Undertriage in older emergency department patients--tilting against windmills?

The aim of this study was to investigate the long-term effect of a teaching intervention designed to reduce undertriage rates in older ED patients. Further, to test the hypothesis that non-adherence to the Emergency Severity Index (ESI) triage algorithm is associated with undertriage. Additionally, to detect patient related risk factors for undertriage.Pre-post-test design. The study sample consisted of all patients aged 65 years or older presenting to the ED of an urban tertiary and primary care center in the study periods. A teaching intervention designed to increase adherence to the triage algorithm. To assess, if the intervention resulted in an increase of factual knowledge, nurses took a test before and immediately after the teaching intervention. Undertriage rates were assessed one year after the intervention and compared to the pre-test period.In the pre-test group 519 patients were included, and 394 in the post-test-group. Factual knowledge among triage nurses was high already before the teaching intervention. Prevalence of undertriaged patients before (22.5%) and one year after the intervention (24.2%) was not significantly different (χ2 = 0.248, df = 1, p = 0.619). Sex, age, mode of arrival, and type of complaint were not identified as independent risk factors for undertriage. However, undertriage rates increased with advancing age. Adherence to the ESI algorithm is associated with correct triage decisions.Undertriage of older ED patients remained unchanged over time. Reasons for undertriage seem to be more complex than anticipated. Therefore, additional contributing factors should be addressed

Sample characteristics.

<p>a/b/c represent the lower quartile a, the median b, and the upper quartile c for continuous variables.</p><p>n is the number of non-missing values.</p><p>Numbers after percentages are frequencies.</p

Estimated proportions of patients with undertriage in the pre- and post- treatment groups.

<p>The proportions are given as ratios of the kernel probability density estimate of age of patients with undertriage and the kernel probability density estimate of age of all patients.</p

Reasons for undertriage (according to the decision points A-D of the ESI triage algorithm).

<p>Reasons for undertriage (according to the decision points A-D of the ESI triage algorithm).</p

Results of simple logistic regression models for undertriage on risk factors. Intercepts (odds) are not shown.

<p>^* The variables “admission mode” and “presenting complaint” were collected in the post test group only.</p><p>nsc, non-specific complaint.</p

Logistic regression for correct triage on the predictors “vital signs” and “respiratory rate” which serve as surrogate for adherence, and full adherence, respectively.

<p>(post treatment group, N = 174).</p