Geriatric/original researchTriage of Geriatric Patients in the Emergency Department: Validity and Survival With the Emergency Severity Index
Introduction
The Emergency Severity Index (ESI) version 3 algorithm is a 5-level triage instrument that has been shown to demonstrate reliability and validity in a wide range of patient populations.1, 2, 3, 4, 5, 6, 7 The algorithm was designed to evaluate both patient acuity and anticipated resource utilization necessary to reach disposition.3 The ESI instrument stratifies emergency department (ED) patients into 5 mutually exclusive categories, with ESI category 1 assignment representing the most acute, high-resource-utilization patients (cardiac arrest) and ESI category 5 representing patients who are the least acute and resource intense (medication refill).7 EDs nationally have identified crowding as one of their top areas of concern. The number of ED visits continues to climb, with fewer departments available to handle the volume.8 Coupled with hospital inpatient capacity that has become more constrained, entire initiatives have developed focusing on crowding and its ED impact.9 A reliable and valid triage instrument to accurately characterize waiting patients becomes essential for patient safety when one considers the resultant increased length of stay of ED patients.
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Importance
Despite the increasing size of the older population and evidence suggesting that elders more frequently utilize emergency services than their younger counterparts, little is known about the validity of many frequently used instruments in the geriatric population.10 Several instruments have been tested in the geriatric population to risk-stratify after an ED visit. The Triage Risk Screening Tool is an instrument that stratifies older ED patients who are discharged from the ED into risk groups
Study Design
This investigation used both a retrospective health records survey methodology and a survival analysis for a cohort of older patients presenting to the study ED between May 13, 2004, and June 12, 2004. The institutional review board at Maine Medical Center exempted the study and waived the requirement for written informed consent.
Setting and Selection of Participants
The Maine Medical Center ED is an academic referral center that houses an emergency medicine residency training program. The annual ED census at Maine Medical Center
Results
During the investigation, there were 1,088 patients aged 65 years or older registered in the ED. Six patients were found to be direct admissions to the hospital, 1 patient had an incomplete ED record, and 152 registrations were found to be repeated patient visits, leaving 929 visits for analysis. Table 1 displays demographic characteristics of the subjects. Interrater agreement between the data abstractors on 5 key data elements represented excellent agreement, with weighted κ scores ranging
Limitations
This study was conducted at a single tertiary care hospital in a small city serving an extensive suburban and rural geographic area. These results may be difficult to generalize to EDs serving dissimilar communities. In addition, the retrospective nature of the health records review methodology introduces the possibility of bias. We made diligent efforts to limit bias introduced by the retrospective methodology by reviewing multiple data sources (dictated attending physician notes, test
Discussion
In this cohort of ED patients aged 65 years or older, the third iteration of the ESI triage algorithm accurately predicted hospitalization, ED length of stay, and resource utilization. In addition, ESI triage categorization was strongly correlated to survival at 1 year after the index ED visit. The ESI provides an accurate snapshot of overall acuity in this vulnerable ED population. Coupled with other screening tools for the geriatric ED population, it could provide the basis for a complete
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Cited by (0)
Author contributions: MRB and TDS conceived the study, designed the trial, supervised the conduct of the trial, participated in data collection, performed data analysis, and drafted the manuscript, and both authors contributed substantially to its revision. TDS undertook data management. MRB takes responsibility for the paper as a whole.
Supervising editor: Knox H. Todd, MD, MPH
Reprints not available from the authors.
Funding and support: The authors report this study did not receive any outside funding or support.
Publication dates: Available online June 9, 2006.