Accuracy of the Emergency Severity Index

Triage Instrument for Identifying Elder

Emergency Department Patients Receiving an
Immediate Life-saving Intervention
Timothy F. Platts-Mills, MD, Debbie Travers, PhD, RN, Kevin Biese, MD, Brenda McCall, RN, Steve
Kizer, MD, Michael LaMantia, MD, MPH, Jan Busby-Whitehead, MD, and Charles B. Cairns, MD

Abstract
Objectives: The study objective was to determine the sensitivity and specificity of the Emergency
Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate
life-saving intervention in the emergency department (ED).
Methods: The authors reviewed medical records for consecutive patients 65 years or older who pre-
sented to a single academic ED serving a large community of elders during a 1-month period. ESI triage
scores were compared to actual ED course with attention to the occurrence of an immediate life-saving
intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients
receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was
compared to the triage level determined by an expert triage nurse based on retrospective record review.
Results: Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI
level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of
4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention.
ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and
ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was
42.3% (95% confidence interval [CI] = 23.3% to 61.3%); the specificity was 99.2% (95% CI = 98.0% to
99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, under-
triage by the triage nurses was more common than overtriage (13 vs. 4 patients).
Conclusions: The ESI triage instrument identified fewer than half of elder patients receiving an immedi-
ate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients
may contribute to apparent undertriage.
ACADEMIC EMERGENCY MEDICINE 2010; 17:238–243 ª 2010 by the Society for Academic Emergency
Medicine
Keywords: triage, geriatrics, emergency treatment

T
he annual rate of emergency department (ED)
visits for elder patients is increasing.1–3 A
descriptive study of a national database found a
34% increase in ED visits between 1993 and 2003 for
From the Department of Emergency Medicine (TFPM, DT, KB,
CC) and the Division of Geriatrics, Department of Medicine
(BM, SK, ML, JBW), University of North Carolina, Chapel Hill,
NC.
Received August 31, 2009; revision received October 6, 2009;
accepted October 7, 2009.
Presented at the American Geriatric Society National Meeting,
Chicago, IL, April 2009; and at the Society for Academic Emer-
gency Medicine annual meeting in New Orleans, LA, May 2009.
Address for correspondence: Timothy F. Platts-Mills, MD;
e-mail: tplattsm@med.unc.edu. Reprints will not be available.
patients aged 65 to 74 years and predicted a further
doubling in ED visits by this population by 2013.1 Con-
current with this increase in ED visits by elders is an
increase in ED crowding, resulting from both a nation-
wide increase in ED visits and a reduction in the total
number of EDs.2,4–6 Elder patients are an important
subset of ED patients because they have a higher per-
centage of severe illness and injury than other age
groups of patients, as evidenced by higher rates of
hospital and intensive care unit (ICU) admission.3,7
Because of the large number of ED visits by elders,
the high proportion of acute and severe illness among
elders, and the growing problem of ED crowding,
accurate triage of elder patients is a key component to
providing timely emergency care for this vulnerable
population.

ISSN 1069-6563 ª 2010 by the Society for Academic Emergency Medicine

238 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2010.00670.x
ACAD EMERG MED • March 2010, Vol. 17, No. 3 • www.aemj.org
Existing data on the triage of elder ED patients
demonstrate mixed performance, with some triage
tools appearing to predict outcomes better than others.
The Emergency Severity Index (ESI) is a widely used
five-level triage instrument that has been shown to be
reliable and valid in both pediatric and adult popula-
tions for identifying ED resource use and hospital
admission.8–12 A single study of the triage of elders
using the ESI has demonstrated that it is a valid predic-
tor of hospitalization, ED length of stay, ED resource
use, and survival at 1 year.12 In contrast, a study of the
five-question Triage Risk Screening Tool found it to
only weakly predict for ED revisit, hospitalization, or
long-term care placement for patients 65 years or
older.13 Although matching patients with resource
needs is an important function of a triage system, the
other essential function is to identify patients with acute
severe illness or injury who are in need of an immedi-
ate life-saving intervention. To the best of our knowl-
edge, no published study has evaluated the ability of
ESI or any other triage instrument to identify elders in
need of an immediate life-saving intervention.
The objective of this study was to assess the sensitiv-
ity and specificity of the ESI version 4 triage instrument
in predicting the need for an immediate life-saving
intervention among elder ED patients. Additionally, we
sought to determine if mistriage of patients receiving
an immediate intervention was due to misapplication of
existing criteria or to lack of accuracy of the criteria
themselves.
METHODS
Study Design
We conducted an observational study of consecutive
patients 65 years or older presenting to a single aca-
demic ED during a 1-month period to determine the
accuracy of ESI Level 1 for identifying patients who
receive an immediate life-saving intervention. We com-
pared ESI triage designations made by triage nurses to
actual ED course to calculate the sensitivity and speci-
ficity of ESI Level 1. Additionally, all patients who were
admitted to the ICU or died within 24 hours were
reviewed by a second study author (TPM) to identify
patients who should have received an immediate inter-
vention but did not. For a subset of patients, triage
nurse ESI designations were compared to expert triage
nurse review of the triage portion of the patient’s chart.
The study received approval from the hospital’s institu-
tional review board with a waiver of informed consent.
Study Setting and Population
The study site is a single ED at a Level 1 trauma center,
with an emergency medicine residency program and an
annual census of approximately 64,000 patients. The ED
is located in a city of 50,000 people with a large
surrounding population of elders. It is also a tertiary
referral center for the state of North Carolina. The
study enrollment period was June 20 to July 20, 2008.
All patients 65 years of age or older who presented to
the ED during the study period were included in the
assessment of whether patients received an immediate
intervention. This included patients who came by
239
emergency medical services transport or by private
transport. However, patients who did not have a triage
level recorded in the ED record were excluded from
the calculations of the sensitivity and specificity of the
ESI triage instrument.
Triage designations were made by one of 31 triage
nurses who performed triage duties during the study
period. Each of these triages nurses have worked full
time as a nurse in the ED at our institution for 1 year
prior to working at triage, and each have had formal
training in the use of ESI criteria. Additionally, the ESI
triage algorithm is present on the wall of each triage
room. ESI has been the exclusive triage tool at our
institution since its introduction in 1999. Triage nurses
were not informed that a study was being performed.
Study Protocol
Data were abstracted using a computer-based abstrac-
tion form (Microsoft Excel 2007, Microsoft Corp., Red-
mond, WA) by a single research nurse with extensive
experience in the care of geriatric patients. Definitions
of variables were established and refined during a
2-week preliminary enrollment period during which
time the research nurse received training in data
abstraction methods. Data collected during the preli-
minary enrollment period were from patients who pre-
sented to the ED prior to June 20 and were not
included in analysis. During data abstraction, weekly
meetings were held between the research nurse and
other study authors to answer questions. Triage scores
were obtained from the ED’s computerized patient
record system (The T-system EV, version 2.5, 2001–
2005; T-System Inc., Dallas, TX).
The determination of whether a patient received an
immediate intervention was obtained from a review of
the entire nursing and physician record for each
patient. An immediate intervention was defined based
on criteria established by the ESI version 4 guidelines
(Table 1).14 The ESI Handbook does not define a spe-
cific time period during which a life-saving intervention
must occur to be ‘‘immediate.’’9 To improve the consis-
tency and reproducibility of our determination of the
occurrence of an immediate intervention, we further
defined an immediate life-saving intervention as one
that occurred in the first hour following patient arrival
to the ED. All cases designated as receiving an immedi-
ate intervention by the research nurse were reviewed
by another study author to confirm that the case met
the previously defined criteria and to determine
whether an adverse outcome resulted from a delay in
care in the ED. This determination was made based on
a review of the entire ED and inpatient chart and spe-
cifically concerned the nature of the intervention pro-
vided, the time until the intervention was provided, and
the patient’s ED and hospital course. To identify
patients who may have needed an immediate interven-
tion but did not receive one, an additional study author
reviewed all patients in the study population who were
admitted to the ICU or who died within 24 hours.
A weighted sample of randomly selected patients, 18
of whom received an immediate intervention and 32 of
whom did not, was reviewed by one of the study
authors (KB) who is an emergency physician. This
240 Platts-Mills et al. • ACCURACY OF THE ESI FOR ELDERS

Table 1
Study Definition of an Immediate Life-saving Intervention*

1. Airway and breathing support, including intubation or emergent noninvasive positive pressure ventilation.
2. Electrical therapy, including defibrillation, emergent cardioversion, or external pacing.
3. Procedures, including chest needle decompression, pericardiocentesis, or open thoracotomy.
4. Hemodynamic support, including significant intravenous fluid resuscitation in the setting of hypotension, blood administra-
tion, or control of major bleeding.
5. Emergency medications, including naloxone, dextrose, atropine, adenosine, epinephrine, or vasopressors.

*Adapted with author permission from Table 3-1 in Gilboy N, Tanabe P, Travers DA, et al. Emergency Severity Index, Version
4: Implementation Handbook. AHRQ Publication No 05-0046-2. Washington, DC: Agency for Healthcare Research and Quality,
2005.14

sample was generated using a random number table to immediate intervention was calculated using the kappa
identify 34 patients from the total population and an statistic. The interrater reliability between triage nurses
additional 16 patients from the immediate intervention and the expert triage nurse was determined using the
population. The reviewing physician was provided with weighted kappa statistic.
the definition of immediate intervention and the entire
ED medical record for each patient, but was blinded to RESULTS
the triage ESI score, the proportion of patients with an
immediate intervention in the weighted sample, and the During the enrollment period, 4188 adult patients pre-
categorization by the research nurse as to whether the sented to the ED, of whom 782 (18.7%) were 65 years
patient had received an immediate life-saving interven- or older. Characteristics of all patients 65 years and
tion. For each of the 50 charts, this physician desig- over and the subset of patients receiving an immediate
nated the case as receiving or not receiving an intervention were similar, except in regard to disposi-
immediate intervention. tion (Table 2). Twenty-six (3.3%) of the 782 elders seen
Additionally, the triage notes for these 50 patients in the ED during the study period received an immedi-
were reviewed by an expert triage nurse blinded to the ate intervention. Nine (1.2%) of the 782 patients were
initial ESI triage level designation. This expert triage missing triage acuity ratings; none of these nine
nurse (DT) has both taught and studied the ESI and has received an immediate intervention. The most common
been involved in numerous revisions of the ESI criteria. types of immediate interventions were intubation or
The expert triage nurse gave each of these 50 cases an emergent noninvasive positive pressure ventilation (15
ESI designation, and the initial triage nurse and expert patients) and emergent medications (six patients). The
triage nurse designations were compared to assess for primary source of triage information was someone
triage nurse compliance with ESI triage criteria. other than the patient for 313 of 782 (40%) of all
Although the triage nurses who made the initial ESI
designations and the expert triage nurse had access to
the ESI criteria while they were making triage level Table 2
decisions, the expert triage nurse was encouraged to Demographic Characteristics and Dispositions for All Patients
and for Patient Receiving an Immediate Intervention
apply the ESI criteria to each patient. The triage nurses
who made the initial designations were not notified that
a study was being conducted and were not provided Patients Receiving
All Patients an Immediate
with any instructions.
Characteristic (n = 782) Intervention (n = 26)
To allow a comparison of elder adult ESI triage levels
to those of nonelder adults, ESI levels for nonelder Sex
Female 450 (58) 11 (42)
adults were obtained from the ED’s computerized medi- Male 332 (42) 15 (58)
cal records for the 1-month study period. Further anal- Race
ysis was not performed on the nonelder population. White 528 (68) 18 (70)
Black or African 219 (28) 3 (12)
American
Data Analysis Other 35 (5) 5 (19)
A sample size determination was not performed for this Age
study. We did not know what the rate of immediate Median age, yr (range) 76 (65–99) 74 (65–92)
interventions would be in this population. Our objective Age 65–74, yr 342 (44) 14 (54)
was to provide an estimate of the sensitivity and speci- Age 75–84, yr 286 (37) 7 (27)
Age ‡ 85, yr 154 (20) 5 (19)
ficity of ESI for identifying patients with an immediate Disposition 327 (42) 0
intervention, and we felt that data collection over a 1- Discharged 421 (54) 14 (54)
month period should be sufficient to allow such an esti- Admitted—non-ICU 31 (4) 12 (46)
mate. The sensitivity and specificity of ESI Level 1 for Admitted—ICU 3 (0.4) 2 (8)
Death in first 24 hours
identifying patients receiving an immediate intervention
were calculated with 95% confidence intervals (CIs). In-
Values are n (%) unless otherwise noted.
terrater reliability between the study nurse and the ICU = intensive care unit.
blinded physician as to whether a patient received an
ACAD EMERG MED • March 2010, Vol. 17, No. 3 • www.aemj.org 241

patients 65 years or older and 22 of 26 (85%) of patients 3 to wait in the waiting room if a bed is not available,
receiving an immediate intervention. Prehospital emer- these six patients were at particularly high risk for an
gency medical services (EMS) providers and family adverse outcome due to a delay in care. The immediate
members were the primary source of information for interventions for these patients were positive pressure
22 and 14% of all patients, respectively, and 65 and ventilation for a patient with respiratory distress due to
19% of patient receiving an immediate intervention. an exacerbation of chronic obstructive pulmonary dis-
Among all patients 65 years and older who presented ease, large-volume resuscitation for hypotension (two
to the ED during the study period, the admission rate cases), intravenous naloxone for altered mental status
was 58%, and the ICU admission rate was 4%. All 26 of unknown etiology (two cases), and intravenous dex-
patients who received an immediate intervention were trose for altered mental status and hypoglycemia. As
admitted, and 12 of these (46%) were admitted to the per the study definition, all six patients received the
ICU. Of the 26 patients receiving immediate interven- immediate intervention within 1 hour of arrival to tri-
tions, eight (31%) died prior to hospital discharge, and age. None of these six patients died during the subse-
two died within the first 24 hours. Thirty-four patients quent hospitalization. In reviewing the ED course, we
who did not receive an immediate intervention died in did not see evidence for a delay in ED care for these six
the first 24 hours (n = 3) or were admitted to the ICU patients or the remaining 20 patients who received an
(n = 31). Based on review of their ED charts, none were immediate intervention but had ESI levels of 1 or 2.
felt to have been candidates for an immediate interven- For the 50 cases in which an emergency physician
tion. reviewed the designation of an immediate intervention,
Patients 65 years of age or older had a larger propor- the research nurse and second author agreed on the
tion of ESI scores of 1, 2, and 3 than did nonelder occurrence of an immediate intervention on 48 cases
adults (Table 3). Of the 26 patients receiving an immedi- (j = 0.91). For one case, the research nurse failed to
ate intervention, 11 had an ESI of 1, nine had an ESI of identify an immediate intervention that was identified
2, and six had an ESI of 3. The sensitivity of an ESI by the physician. In the other case, the research nurse
score of 1 for identifying patients receiving an immedi- identified an immediate intervention that was not felt to
ate intervention was 42% (95% CI = 26% to 61%), and be an immediate intervention by the physician. These
the specificity was 99.1% (95% CI = 98.1% to 99.5%; two discrepancies were reviewed by the study group
Table 4). and both were decided, for the purpose of analysis, to
There were six patients during the study period who be consistent with the designation by the physician
received an immediate intervention but received an ESI reviewer.
score of 3. As both ESI recommendations and the prac- In comparison to the review by the expert triage
tice in our ED is to allow patients with an ESI score of nurse, triage nurse ESI level designations were the
same in 33 cases (weighted j = 0.61). For the 17 cases
where they differed, triage nurses gave higher acuity
triage designations than the expert nurse for four
Table 3
Distribution of ESI Triage Levels of Nonelder Adults, Elder patients and lower acuity triage designations for 13
Adults, and Elder Adults Receiving an Immediate Intervention patients. Of the 18 cases in this weighted randomly
During the 1-Month Study Period selected subset of cases in which a patient received an
immediate intervention, 13 were designated as ESI
Patients Aged Patients ‡ Patients ‡ 65 yr Level 1 by the expert triage nurse, nine were desig-
ESI 18–64 yr 65 yr With an Immediate nated as ESI Level 1 by the triage nurse, and four cases
Level (n = 3,364) (n = 773) Intervention (n = 26) were designated as ESI > 1 by both the expert and non-
1 40 (1.2) 18 (2) 11 (42) expert triage nurses.
2 562 (16.7) 176 (23) 9 (35)
3 1604 (47.7) 461 (60) 6 (23)
4 911 (27.1) 100 (13) 0 DISCUSSION
5 247 (7.3) 18 (2) 0
Immediate interventions occurred infrequently in this
Values are n (%). population of ED patients aged 65 years and older.
ESI = Emergency Severity Index. When they did, more than half of the patients had an
ESI score other than 1, indicating a lack of agreement
between the ESI Level 1 definition, which should
include all patients in need of an immediate interven-
Table 4 tion, and the application of ESI by our triage nurses.
ESI Triage Level Versus Immediate Life-saving Intervention There are several possible reasons for this discrepancy.
Accurate triage of elder patients, in particular the
Immediate Intervention identification of elder patients in need of an immediate
intervention, may be more difficult than for nonelder
ESI Level Received Not Received
adults for several reasons. High rates of chronic illness
1 11 9 in this population may make acute illness more difficult
2–5 15 738
to identify. High rates of triage by proxy, which in this
study occurred in 40% of all patients and 85% of
n = 773.
ESI = Emergency Severity Index. patients receiving immediate interventions, may make it
difficult for triage nurses and other medical providers
242
to identify the severity and acuity of an elder’s condi-
tion. Finally, physiologic and pharmacologic factors
may limit changes in vital signs in response to illness or
injury,15,16 limiting the ability of triage nurses to rely on
vital sign abnormalities to identify life-threatening ill-
ness in this population.
Both limitations of existing ESI criteria, and a failure
to appropriately apply criteria, may have contributed to
the rate of undertriage. The high number of cases in
which the triage nurses undertriaged the patient rela-
tive to the expert triage nurse (13 of 50 total cases and
5 of 13 cases in which a patient received an immediate
intervention) suggests that undertriage in this popula-
tion may be in part due to a failure of triage nurses to
appropriately apply ESI criteria. One possible explana-
tion for the apparent inappropriate application of ESI
criteria in this population may be an unconscious bias
against elders by triage nurses.17,18 However, there
were four cases in which an immediate intervention
occurred in which neither the triage nurse nor expert
triage nurse review gave the patient an ESI Level 1 des-
ignation, suggesting that there may also be a limitation
in the ESI criteria for identifying these patients. Both
problems with the application of triage criteria to elders
and problems with the criteria themselves have been
previously described in the context of the prehospital
triage of elder trauma patients15,18,19 and in ED triage
instruments.17,20 The study was not designed to identify
the cause of undertriage in elders, and further study is
needed to attempt to better define the extent of this
problem, the risk it poses to elder ED patients, and
ways to address it.
Our results suggest that additional triage nurse train-
ing in the application of ESI criteria, and revisions to
the ESI criteria, may serve to improve the triage of
elder patients with acute illness and injury. Geriatric-
specific triage criteria, including geriatric-specific defi-
nitions of abnormal vital signs, may serve to improve
the accuracy of ESI in identifying elder patients in need
of an immediate intervention. Further study is needed
to better define the value of either additional training
or changes in ESI criteria. Future studies might also
consider the performance of ESI for elders in nonaca-
demic settings, the effect of ED crowding on the accu-
racy of ESI, and whether certain demographic groups
are at increased risk for undertriage.
Balancing sensitivity and specificity of a clinical deci-
sion tool requires tradeoffs. To increase the sensitivity
of triage criteria for elders in need of an immediate
intervention, an increased number of patients not in
need of an immediate intervention would be given an
ESI Level 1 designation. The impact of these false-posi-
tive cases on ED flow and the timely care of all patients
must be carefully considered prior to embracing a revi-
sion to existing triage criteria. However, the risk of un-
dertriaging a patient and delaying an immediate
intervention must be taken seriously.
LIMITATIONS
This study was conducted at a single ED, and the appli-
cation of ESI by triage nurses in other EDs may differ.
Triage nurse training and experience in evaluating and
Platts-Mills et al. • ACCURACY OF THE ESI FOR ELDERS
caring for elder patients likely influences the perfor-
mance of ESI for this population.
In reviewing the charts of those patients who
received an immediate intervention but were given an
ESI score other than 1, we did not see evidence of
either a significant delay in care or an adverse outcome
due to a delay in care. Therefore, the argument could
be made that the ESI designation did not matter for
these patients; they still got what they needed. Although
we did not identify such an event in our study, we
believe that incorrect ESI designations for patients in
need of an immediate intervention place these patients
at increased risk for a delay in care and associated mor-
bidity and mortality. This risk is probably particularly
high in crowded EDs where patients may have
extended waiting room stays if they are undertriaged,
or in EDs that are understaffed with physicians or
nurses, resulting in long times prior to evaluation. Our
data suggest that in our ED, adverse events probably
occur in only a small portion of undertriaged patients; a
larger study would be needed to identify the rates of
adverse events associated with undertriage.
In our study, the sensitivity of an ESI level of 1 for
identifying patients in need of an immediate interven-
tion was 42% (95% CI = 26% to 61%). A similar mea-
surement of the performance of ESI is not available for
nonelders, and we do not know if the low sensitivity we
identified for elder patients reflects a characteristic of
the ESI triage instrument as applied to elders or to all
patients.
For the purpose of comparison with triage nurse ESI
levels, we generated an expert triage nurse ESI level
using her review of the chart. The expert triage nurse
did not see the patient. This is an imperfect method for
comparing triage scores by regular and expert triage
nurses, because the normal triage process relies upon
both information that is included in the chart and infor-
mation obtained from seeing and interacting with the
patient that is often not included in the chart. Our find-
ing that triage nurses were more likely to undertriage
than overtriage elders when compared to the expert
nurse may have been influenced by our method of gen-
erating expert nurse ESI levels.
Our methods were designed to identify all patients
who received an immediate intervention. We did not
attempt to determine if the immediate intervention was
appropriate or helpful. If we had instead attempted to
measure the sensitivity of an ESI level of 1 for patients
who benefited from an immediate intervention, the sen-
sitivity of the triage instrument would have been differ-
ent. It is also possible that a patient required an
immediate intervention but did not get one in the first
hour. We reviewed all deaths during the first 24 hours
and ICU admissions in an attempt to identify such indi-
viduals. However, it is possible that one or more elderly
patients in need of an immediate intervention presented
to the ED during the study period but was not identified
by our methods either because no immediate interven-
tion was provided and the patient did not die or get
admitted to the ICU or because the study nurse missed a
case in which an immediate intervention was provided.
We did not collect information on ‘‘do not resusci-
tate’’ (DNR) orders on our patients. However, there
ACAD EMERG MED • March 2010, Vol. 17, No. 3 • www.aemj.org
was at least one patient who was DNR, who would
have received an immediate intervention if he or she
did not have a DNR order. This patient died within
24 hours of ED arrival. None of the 26 patients who
received an immediate intervention in our study had a
DNR order documented in the triage or ED note. It
may be true that patients with a DNR order with them
at triage receive lower triage scores because of this
order, and this may or may not be appropriate.
Because of variations in the meaning of DNR and in
the availability of accurate DNR information at the
time of triage, careful consideration would be needed
to study the effect of DNR status on the triage pro-
cess.
There may be characteristics of elder patients, such
as age, sex, race, residing in a nursing home, or having
a history of dementia, that are associated with under-
triage. Our study was not powered to allow for the
identification of differences between patients receiving
an immediate intervention with an ESI level of 1 and
those with an ESI level more than 1. A larger study
would be needed to determine if such characteristics
are associated with undertriage in elders.
Emergency department overcrowding may affect tri-
age designations. Triage nurses may undertriage when
the ED is crowded to avoid having a patient with a high
acuity score, such as a 1 or 2, wait in the waiting room
before a room becomes available. Undertriage and
delays in care for patients in need of an immediate
intervention may be a more serious problem in severely
overcrowded EDs and at times of day when overcrowd-
ing is worse. We did not attempt to assess the effect of
ED crowding on ESI designation, but future studies of
triage might consider evaluation of the effect of ED
crowding on the triage process.
CONCLUSIONS
An Emergency Severity Index Level 1 designation is
insensitive for identifying elder patients receiving an
immediate life-saving intervention. Changes to the
index criteria for elders, or further training of triage
nurses in the application of the criteria, may be war-
ranted to improve the performance of the Emergency
Severity Index in this population.
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