The Emergency Severity Index (ESI), A Triage System: Research and Implementation

Slide Presentation from the AHRQ 2008 Annual Conference

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On September 8, 2008, Paula Tanabe, Ph.D., M.P.H., R.N., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.9 MB).

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Slide 1

The Emergency Severity Index (ESI), A Triage System: Research and Implementation

AHRQ Annual Meeting 2008

Paula Tanabe, PhD, MPH, RN
Northwestern University, Feinberg School of Medicine
Department of Emergency Medicine and the Institute for Healthcare Studies

Slide 2

ESI Research Team Members

• David Eitel, MD, MBA, York Hospital, Pennsylvania.
• Nicki Gilboy, MS, RN, FAEN, Massachusetts.
• Alex Rosenau, DO, Pennsylvania.
• Debbie Travers, PhD, RN, FAEN, North Carolina.

Special acknowledgement to Debbie Travers for assistance in the development of this presentation.

Slide 3

Importance of Triage

• Emergency departments (ED) are crowded with long waits for physician evaluation.
• Incoming patients are initially assessed by a triage nurse and assigned an acuity level:
  • Who needs to be seen immediately?
  • Who is safe to wait?
• Waiting room is the highest risk area of the ED.
• Requires a scientifically validated triage acuity rating system.

Slide 4

Estimates of Triage System Choice in the United States (n=444)

Type	No of EDs	%
Uses triage	413	93%
3 level	193	45%
4 level	47	11%
CTAS	32	7%
ESI	134	30%

Slide 5

Evaluating Triage Systems Validity and Reliability

• Validity:
  • Proxy measures for acuity include death and hospitalization.
• Reliability: Inter-rater:
  • Will nurses rate the same patient with the same ESI rating?
  • Measured with Weighted kappa (K).
  • Range (0-1, no to perfect agreement).

Slide 6

Early work in ESI—Late 1990's

• Drs. Richard Wuerz and David Eitel devised the original algorithm.
• Piloted at Boston hospitals—1998 for ages 14 and older
• ESI shown to be reliable and valid.
• Produced 5 distinct categories by:
  • Admission, length of stay
  • Resources, charges
• Obtained funding from AHRQ.

Source: Wuerz, Milne, Eitel, Travers, Gilboy (2000), Reliability & validity of a new 5-level triage instrument. Acad Emerg Med 7:236-242.

Slide 7

AHRQ Funded Multi-Center Trial—1999-2001

• Funded by AHRQ (Agency for Healthcare Research and Quality).
• Seven EDs in 3 states:
  • Brigham & Women's (BWH, Boston)
  • Faulkner (Boston)
  • University of North Carolina (UNC, Chapel Hill, NC)
  • York (York, PA)
  • Lehigh Valley (LVH, Allentown, PA)—3 sites.
• Excellent reliability (k=.78) and validity.

Slide 8

Hospitalization: AHRQ Multi-center Study

Screen shot of a line graph showing the AHRQ Multi-center Study at the study sites BWH, LVH, UNC, York, Faulkner, 17th, and Muhl. The vertical axis goes from 0% to 100% and the horizontal axis goes from 1 to 5. BWH, LVH, and UNC begin between 80%-100% during period 1. York, Faulkner, and Muhl begin between 60%-80%, while 17th begins at 100% during period 2. All finish between 0%-10% by period 5.

Slide 9

Casemix: AHRQ Multi-center Study

Screen shot of a line graph showing the AHRQ Multi-center Study at the study sties BWH, LVH, UNC, York, Faulkner, 17th, and Muhl. The vertical axis goes from 0% to 60% and the horizontal axis goes from 1 to 5. All begin between 0%-5% during period 1. BWH, LVH, UNC, York, and Muhl peak between 30%-50% during period 3, while Faulkner and 17th peak between 35%-52% during period 4. All end between 3%-27% during period 5.

Slide 10

ESI Version 4

The document image shows a copy of the document entitled: "ESI Triage Algorithm, v4."

Slide 11

ESI v.4 Materials

• Published May 2005:
  • ESI Implementation Handbook.
  • Educational DVDs
  • Total requests: 17,142 (as of April 30, 2008)
• Agency for Healthcare Research and Quality (AHRQ):
  • Translating research into practice: https://www.ahrq.gov/research/esi.
• Free of charge:
  • Handbook—downloadable.
  • DVD's.

Slide 12

Emergency Severity Index

Screen shot of the cover of the AHRQ ESI handbook from February 2005.

Slide 13

Ongoing Research

• Pediatric validation study funded by the Health Resources and Services Administration (HRSA).
• Coordinating center:
  • UNC Department of Emergency Medicine.
• Several new pediatric centers added as research sites.

Slide 14

AHRQ Formal Evaluation

• NORC, and The George Washington University.
• Formal assessment of the ESI training materials.
• Timeline:
  • Fall 2008 with final report to AHRQ in February 2009.
• Goals:
  • Measure the acceptance of the ESI by ED personnel.
  • Assess the satisfaction training materials.
  • Compare usefulness of the ESI with other similar triage tools.
  • Determine what improvements users would like to see in the next version of the products.

Slide 15

References

• Eitel D, Travers D, Rosenau A, Gilboy N, Wuerz R. The Emergency Severity Index Triage Algorithm Version 2 is Reliable and Valid. Academic Emergency Medicine 2003; 10(10):1070-1080.
• Tanabe, P, Travers, D, Gilboy, N, Rosenau, A, Sierzega, G, Rupp, V, Martinovich, Z, Adams, JG. Refining emergency severity Index triage criteria. Academic Emergency Medicine 2005; 12(6):497-501.

Slide 16

Questions?

www.ahrq.gov/research/esi
E-mail: esitriage@yahoo.com