Physicians' Disease Severity Ratings are Non-Inferior to the Emergency Severity Index

Abstract

Our objective was to compare informal physicians' disease severity ratings (PDSR) at presentation with the well-established Emergency Severity Index (ESI) in order to test for non-inferiority of the discriminatory ability regarding hospitalization, intensive care, and mortality. We made a prospective observational study with consecutive enrollment. At presentation, the PDSR and subsequently Emergency Severity Index (ESI) levels were recorded. The primary outcome was the non-inferiority of the discriminatory ability (PDSR versus ESI) regarding hospitalization, intensive care, and mortality. The secondary outcomes were the reliability, the predictive validity, and the safety of PDSR. We included 6859 patients. The median age was 51 years (interquartile range (IQR) = 33 to 72 years); 51.4% were males. There were 159 non-survivors (2.4%) at the 30 day follow-up. The PDSR's discriminatory ability was non-inferior to the ESI's discriminatory ability. The safety assessment showed mortality of <0.5% in low-acuity patients in both tools. The predictive validity increased by 3.5 to 7 times if adding high-acuity PDSR to ESI in all categories with mortality of >1%. Our data showed the non-inferiority of PDSR compared with ESI regarding discriminatory ability, a moderate reliability, and an acceptable safety of both tools.

Keywords: emergency severity index; prospective study; triage.

Figure 1

Inclusion procedure. ESI = Emergency Severity Index; PDSR = Physicians’ Disease Severity Rating.

Figure 2

Receiver operating characteristic (ROC) curves for ESI and PDSR regarding hospitalization, ICU admission, in-hospital mortality, and 30 day mortality. The ESI level was coded inversely for the receiver operating characteristic curves to lie above the diagonal. PDSR = Physicians’ Disease Severity Rating; ESI = Emergency Severity Index; AUC = Area under the ROC curve; ICU = Intensive care unit.