10 The Impact of Triage-Leveling in an Environment of Emergency Department Crowding

Emergency departments (EDs) use triage classifications systems such as Emergency Severity Index (ESI) to stratify patients into groups based on acuity and resource utilization. Patients are commonly triaged into 5 levels with 1 being the highest acuity. Level 1 and 2 patients are given priority for ED bed assignment and 4 and 5 patients are often seen in designated locations. It is unclear what happens to level 3 patients, who do not get priority for the available beds and are too sick to go to a minor care area. The purpose of this study is to determine triage level 3 patients’ throughput and utilization characteristics compared to other triage levels. We performed a cross-sectional secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) database from 2009-2010. This is a multi-stage survey of ED visits from the US conducted by the Centers for Disease Control. A subset of the database was identified using a survey item indicating patient triage level. Data collected on this subset included demographics, arrival mode, timing of visit, waiting time, length of visit, diagnosis, tests/procedures performed, and disposition. National visit estimates for this combined time period were made using survey procedures in SAS (Cary, NC) and presented with SDs and 95% CIs. During this 2-year period there were an estimated 254 million ED visits and 113 million of these were level 3 patients. The median age of the level 3 patients was 37. Nineteen percent arrived by ambulance (compared to 9% for level 4 and 32% for level 2), with the most common chief complaints being abdominal pain, nausea/vomiting, and chest pain. The most common final diagnosis for level 3 patients was GI-related disease, followed by trauma. Day of the week, time of arrival, and average pain scale did not vary significantly between any triage level groups. The mean waiting time (57 minutes) was the longest for level 3 patients compared to other levels (Table). The average length of visit and proportion requiring tests or procedures was similar for level 1-3 patients and significantly higher than level 4-5 patients. In addition, significantly higher proportion of level 3 patients were admitted to the hospital than level 4 and 5 patients but less than level 1 and 2 patients (Table). With increasing ED crowding and limited bed availability, triage is an important tool for resource allocation. Triage level 3 patients are more similar to triage level 1 and 2 (as compared to triage level 4 and 5) patients in relation to length of stay, admission rates, and number of tests and procedures ordered. Yet, triage level 3 patients are waiting longer for evaluations and are at higher risk of delayed care. Further strategies in ED management should focus on processes to better evaluate triage level 3 patients.TableTriage level12345Waiting time (min) mean (SD)28 (0.97)46 (0.53)57 (0.34)53 (0.48)47 (0.83)Length of ED stay (min) mean, (SD)230 (7.3)272 (2.19)237 (1.29)161 (0.96)139 (2.03)Proportion with test-procedure (95% CI)78% (95% CI 74, 81)83% (95% CI 82, 84)78% (95% CI 78, 79)57% (95% CI 56, 58)42% (95% CI 41, 45)Admitted to hospital (95% CI)27% (95% CI 23, 30)32% (95% CI 30, 33)16% (95% CI 16, 17)5% (95% CI 4, 5)4% (95% CI 3, 5)Min, minutes. Open table in a new tab