Paula Tanabe, PhD, MPH, RN Northwestern University, Feinberg School of Medicine

1. The Emergency Severity Index (ESI), A Triage System: Research and ImplementationAHRQ Annual Meeting 2008 Paula Tanabe, PhD, MPH, RN Northwestern University, Feinberg School of Medicine Department of Emergency Medicine and the Institute for Healthcare Studies

2. ESI Research Team Members • David Eitel, MD, MBA, York Hospital, Pennsylvania • Nicki Gilboy, MS, RN, FAEN, Massachusetts • Alex Rosenau, DO, Pennsylvania • Debbie Travers, PhD, RN, FAEN, North Carolina Special acknowledgement to Debbie Travers for assistance in the development of this presentation.

3. Importance of Triage • Emergency departments (ED) are crowded with long waits for physician evaluation • Incoming patients are initially assessed by a triage nurse and assigned an acuity level • Who needs to be seen immediately? • Who is safe to wait? • Waiting room is the highest risk area of the ED • Requires a scientifically validated triage acuity rating system

4. Estimates of Triage System Choice in the United States (n=444) Type No of EDs % Uses triage 413 93 3 level 193 45 4 level 47 11 CTAS 32 7 ESI 134 30

5. Evaluating Triage SystemsValidity and Reliability • Validity • Proxy measures for acuity include death and hospitalization • Reliability: Inter-rater • Will nurses rate the same patient with the same ESI rating? • Measured with Weighted kappa (K) • Range (0-1, no to perfect agreement)

6. Early work in ESI – Late 1990’s • Drs’ Richard Wuerz and David Eitel devised the original algorithm • Piloted at Boston hospitals- 1998 for ages 14 and older • ESI shown to be reliable and valid • Produced 5 distinct categories by • Admission, length of stay • Resources, charges • Obtained funding from AHRQ Wuerz, Milne, Eitel, Travers, Gilboy (2000), Reliability & validity of a new 5-level triage instrument. Acad Emerg Med, 7:236-242.

7. AHRQ Funded Multi-Center Trial- 1999-2001 • Funded by AHRQ (Agency for Healthcare Research and Quality) • Seven EDs in 3 states • Brigham & Women’s (Boston) • Faulkner (Boston) • UNC (Chapel Hill, NC) • York (York, PA) • Lehigh Valley (Allentown, PA)- 3 sites • Excellent reliability (k=.78) and validity

8. Hospitalization AHRQ Multi-center Study

9. Casemix AHRQ Multi-center Study

10. ESI Version 4

11. ESI v.4 Materials • Published May 2005 • ESI Implementation Handbook • Educational DVDs • Total requests: 17,142 (as of April 30, 2008) • Agency for Healthcare Research and Quality (AHRQ) • Translating research into practice • http://www.ahrq.gov/research/esi • Free of charge • Handbook- downloadable • DVD’s

12. www.ahrq.gov/research/esi

13. Ongoing Research • Pediatric validation study funded by the Health Resources and Services Administration (HRSA) • Coordinating center • UNC Department of Emergency Medicine • Several new pediatric centers added as research sites

14. AHRQ Formal Evaluation • NORC, and The George Washington University • Formal assessment of the ESI training materials • Timeline • Fall 2008 with final report to AHRQ in February 2009 • Goals • measure the acceptance of the ESI by ED personnel • assess the satisfaction training materials • compare usefulness of the ESI with other similar triage tools • determine what improvements users would like to see in the next version of the products.

15. References • Eitel D, Travers D, Rosenau A, Gilboy N, Wuerz R. The Emergency Severity Index Triage Algorithm Version 2 is Reliable and Valid. Academic Emergency Medicine. 2003; 10(10) 1070-1080. • Tanabe, P, Travers, D, Gilboy, N, Rosenau, A, Sierzega, G, Rupp, V, Martinovich, Z, Adams, JG. Refining emergency severity Index triage criteria. Academic Emergency Medicine. 2005; 12(6): 497-501.

16. Questions? www.ahrq.gov/research/esi Hotmail account: esitriageteam@hotmail.com