Predicting Pediatric Emergency Severity Index Level Based on Emergency Department Pre-Arrival Information
Introduction
Emergency departments (EDs) often receive referral calls from outside providers ahead of time to alert them that patients are coming to be evaluated and treated. Understanding these pre-arrival patients' severity status and likely need for resources would potentially be helpful in allocating appropriate nursing staffing.
Triage levels are assigned to patients arriving to EDs indicating the patient's clinical status and anticipated resources as a means to prioritize the patients presenting for care. Emergency nurses also use triage levels for approximating the number of required interventions, balancing patient assignments, and standardizing the frequency and timing of assessments.
The Emergency Severity Index (ESI) is a commonly used, validated triage leveling tool typically assigned at the time of patient arrival to the emergency department (Dateo, 2013, Gilboy et al., 2011, Green et al., 2012, Worster et al., 2007). In a recently published study, it was found that prediction of ESI by physicians using emergency medical services (EMS) referral information was only fairly reliable (Williamson, Gochman, Bullaro, Kaufman, & Krief, 2017). There are no studies to date evaluating emergency nurses' assignment of ESI levels for pre-arrival patients and it is unclear if ESI level can be accurately determined based on phone referral information from multiple referral sources.
The purpose of this study was to determine the ability of emergency nurses to predict ESI levels for pre-arrival patients based on phone referral information and to assess the relationship between the predicted pre-arrival ESI level and ultimate patient disposition.
Section snippets
Design
A prospective single group exploratory study was conducted with ESI levels determined by emergency nurses before the patient's arrival and again at the time of arrival.
Setting and Sample
This study was conducted in the emergency department of a pediatric tertiary care center with an average of approximately 38,000 patients per year. In this emergency department, patients can be called in ahead of their arrival to the ED Communication Center located within the emergency department. This center fields an average of
Results
There were 500 patients enrolled in the study. A total of 19 (3.8%) mental health patients were excluded from the analyses because in this emergency department, these patients are automatically assigned an ESI level of 2. A total of 481 patients were included in the analyses.
Table 1 contains a description of the sample characteristics of the patients (N = 481) enrolled in the study based on the binary pre-arrival ESI levels assigned. Patient age and gender did not differ significantly between the
Discussion
In this study, we demonstrated that trained emergency nurses could predict ESI levels that had moderate agreement with arrival ESI levels based on standardized phone referral information. We also demonstrated that the majority of patients with a pre-arrival ESI level of < 3 were more likely to be admitted to the hospital, including the ICU.
Implementing this practice could improve efficiency of response upon patient arrival and inform ED team assignments and staffing plans based on predicted
Limitations
This study had several limitations. It was conducted in the emergency department of one pediatric tertiary care center with a stable referral base; this feature may limit generalizability of the study results.
While ESI Version 4 has been found to be a valid, reliable tool with good inter-rater reliability (Dateo, 2013, Green et al., 2012, Worster et al., 2007), the inter-rater reliability of the emergency nurses participating in this study was not assessed. In a previous study of pediatric ESI
Conclusions
Experienced emergency nurses were able to use standardized telephone referral information to predict pre-arrival ESI levels. Our study showed that the pre-arrival ESI levels had moderate agreement with the ESI level assigned upon patient arrival to the emergency department. The majority of patients with pre-arrival ESI level of 1 or 2 were admitted to the hospital; furthermore, these patients were also more likely to be admitted to the ICU.
Implementing a predictive ESI leveling practice could
Acknowledgments
I would like to thank Rupy Sandhu, RN, for her encouragement and support when this project was first being considered. I am also grateful to Karen Thomas, PhD, for her mentorship and Ellen Kuwana, MS, for her editing expertise. This work was supported by a grant from the Seattle Children's Research Institute Nursing Research Program (1149).
References (10)
What factors increase the accuracy and inter-rater reliability of the emergency severity index among emergency nurses in triaging adult patients?
Journal of Emergency Nursing
(2013)- et al.
Triage tool inter-rater reliability: A comparison of live versus paper case scenarios
Journal of Emergency Nursing
(2007) - et al.
Large sample standard errors of kappa and weighted kappa
Psychological Bulletin
(1969) - Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A.M. (2011). Emergency severity index (ESI): A triage tool for...
- et al.
Emergency severity index version 4: A valid and reliable tool in pediatric emergency department triage
Pediatric Emergency Care
(2012)