By Brian Armstrong and Renee’ Cecil

Triage is a critical step in the care of a patient presenting to the emergency department for treatment. The emergency severity index (ESI) has been adopted in most US hospitals as a tool to yield quick, consistent clinical prioritizations of patients into five category groups. Recently, its effectiveness and reliability has been criticized, and new technology, such as artificial intelligence (AI) and machine learning (ML), has been proposed as an aide to the triage process. Experiences in hospitals across the US, however, have shown that ESI has not been implemented, validated and audited correctly, leading to a lack of competency and effective utilization. This leads to the question: is the ESI system itself flawed? This answer simply is no, but there are many opportunities to consider to ensure hospitals have a valid and reliable triage process in place.

What is the ESI’s purpose?
Since the ESI was developed in the late 1990s, the tool has been revised four times, with input from both physicians and nursing professionals. It is now utilized by more than 80% of emergency departments across the US, and has also been adopted by many facilities internationally. A simple, single-page algorithm is used as a rapid guide to assist the nurse in assigning the appropriate ESI score that also enhances inter-rater reliability. The tool is structured in a way that focuses first on patient acuity and then assesses resource utilization as a proxy for acuity.

An emergency department (ED) nurse must utilize their clinical experience and foundational skills to determine the most appropriate treatment plan for their patients. One could assume the only requirement to sort patients into the treatment areas is to be an experienced ED nurse. However, the Emergency Nurses Association (ENA) suggests that experience in conjunction with formal triage training, documented competency validations, and strong critical-thinking skills are required to ensure the safety of all patients. While the challenges of working in EDs today may be overwhelming, through formal continuing education and auditing of the ESI tool, an ED nurse may provide each patient unbiased, compassionate care while ensuring that every patient gets to the provider within an appropriate timeframe.

As with any process, if left to operate in an environment without a system of checks and balances, the expected outcome of the process can become unreliable and vulnerable to subjective influences. Poor implementation or a lack of a strong educational foundation can have a detrimental effect on ED patient flow and ultimately put patients at risk.

Strengthening the ESI to improve patient care
With the recent acquisition of the ESI by the ENA, there are anticipated updates to the tool to improve patient care by enhancing how nurses initially assess patients in the ED. So how does a leader determine if the system is hardwired and working as intended? We have found the following to be most effective:

• A comprehensive education program to assure initial understanding: A strong education program helps to level-set nurses’ understanding of how to appropriately triage patients. This includes a strong introduction and conclusion that provides a brief overview of the ESI’s relevance, background, and the impact it has on their practice. The program should also include a pre-test and a post-test to ensure competency and demonstrate improved understanding, with a score of at least 80% needed to pass the post-test. The training session should also incorporate a considerable level of hands-on and role-play training, and staff should have the opportunity to provide feedback on the training.

• Validation in the clinical setting: In order to ensure the ESI is hardwired and effective, leaders need to establish a standardized plan for validating processes, including review, tracking and analysis. A validation and achievement of at least five accurate ESI ratings out of six attempts is recommended. Leaders also need to ensure validation is required of new hires.

• Quality improvement audit system: In order to validate that nurses are applying the algorithm correctly, once in-person validations are completed, a plan for long-term auditing helps to ensure ongoing compliance and inter-rate reliability. This can be done by auditing documentation on a standardized form for reviewing, tracking, and analysis.

• Remediation and retraining: When you find that staff are falling out of compliance, or struggling with proper ESI scoring, remediation and retraining may be needed to assure ongoing learning. This type of remediation is to be determined on a case-by-case basis and may include retaking the class, one-on-one retraining, repeating the post-test, or revalidation.

Reaping the benefits of effective ESI implementation
Successful training can result in exceptional improvements, especially when combined with other front-end process improvement initiatives. We integrate ESI best practices and education programs in many of our consulting engagements, resulting in increases in ESI inter-rater reliability and decreases in walk-out rates and wait times.

Accurately assigning an ESI level upon patient arrival is paramount to the appropriate movement of the patient. Inappropriate ESI assignment, or delay of determining the ESI level, can result in poor patient outcomes, inefficient care delivery and diminished patient experience. While innovative technology will complement the triage process, institutions need to ensure there is consistency of staff education and adherence to triage protocols. By strategically creating an effective process, leaders can mitigate adverse outcomes and develop an efficient and safe environment for both patients and staff.

About the authors: Renee’ Cecil, DNP, RN, CEN, TCRN, SANE, NREMT, is a senior healthcare consultant with Philips Healthcare Transformation Services: Renee’ has over 16 years of healthcare clinical and leadership experience and has worked in community hospitals, academic trauma centers, critical care, helicopter EMS services, as well as a large healthcare system.

Brian Armstrong, MBA, BSN, NRP, FP-C, CCEMTP, is a senior healthcare consultant with Philips Healthcare Transformation Services: Brian brings decades of clinical and leadership experience in prehospital, emergency department, inpatient, and disaster response situations.