Written by Joshua Belfer
Spoon Feed
Mistriage was common in a cohort of children presenting to the pediatric ED, with the majority of children being overtriaged.
Understanding mistriage in the ED
A retrospective cohort study of over a million pediatric ED visits at 21 EDs within Kaiser Permanente Northern California assessed the frequency of mistriage using Emergency Severity Index (ESI) levels. Utilizing a modified Delphi process to determine events suggesting greater intensity of care, the authors applied a mistriage algorithm to compare algorithm-determined ESI levels against the assigned ESI level. Overtriage occurs when fewer resources than anticipated are used, while undertriaged patients are more ill or require more resources than expected. Most visits were assigned an ESI level 3 (51.5%) or level 4 (46.5%). Of all the visits analyzed, 34.1% were assessed as correctly triaged, 58.5% were overtriaged, and 7.4% were undertriaged. ESI level 3 visits were the most common ESI level mistriaged, with most (65%) being overtriaged. While rates of mistriage varied among the 21 hospitals, they did not vary consistently with greater availability of pediatric resources or pediatric ED volumes. Multivariable analysis identified multiple sociodemographic characteristics associated with mistriage, with those more likely to be undertriaged being older (≥6 years); male; of Asian, Black, or Hispanic race or ethnicity; or having arrived by ambulance. While the study utilized version 4 of the ESI, the currently available version is version 5, so these findings cannot be generalized to this version. Additionally, subjective information such as pain or social complexity is difficult to capture in the EHR, and may contribute to ESI levels assigned by triage nurses.
How will this change my practice?
This study comes from the same group that found that roughly 1 of every 3 adult ED patients in the Kaiser Permanente system were mistriaged. We also know that information from triage may bias the workup done in the ED. While the majority of patients were overtriaged, I would rather the ESI system overestimate severity than underestimate. When there are several patients to be seen, I rely on the ESI level and triage information to prioritize the order in which I see children. A crucial question not addressed is the association between mistriage and patient care. In an ED like mine, where the majority of triage is done by a different nurse than the one that cares for the patient, my hunch would be that despite an ESI level, if the nurse recognizes the patient is ill, he or she will grab the physician immediately; in these scenarios, mistriage may have a less significant clinical impact.
Source
Kaiser Permanente Clinical Research on Emergency Services & Treatments (CREST) Network. Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients. JAMA Pediatr. 2024 Oct 1;178(10):1027-1034. doi: 10.1001/jamapediatrics.2024.2671. PMID: 39133479
