SGEM#471: Are ESI Levels Accurate for Triage of Pediatric Patients?

Reference: Sax DR, et al. Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients. JAMA Pediatrics, October 2024 Date: February 12, 2025 Dr. Brandon Ho Guest Skeptic: Dr. Brandon Ho is a graduating pediatric emergency medicine fellow at Children’s National Hospital in Washington DC and soon to be attending physician at Seattle Children's. His research interests include AI in healthcare, medical education, and social determinants of health. Case: You are approached by the medical director of your emergency department (ED). She has noticed that recently, there has been an increasing number of pediatric cases presenting to your facility. In some of these cases, the children ended up being more sick than initially triaged. As the institution’s evidence-based medicine enthusiast, she asks you, “What do you think of the triage system we’re using now? How accurate is it for children?” Background: Pediatric triage is a fundamental component of emergency medicine, serving as the first critical step in managing acutely ill or injured children in the emergency department (ED). Unlike adult triage, pediatric triage presents unique challenges due to variations in physiology, developmental differences, and communication barriers in younger patients. Accurately assessing the severity of a child’s condition is essential for ensuring timely intervention while avoiding unnecessary resource utilization.  The Emergency Severity Index (ESI) is the most widely used triage system in the United States. It classifies patients based on acuity and predicted resource utilization, ranging from ESI Level 1 (requiring immediate, life-saving intervention) to ESI Level 5 (requiring no resources beyond physician evaluation). However, pediatric triage remains particularly challenging due to factors such as age-based vital sign variations, difficulty in obtaining an accurate history, and non-specific presentations of critical illness​. Typically, ESI levels 1 and 2 are used to assess acuity and risk of instability. ESI levels 3, 4, and 5) are determined by expected resource needs. Those resources can be labs, imaging, medications, consultations, etc. Despite its widespread use, it’s imperfect with previous studies reporting mistriage rates as high as 50%. Pediatric patients can either be undertriage (assigning a lower acuity level than warranted) or overtriage (assigning a higher acuity level than necessary). This can have significant consequences when EDs are experiencing prolonged wait times, the boarding of patients, and are chronically short-staffed. Undertriage may lead to delayed care for critically ill children, whereas overtriage can result in unnecessary resource use, increased healthcare costs, and prolonged ED crowding. Studies have shown that pediatric patients are frequently subject to both types of errors, with younger children and those presenting with atypical symptoms being at risk​. Clinical Question: How accurate is ESI version 4 in predicting acuity and resource needs among pediatric ED patients? Reference: Sax DR, et al. Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients. JAMA Pediatrics, October 2024 Population: Pediatric patients (aged 0-18 years) presenting to 21 Kaiser Permanente Northern California ED’s from January 1, 2016, to December 31, 2020. Excluded: Missing ESI, incomplete ED time variables, transferred patients, patients who left against medical advice (AMA) or left without being seen (LWBS). Exposure: Assigned ESI level compared to actual resource utilization and critical interventions. Comparison: Correct triage rates were compared against undertriaged and overtriaged cases to identify patterns of mistriage​. Outcome: Primary Outcome: The rate of mistriage (undertriage or overtriage) of pediatric patients using ESI v4​. Secondary Outcomes: Patient and visit characteristics assoc...