ESI Triage Distribution in U.S. Emergency Departments

The accurate triage of arriving emergency department (ED) patients is a key component of emergency nursing practice. Overtriage assignment of patients misallocates scarce resources in a time of department overcrowding, whereas patient undertriage can create risks for negative patient outcomes secondary to care delays. Limited evidence is available regarding ED triage accuracy. It is estimated that appropriate adherence to the Emergency Severity Index (ESI) triage tool and assigning triage categories could be as low as 60% (McFarlane, 2019a, 2019b). The purpose of this retrospective observational study was to examine the 2019 triage distribution of 954,847 ED encounters at 25 hospitals. Comparisons were then made with the spreads identified in the ESI Implementation Handbook (Gilboy, Tanabe, Travers, & Rosenau, 2020). Study results reflect the presence of wide variations in distribution when compared with the expected spread published by Gilboy et al. (2020). These variations illustrate the need for further facility-level evaluation. ESI Level 2 percentages varied from as little as 2.6% to as high as 69% of each facility's ED visit population. Examining an individual facility's annualized triage distribution may serve as a swift method in determining whether additional investigation into triage accuracy is warranted. EDs must implement and sustain an ongoing quality control program to achieve and maintain triage inter- and intrarater reliability. Further research is needed on the value of triage inaccuracy with real-time feedback on nurses' clinical decision-making and patient outcomes. It is also imperative that the expected and observed ESI triage distribution in U.S. EDs is updated when established accuracy quality control programs are present.