Kaiser Permanente analysis suggests more accurate triage approach could increase efficiency, shorten ER visits for low-acuity patients
The current method used by most U.S. hospitals to initially evaluate pediatric patients in the emergency department (ED) overestimates the severity of children’s health status more than half the time, according to a new analysis by Kaiser Permanente researchers published in the journal Hospital Pediatrics.
The authors suggest that triage could be more accurate and efficient, benefiting patients with fewer tests and shorter visits, while maintaining safety.
“Our triage teams do a really great job trying to sort all patients on arrival,” said study co-author Dana Sax, MD, an emergency medicine physician with The Permanente Medical Group and a research scientist with the Kaiser Permanente Division of Research. “While we want to make sure we aren’t undertriaging and delaying care for the sickest patients, overtriage of more mild illness or injuries can also contribute to longer wait times and crowding.”
The study team examined more than a million pediatric patient visits between 2016 and 2020 at 21 Kaiser Permanente Northern California emergency departments, which use the Emergency Severity Index (ESI). ESI is the most common triage method, used in 70% of U.S. hospitals.
They compared how the initial severity level (of 5 levels, ESI I through V) aligned with eventual health care and resource use, categorizing each visit as accurately triaged or under- or overtriaged.
The researchers found 58.5% of the young patients were overtriaged, meaning they were identified as being more sick or unstable than they were later evaluated as being. Patients who were low acuity but assigned a higher severity score spent more time in the emergency department (an additional 36 minutes) than patients who were accurately triaged.
“This is a larger group of pediatric patients than has been studied before in the ED triage literature,” said lead author Daniel DiLena, a research associate with the Division of Research. “Our analysis identified opportunities for making the process more efficient, which would benefit both patients and flow through the ED and hospital inpatient units. If low-acuity patients are identified at first, by a triage nurse, they can be directed to teams managing these less acute patients in the ED.”
EDs at most hospitals have high volumes of patients and triage nurses have just a few minutes to collect information about a patient’s status before assigning them to one of the 5 triage severity levels.
The study found 4.3% of patients were undertriaged, or placed in a severity category lower than their eventual medical record reflected. The authors said this was a relatively small but important group to understand, because identifying high-risk patients and prioritizing their care is the most important job of triage teams. There are several possible reasons for undertriage; one possibility is that the patient’s symptoms were subtle when they first arrived at the ED and evolved over the course of their stay.
Overtriage in children could occur through an abundance of caution by triage teams to prevent complications in children with minor trauma, fever, or respiratory distress, the authors said.
Previous analysis in adults
The study team also recently published a similar analysis of triage in adult ED patients in Annals of Emergency Medicine. That study included 5.3 million ED visits between 2016 and 2020, and found about a third of high-acuity patients received an initial underestimate of their severity. Although these undertriaged patients waited longer for their initial diagnostic and therapeutic orders, the study showed no increased risk of mortality associated with the undertriage or delay in care.
Another one-third of adult patients were overtriaged. These patients had an average 42-minute longer ED visit than patients who were originally identified as low acuity.
“Further work is needed to refine triage protocols to improve the safety, quality, and efficiency of emergency care,” the authors wrote.
“Triage is, of course, an inherently difficult and very complex task,” said senior author Mary Reed, DrPH, a DOR research scientist. “We’re hoping to study the process to see if we can help improve the process. We’re interested in ways to reduce the uncertainty at emergency department triage so that patients get what they need sooner — both the sickest patients and those who are less sick.”
The study team, led by Sax and Reed, are using the data they’ve collected to build tools to improve the ED triage process, in collaboration with triage nurses who interact with patients each day.
One project involves development of a predictive model using machine learning and data elements from a patient’s own medical record at triage to better categorize patients by severity. Another team initiative involves designing a summary in the medical record that will allow triage nurses to have a high-level snapshot during the triage process that highlight’s each patient’s higher risk features to help them determine acuity assignments.
The study was funded by Kaiser Permanente Community Health.
Additional co-authors were Adina S. Rauchwerger, MPH, and Margaret Warton, MPH, of the Division of Research; Dustin Mark, MD, of The Permanente Medical Group; and Tina J. Vitale-McDowell, RN, of Kaiser Permanente Medical Center San Rafael.
###
About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org.
Comments (0)