How Johns Hopkins revamped triage—and reprioritized 14,000 ED patients

Johns Hopkins has developed a new e-triage tool that reduces wait times in the ED and more accurately assesses patients' Emergency Severity Index (ESI) score, Maria Castellucci writes for Modern Healthcare.

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How the ESI works

According to Castellucci, the ESI is a tool that nurses use to determine how severe a patient's condition is based on a scale from one to five. Patients categorized as Level 1 have the most urgent conditions, such as cardiac arrest, that require immediate attention, while those categorized as Level 5  have less urgent conditions, such as a rash.

While the system enables nurses to facilitate treatment by categorizing patients quickly, ESI is not always accurate, and it relies in large part on nurses' subjective assessment of patients, according to according to Scott Levin, an associate professor of emergency medicine at Johns Hopkins University School of Medicine.

In fact, research indicates that about 70 percent of patients are categorized as Level 3 on the ESI scale, even though the severity of patients' symptoms and diagnoses tend to vary substantially.  "The major challenge of the ESI is that it's completely subjective," Levin said. "When something is completely subjective, there can be untoward variability."

The development of the e-triage tool

To bolster the ESI's objectivity, Levin and his team in 2016 developed an e-triage tool to complement and support nurses' triage assessment. The tool estimates the severity of a patient's potential diagnosis by using an algorithm that is based on data from about 200,000 patients treated at six Johns Hopkins' hospitals. It gives each patient an ESI score based on how providers have previously treated patients with similar symptoms, as well as those patients' risk of death, likelihood of ICU admittance, and odds of requiring an emergency procedure.

And the tool has been a success, Castellucci reports. It has identified 14,000 patients who had originally been categorized as Level 3 who should have either been Level 1 or 2, according to a study of the tool led by Levin and published in the Annals of Emergency Medicine. It also increased the overall number of patients categorized as Level 4 or 5—and spotting patients with less urgent conditions saves them time, Levin said, as they can then be "fast-track[ed]" for treatment. "If we put [patients with less-serious conditions] in line with the very sick, they would never get out," said Levin. "The hope is to not have them wait and get out quickly."

Overcoming hesitations

Some Johns Hopkins staff were hesitant to implement the tool, expressing concern that they were being replaced by a machine. "We were very resistant at first because for us, being trained as a triage nurse is an honor," Sophia Henry, a triage nurse in the Johns Hopkins ED, said. "It shows clinical excellence and that you understand clinical decisionmaking."

However, after a few months, Levin was able to convince the nurses that the e-triage tool was supporting—not replacing—them. In fact, Levin has encouraged nurses to disagree with the e-triage tool when appropriate, because the tool cannot interact with patients as nurses do.

But ultimately, Levin said providers have come around in support of the tool because it's uniquely designed around John Hopkins' unique patient population. According to Levin, many providers are hesitant about using algorithms because they don't trust the data—but Johns Hopkins' providers have confidence in the data supporting the e-triage tool. The tool "is more meaningful to the people who are using it," Levin said. "Every ED is so different—the patient populations they treat, the resources they bear and the care processes they use" (Castellucci, Modern Healthcare, 10/14).

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