Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department. Issue 4 (1st July 2022)

• Record Type: Journal Article
• Authors: Berkowitz, Deena; Morrison, Sephora; Shaukat, Haroon; Button, Katherine; Stevenson, Michele; LaViolette, Debbie; Meisler, Yael; Gallagher, Kerri A.; Chamberlain, James
• Is Part Of: Pediatric quality & safety. Volume 7:Issue 4(2022)
• Page Start: e581
• Publication Date: 2022-07-01
• Subjects: Pediatric nursing -- Periodicals; Pediatrics -- Periodicals; Patients -- Safety measures -- Periodicals; Children -- Hospital care -- Periodicals; 618.92
• DOI: 10.1097/pq9.0000000000000581
• Languages: English
• ISSNs: 2472-0054

Abstract

Abstract : Introduction: 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.