Introduction
Accurate and reliable triage is needed to safely prioritize care and achieve optimal resource allocation in busy emergency departments (EDs). The 5-level Emergency Severity Index (ESI) is among the most popular ED triage algorithms, currently in use by a majority of EDs in the United States and increasingly adopted internationally.1, 2 The ESI facilitates rapid decisionmaking through 3 primary questions: (1) Does this patient require an immediate lifesaving intervention? (2) Is this a high-risk situation? and (3) How many resources are required to care for this patient?1Editor’s Capsule Summary
What is already known on this topic
The Emergency Severity Index (ESI) is a simple, commonly used tool for emergency department (ED) triage categorization.
What question this study addressed
Does ESI use by nurses create accurate and consistent acuity designations in similar patients?
What this study adds to our knowledge
Using standard triage scenarios presented to 87 ESI-trained nurses in 3 countries, the mean accuracy was 59.2%, with only modest interrater reliability. Medium-acuity and adult patient scenarios had greater but still truncated accuracy.
How this is relevant to clinical practice
The ESI has limits when used to guide triage. Opportunity for a better initial ED triage tool exists.
The ESI is unique in its explicit consideration of resource use and use of a simple algorithm that is subjective and relies heavily on nursing intuition to facilitate rapid decisionmaking. In an era in which ED crowding is commonplace, with time and resources universally constrained, the utility of the ESI is obvious and its popularity is not surprising. However, it has not been well validated against time-sensitive or critical outcomes, and the majority of studies establishing ESI validity and reliability were performed soon after its implementation and in the United States, where the tool was developed.1 Several lines of evidence, including a wide range of interrater reliability,2 lack of true discrimination, with nearly half of patients nationwide triaged to the middle-tier ESI level 3,2, 3 and reports of suboptimal performance with low accuracy and high variability outside the United States,4, 5 suggest that the ESI may perform less well in true clinical context than expected.3, 6
In this internationally collaborative study, we sought to assess accuracy and variability of triage score assignment by ESI-trained nurses using standardized triage cases in 3 countries. We hypothesized suboptimal concordance with reference standard (ie, low accuracy) and high variability between individual raters across all sites. We also hypothesized higher accuracy among more experienced nurses and explored relationships between triage scenario type (ie, trauma versus nontrauma and adult versus pediatric) and accuracy and variability.