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Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients
Dana R Sax1, E Margaret Warton2, Mamata V Kene1
1The Permanente Medical Group and Kaiser Permanente Division of Research, Pleasanton, California.
Insights
Mistriage using the Emergency Severity Index (ESI) is common in pediatric emergency departments. This study found opportunities to improve triage accuracy for both critically ill and low-acuity pediatric patients.
Area of Science:
- Emergency Medicine
- Pediatric Care
- Healthcare Quality Improvement
Background:
- The Emergency Severity Index (ESI) is widely used in US emergency departments (EDs) to predict patient acuity and resource needs.
- A comprehensive assessment of ESI accuracy specifically for pediatric patients is currently lacking.
Purpose of the Study:
- To evaluate the frequency of mistriage in pediatric emergency department visits using the Emergency Severity Index (ESI) version 4.
- To identify patient and visit characteristics associated with undertriage and overtriage in pediatric populations.
Main Methods:
- A retrospective cohort study was conducted using data from 21 Kaiser Permanente Northern California EDs between January 1, 2016, and December 31, 2020.
- Operational measures for each ESI level were used to classify encounters as undertriaged, overtriaged, or correctly triaged.
- Data included over 1 million pediatric ED visits, with exclusions for missing ESI, incomplete data, transfers, and patients leaving without being seen or against medical advice.
Main Results:
- Correct triage occurred in 34.1% of pediatric ED visits, while overtriage occurred in 58.5% and undertriage in 7.4%.
- Undertriage was more prevalent in older children (≥6 years), males, non-White races/ethnicities, those with comorbidities, and patients arriving by ambulance.
- Overtriage was significantly more common than correct triage across all pediatric visits.
Conclusions:
- Mistriage, both undertriage and overtriage, is a common issue with the ESI version 4 in pediatric emergency departments.
- There is a significant opportunity to enhance pediatric ED triage systems to improve the identification of critically ill children and the efficient allocation of resources for low-acuity patients.
- Future research should evaluate the performance of ESI version 5, which was released after this study period.
Importance:
Most emergency departments (EDs) across the US use the Emergency Severity Index (ESI) to predict acuity and resource needs. A comprehensive assessment of ESI accuracy among pediatric patients is lacking.
Objective:
To assess the frequency of mistriage using ESI (version 4) among pediatric ED visits using automated measures of mistriage and identify characteristics associated with mistriage.
Design, Setting, And Participants:
This cohort study used operational measures for each ESI level to classify encounters as undertriaged, overtriaged, or correctly triaged to assess the accuracy of the ESI and identify characteristics of mistriage. Participants were pediatric patients at 21 EDs within Kaiser Permanente Northern California from January 1, 2016, to December 31, 2020. During that time, version 4 of the ESI was in use by these EDs. Visits with missing ESI, incomplete ED time variables, patients transferred from another ED, and those who left against medical advice or without being seen were excluded. Data were analyzed between January 2022 and June 2023.
Exposures:
Assigned ESI level.
Main Outcomes And Measures:
Rates of undertriage and overtriage by assigned ESI level based on mistriage algorithm, patient and visit characteristics associated with undertriage and overtriage.
Results:
This study included 1 016 816 pediatric ED visits; the mean (SD) age of patients was 7.3 (5.6) years, 479 610 (47.2%) were female, and 537 206 (52.8%) were male. Correct triage occurred in 346 918 visits (34.1%; 95% CI, 34.0%-34.2%), while overtriage and undertriage occurred in 594 485 visits (58.5%; 95% CI, 58.4%-58.6%) and 75 413 visits (7.4%; 95% CI, 7.4%-7.5%), respectively. In adjusted analyses, undertriage was more common among children at least 6 years old compared with those younger 6 years; male patients compared with female patients; patients with Asian, Black, or Hispanic or other races or ethnicities compared with White patients; patients with comorbid illnesses compared with those without; and patients who arrived by ambulance compared with nonambulance patients.
Conclusions And Relevance:
This multicenter retrospective study found that mistriage with ESI version 4 was common in pediatric ED visits. There is an opportunity to improve pediatric ED triage, both in early identification of critically ill patients (limit undertriage) and in more accurate identification of low-acuity patients with low resource needs (limit overtriage). Future research should include assessments based on version 5 of the ESI, which was released after this study was completed.
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