resource use.
Main Results:
- Interrater reliability for ESI in pediatric triage was moderate (kappa=0.77 for scenarios, 0.57 for actual patients).
- Triage inconsistencies were observed for very young patients, medical complaints, and extreme acuity levels.
- ESI levels significantly correlated with patient outcomes, demonstrating validity.
Conclusions:
- The ESI demonstrates moderate reliability and validity for pediatric triage.
- Targeted educational interventions are needed to address identified areas of inconsistency in pediatric ESI application.
Objectives:
The Emergency Severity Index (ESI) triage algorithm is a five-level triage acuity tool used by emergency department (ED) triage nurses to rate patients from Level 1 (most acute) to Level 5 (least acute). ESI has established reliability and validity in an all-age population, but has not been well studied for pediatric triage. This study assessed the reliability and validity of the ESI for pediatric triage at five sites.
Methods:
Interrater reliability was measured with weighted kappa for 40 written pediatric case scenarios and 100 actual patient triages at each of five research sites (independently rated by both a triage nurse and a research nurse). Validity was evaluated with a sample of 200 patients per site. The ESI ratings were compared with outcomes, including hospital admission, resource consumption, and ED length of stay.
Results:
Interrater reliability was 0.77 (95% confidence interval [CI] = 0.76 to 0.78) for the scenarios (n = 155 nurses) and 0.57 (95% CI = 0.52 to 0.62) for actual patients (n = 498 patients). Inconsistencies in triage were noted for the most acute and least acute patients, as well as those less than 1 year of age and those with medical (rather than trauma) chief complaints. For the validity cohort (n = 1,173 patients), outcomes differed by ESI level, including hospital admission, which went from 83% for Level 1 patients to 0% for Level 5 (chi-square, p < 0.0001). Nurses from dedicated pediatric EDs were 31% less likely to undertriage patients than nurses in general EDs (odds ratio [OR] = 0.31, 95% CI = 0.14 to 0.67).
Conclusions:
Reliability of the ESI for pediatric triage is moderate. The ESI provides a valid stratification of pediatric patients into five distinct groups. We found several areas in which nurses have difficulty triaging pediatric patients consistently. The study results are being used to develop pediatric-specific ESI educational materials to strengthen reliability and validity for pediatric triage.