Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

Abstract

The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED.

Methods: We defined under-triage as patient visits with an Emergency Severity Index (ESI) score of 4 or 5 (ie, low acuity), and the patient was admitted to the hospital during the same visit. We defined mistriage, or medical error, when nurse-physician dyad reviewers determined that a different ESI level should have been assigned based on the information available at triage. A multidisciplinary team used nominal group technique to build consensus on key drivers and outcome metrics for this new trigger. We randomly selected 267 charts for review utilizing the under-triage trigger.

Results: Of the 125,457 patients triaged as level 4 or 5 in 2019 and 2020, 1.1% (n = 1,423) were under-triaged. Of the 267 charts reviewed, 127 were categorized as mistriage, making the under-triage's positive predictive value trigger 48%. Reviews took 2-10 minutes per chart. We identified 10 categories of under-triage. Nine themes emerged, with four specific and measurable action items mapped to process and outcome metrics.

Conclusions: We identify a new, feasible ED trigger, under-triage, that identifies medical error with a high positive predictive value. We identify process and outcome metrics and interventions to improve triage for future patients.

Fig. 1.

Flow diagram of the study population.

Fig. 2.

Key driver diagram. Mistriage definition: experienced reviewers determine a different ESI level should have been assigned based on information available during triage process.