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

Slide Presentation from the AHRQ 2008 Annual Conference

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; Plugin Software Help).

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)

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: http://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