Undertriage of older ED patients common
MedWire News: The Emergency Severity Index is reliable and valid for the triage of patients aged 65 years and older in the emergency department (ED), yet undertriage often occurs, report researchers.
"Therefore, inadequate triage appears to be due to a lack of adherence to the Emergency Severity Index algorithm rather than to an inherent deficit of the algorithm itself," say Christian Nickel (University Hospital Basel, Switzerland) and colleagues.
For the study, two triage experts (an emergency physician and an advanced practice nurse) reviewed the triage notes for 519 patients aged at least 65 years who presented to a single ED. The experts were not aware of the triage level assigned at the time of presentation or of the patients' outcomes.
Overall, the Emergency Severity Index ratings given by the experts fitted well with patient outcomes. Just seven patients were rated as Emergency Severity Index level 1, and 42.9% died in hospital, compared with 6.2% of 97 rated as level 2, 1.7% of 297 rated as level 3, and none of 118 rated as level 4 or 5.
An Emergency Severity Index rating of 1 was 99.8% specific for predicting which patients received lifesaving treatments, although it was just 46.2% sensitive. The Emergency Severity Index was 74.1% accurate for hospital admission and 74.9% accurate for intensive care unit admission. It was also predictive of resource use and ED length of stay.
Agreement of Emergency Severity Index ratings between the two experts was high, but that between the experts and the triage nurses who had given the original patient ratings was only moderate, reports the team in the Annals of Emergency Medicine.
Overtriage, where the patient was awarded a higher rating than seemed appropriate to the experts in retrospect, occurred in just 15 cases, but 117 patients were undertriaged. In most cases, the nurses gave a level 3 rating where the experts felt level 2 was appropriate, but in two cases the experts assigned a level 1 rating where the nurses assigned level 3. In one case the difference was level 2 versus 4 for the experts and nurses, respectively, and in one case it was level 3 versus 5.
Most (24.8%) cases of undertriage occurred because of nurses incorrectly interpreting high-risk situations, such as new-onset confusion, lethargy, disorientation or severe pain, or distress. Another important factor - affecting 17.1% of cases - was inappropriate interpretation of vital signs.
The researchers say that the reasons for undertriage are probably varied, and include the "complex combination" of comorbidities that can occur in older patients, as well as their tendency to present with atypical symptoms "that might mask a high-risk situation or even the need of a lifesaving intervention."
They conclude: "Triage training programs should stress the importance of vital signs when applying the Emergency Severity Index to older patients. ED triage personnel should be aware of the risk of undertriage in this vulnerable patient group."
By Eleanor McDermid