1. Triage: Fixing the Front End Emergency Nursing Seminar The 2 nd Mediterranean Emergency Medicine Congress David Eitel MD MBA daveitel@cyberia.com

2. In Memory Of: Richard Wuerz MD Associate Clinical Director Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School

4. On Behalf Of The ESI Triage Research Team: Nicki Gilboy Nicki Gilboy Alex Rosenau Alex Rosenau Debbie Travers Tom Stair (the database guru) Melissa Schlenker Dave Eitel Rich Wuerz Thank you for the invitation!

5. Emergency Medicine Explained 1 patient arrives 2 stuff happens 3 patient leaves

6. U.S. Emergency Department Visits www.acep.org The Good News! www.acep.org Millions of visits

7. The Bad News… U.S. GAO, 1993 urgent emergent non-urgent

8. “The Emergency Department Problem” Silver, Manegold, JAMA Oct 24, 1966 ED visits rose 175% from 1955-1965 ED visits rose 175% from 1955-1965 42% ‘nonurgent’ problems 42% ‘nonurgent’ problems Factors: Factors: – Mobility (no primary doctor) – Difficulty finding a physician at night! – Indigent populations – 24/7 diagnostic facilities at hospital

9. “…the most costly care of all…” “…the most costly care of all…” – Marginal costs of minor emergencies = $25 Use of ED as source of primary care Use of ED as source of primary care – 43 M without health insurance – Insurance card does not equal access Definition of ‘emergency’ Definition of ‘emergency’ – Prudent layperson movement Health Care Debate and through the 1990’s

10. Definitions of ‘emergency’ life threat life threat life or limb threat life or limb threat results in hospital admission or operation results in hospital admission or operation requires care within 2 hours requires care within 2 hours requires care within 24 hours requires care within 24 hours severe pain severe pain my lawyer sent me in to get checked my lawyer sent me in to get checked

11. The REAL ED Problems Cost Cost – Perception that we ‘cost too much’ Quality\Satisfaction Quality\Satisfaction –Variation in timeliness to care – Single biggest thing patients complain about is wait time Now overcrowding: “access block” by Aussies Now overcrowding: “access block” by Aussies  Safety and nursing exodus  Safety and nursing exodus

12. What is triage? Why do we do it?

13. What does triage have to do with any of this anyway?

14. Driver of My Interest MBA Operations Management (95): Reengineering 101 MBA Operations Management (95): Reengineering 101 – Pick a business that’s in trouble (The YH ED) – Identify it’s key business processes (?) – If something is broken – FIX IT! Every one did it – but differently – even same later Every one did it – but differently – even same later “Reengineering The ED – Fixing Triage”: Streaming, “Reengineering The ED – Fixing Triage”: Streaming, not just sorting not just sorting  Predictive management and modeling  Predictive management and modeling

15. BWH Triage Guidelines before 4/99 Emergent: 1% Emergent: 1% – requires immediate evaluation & treatment Urgent: 65% Urgent: 65% – can tolerate a period of time in the waiting room Non-urgent: 35% Non-urgent: 35% – minor illness/injury that can be treated within six hours

16. Emergency Nurses Association Emergent/1: Emergent/1: –Life- or limb-threatening illness/injury Urgent/2: Urgent/2: –Requires prompt care, but will not cause loss of life or limb if left untreated for several hours Non-urgent/3: Non-urgent/3: –Time is not a critical factor; minor illness or injury

17. Triage Data Report YH ED 1997 22 % admits 18,029 visits Jan-Apr 97 11 % 73 % 13,150 Level 3 51 % 25 % 4,577 Level 2 69 % 2 % 302 Level 1 ADMIT % %VOLUMETRIAGE

18. Inconsistency of Triage Wuerz: Ann Emerg Med Oct 1998 87 nurses, two academic EDs 87 nurses, two academic EDs triaged 5 standardized patients scenarios triaged 5 standardized patients scenarios – using their three-level scale scales only 35% agreement beyond chance only 35% agreement beyond chance repeat triage of same cases: repeat triage of same cases: – only 25% triaged the same both times Conclusion: the instrument is too blunt! (no instrument…) Conclusion: the instrument is too blunt! (no instrument…)

19. So what?

20. What Else Is Out There? Australian National Triage Scale-1994 Australian National Triage Scale-1994 Canadian Triage and Acuity Scale-1996 Canadian Triage and Acuity Scale-1996 Manchester Triage-1997 Manchester Triage-1997

21. This patient can wait no longer than …to see a physician This patient can wait no longer than …to see a physician Australian & Canadian Triage 120 min 5 60 min 4 30 min 3 15 min 10 min 2 0 min 1CTASNTS Triage level

22. What is triage? Why do we do it?

23. A principal goal of Triage should be: To determine who should be seen first. Right?

24. If that is the only question asked  How long do you think everyone should/could wait?

25. A second major goal should be: Not just to “sort” but to “stream” to get the right patient to the right resources in the right place and at the right time to get the right patient to the right resources in the right place and at the right time

26. The Triage Game! Observation: case scenarios - “they will need…” in agreement

27. There are big emergencies, and there are little emergencies P.S. Experienced ED nurses are excellent at this! (especially those potential big emergencies…)

28. If your little girl falls and cuts her forehead and needs stitches - is that an emergency?

29. It’s about resources! It’s not just about time:

30. Managing by flow, Not capacity! “The Goal”

31. To manage by flow, have to first decide how to stream incoming patients

32. Not only who should be seen first, But also, what does the patient need, in terms of resources, to reach a disposition? In ESI © triage two questions are asked:

33. The Bad News… U.S. GAO, 1993 urgent emergent non-urgent

34. The ESI © V. 1 Triage Algorithm Five levels, explicit definitions, complex tables Five levels, explicit definitions, complex tables In August 1998  Breakthrough! Flowchart-based algorithm by Wuerz and Eitel: (Tufte) In August 1998  Breakthrough! Flowchart-based algorithm by Wuerz and Eitel: (Tufte) Vital signs ancillary (used to up-triage only, from 3 to 2) Vital signs ancillary (used to up-triage only, from 3 to 2) – Heart rate>100 – Respiratory rate>20 – Oxygen sat<90% Adults only (> age 14) Adults only (> age 14)

35. none one many vital signs 1 2 5 4 3 yes no yes patient dying? shouldn’t wait? no how many resources?

36. 1 yes no Intubated/pulseless/apneic? Or Unresponsive? Step 2 Step 1:

37. 2 yes no High risk situation? Or Confused/lethargic/disoriented? Or Severe pain/distress? Step 3 Step 2:

38. 2 How many different resources does the patient need? Step 3&4: none one many Vitals criteri a 54 3 yes no

39. Vital Sign Criteria To Up-Triage Would need ‘face validity’ of vital signs Would need ‘face validity’ of vital signs No clear consensus on ‘abnormal vitals’ No clear consensus on ‘abnormal vitals’ SIRS criteria SIRS criteria

40. Reliability & Validity Reliability: reproducibility & repeatability of a measurement tool (instrument) Reliability: reproducibility & repeatability of a measurement tool (instrument) – Inter-rater agreement – Test-retest agreement Validity: Or So What? Validity: Or So What? – Predictive validity – Outcomes associated with each triage level

41. Initial Adult-ESI Retrospective Study: New Flow Chart Based Algorithm October-December 1998 “Reliability and validity of a new five-level triage instrument”: Wuerz, Milne, Eitel, Travers, and Gilboy: AEM 2000;7(3): 236-42

42. Initial Adult-ESI Study October-December 1998 Brigham and Mass General EDs Brigham and Mass General EDs New algorithm was first pilot tested among the investigators with 20 written scenarios (k =.83 -.96) New algorithm was first pilot tested among the investigators with 20 written scenarios (k =.83 -.96) For 100 hours Oct - Dec 1998 simultaneous blinded triage of patients by a research nurse (n = 493) For 100 hours Oct - Dec 1998 simultaneous blinded triage of patients by a research nurse (n = 493) All hours of the day sampled but by convenience All hours of the day sampled but by convenience

43. Initial Adult-ESI Study October-December 1998 A second experimental ESI triage assignment was done retrospectively by a physician (RW) on 351 of the written staff nurse’s triage note (k =.8) A second experimental ESI triage assignment was done retrospectively by a physician (RW) on 351 of the written staff nurse’s triage note (k =.8) There were 77% exact agreements, 22 one-level disagreements, and 1% (3) two-level disagreements There were 77% exact agreements, 22 one-level disagreements, and 1% (3) two-level disagreements Now we thought we might have something – because “Reliability begets validity” (Yarnold) Now we thought we might have something – because “Reliability begets validity” (Yarnold)

44. Initial Adult-ESI Study Validity Hospitalization rates Hospitalization rates –92% level 1  0% level 5 (table 3 page 239) Composite resource intensity Composite resource intensity –Highly associated with ESI levels (table 3 page 239) ED length of stay made sense by triage level (table 4) ED length of stay made sense by triage level (table 4) ED charges were moderately associated (table 4) ED charges were moderately associated (table 4)

45. Initial Adult-ESI Study October-December 1998 Deb Travers of UNC Chapel Hill added to the study group Jan 1999, just back from New Brunswick and a visit with Dr. Bob Beveridge about the CTAS tool Deb Travers of UNC Chapel Hill added to the study group Jan 1999, just back from New Brunswick and a visit with Dr. Bob Beveridge about the CTAS tool

46. Reliability and Validity of a New Five- Level Triage Instrument : AEM March 2000 54321 37101005 22665004 112811303 01128422 000041Nurse-prospectivePhysician-retrospective Weighted kappa=0.81, p<.001

47. Reference Standards Resources & Outcomes labs labs x-ray x-ray ecg ecg monitor monitor special studies special studies fluids/parenteral meds fluids/parenteral meds consultation consultation Composite resource intensity Admission rates *ED length of stay Charges Case mix

48. Initial Adult-ESI Validation Results Resource Intensity-Composite

49. Initial Adult-ESI Validation Results Inpatient Admission

50. Limitations Sampling bias Sampling bias – academic centers – convenience sampling – > 14 years of age only Choice of outcomes Choice of outcomes

51. Related Work “Triage: How long does it take? How long should it take?”: Travers: JEN 1999;25(3): 238-40 “Triage: How long does it take? How long should it take?”: Travers: JEN 1999;25(3): 238-40 “How reliable is emergency department triage?”: Fernandes, Wuerz et al: Ann. Em. Med. 1999;34:141- 147 “How reliable is emergency department triage?”: Fernandes, Wuerz et al: Ann. Em. Med. 1999;34:141- 147 “Re-evaluating triage in the new millennium: A comprehensive look at the need for standardization and quality.”: Gilboy, Travers and Wuerz: JEN 1999;25(6):468-73 “Re-evaluating triage in the new millennium: A comprehensive look at the need for standardization and quality.”: Gilboy, Travers and Wuerz: JEN 1999;25(6):468-73

52. ESI © V 1 Implementation April 1, 1999 UNC-Chapel Hill and April 15, 1999 @ The Brigham April 1, 1999 UNC-Chapel Hill and April 15, 1999 @ The Brigham ED leaderships decided to replace existing three-level triage with the new ESI © five-level triage algorithm ED leaderships decided to replace existing three-level triage with the new ESI © five-level triage algorithm Nurses: 1.5 hour educational session included a didactic presentation, a group discussion of triage case scenarios, and a 20-case post-test with brief written descriptions and photos Nurses: 1.5 hour educational session included a didactic presentation, a group discussion of triage case scenarios, and a 20-case post-test with brief written descriptions and photos Physicians: informed, not formally trained Physicians: informed, not formally trained

53. ESI © V 1 Implementation Posters and laminated pocket cards, computer-based reinforcement were prepared Posters and laminated pocket cards, computer-based reinforcement were prepared The hospitals’ information systems, ED charts, and ED patient tracking systems were updated The hospitals’ information systems, ED charts, and ED patient tracking systems were updated Change management strategies were actively used, including staff nurse involvement in planning, implementation, communications, and post- implementation quality reviews Change management strategies were actively used, including staff nurse involvement in planning, implementation, communications, and post- implementation quality reviews All new staff nurses received orientation using the same implementation program All new staff nurses received orientation using the same implementation program

54. ESI © V 1 Implementation Reliability Inter-rater reliability was assessed using the post-test case scenarios (n = 62 nurses: k.80) and a series of independent paired triage assessments (n = 219: k.73) Inter-rater reliability was assessed using the post-test case scenarios (n = 62 nurses: k.80) and a series of independent paired triage assessments (n = 219: k.73) For the paired triage assignments there were 23% (51/219) one-level disagreements, 1/219 two level disagreements For the paired triage assignments there were 23% (51/219) one-level disagreements, 1/219 two level disagreements Validation occurred on a one month cohort study: May 1999 (May 1 – May 29, 1999: n = 8,251) Validation occurred on a one month cohort study: May 1999 (May 1 – May 29, 1999: n = 8,251)

55. ESI © V 1 Implementation: Validation Hospitalization rates were strongly associated with triage level Hospitalization rates were strongly associated with triage level –Level 1: 92%  level 5 2% (figure 3 page 172) * Median LOS was strongly correlated with triage level * Median LOS was strongly correlated with triage level –Two hours shorter at either extreme than in intermediate categories (figure 3 page 172)

56. ESI © V 1 Implementation: Staff Feedback Staff survey (in part): Staff survey (in part): –Easier to use –More useful as a triage instrument than previous three- level triage

57. ESI © V 1 Implementation April 1999 Operational Impact Hard to display with data Hard to display with data –“ESI triage categories determines the patients’ priority for treatment and also the physical location of care” –More about this after next data set

58. ESI © V 1 Implementation Limitations Sampled only a portion of the cohort for paired triages Sampled only a portion of the cohort for paired triages Only two sites Only two sites (Only adults) (Only adults)

59. ESI © V 1 Implementation April 1999 “Emergency Severity Index Triage category is associated with six-month survival”: Wuerz, For The ESI Study Group: AEM 2001;8(1)61-65 (January) “Emergency Severity Index Triage category is associated with six-month survival”: Wuerz, For The ESI Study Group: AEM 2001;8(1)61-65 (January) “Implementation and refinement of the Emergency Severity Index”: Wuerz, Travers, Gilboy, Eitel, Rosenau, and Yazari: AEM 2001;8(2)170-176. (February) “Implementation and refinement of the Emergency Severity Index”: Wuerz, Travers, Gilboy, Eitel, Rosenau, and Yazari: AEM 2001;8(2)170-176. (February) “Dr. Richard Wuerz’s Emergency Severity Index” Walls: AEM 2001;8(2)183-184 (February) “Dr. Richard Wuerz’s Emergency Severity Index” Walls: AEM 2001;8(2)183-184 (February)

60. ESI © V 2 (All-Age) Multi-Site: Summer 1999 Same five levels, explicit definitions Same five levels, explicit definitions Vital signs ancillary still (used to up-triage only, from 3 to 2) Vital signs ancillary still (used to up-triage only, from 3 to 2) Peds criteria were added (potentially bacteremic) and vitals signs upgraded August 1999 Peds criteria were added (potentially bacteremic) and vitals signs upgraded August 1999 Research team in place Research team in place $50,000 AHRQ grant awarded in August 1999 $50,000 AHRQ grant awarded in August 1999 Kick-off York Sept-Oct 1999: standardized staff training program and case set; core project management steps  other sites Kick-off York Sept-Oct 1999: standardized staff training program and case set; core project management steps  other sites

61. Reliability & Validity Reliability: reproducibility & repeatability of a measurement tool (instrument) Reliability: reproducibility & repeatability of a measurement tool (instrument) – Inter-rater agreement – Test-retest agreement Validity: Or So What? Validity: Or So What? – Predictive validity – Outcomes associated with each triage level

62. Kappa = statistic Kappa = statistic Observed – expected 1 - expected Reliability Measurement of Agreement

63. Predictive Validity: Outcomes Outcomes associated with each triage level: Composite resource intensity Admission rates *ED length of stay 60 day all cause mortality Case mix (“footprint”)

64. The ESI V. 2 Implementation, Reliability and Validity Study (In Press: Accepted AEM April ‘03) Inter-rater reliability (reproducibility) measured by both case scenarios and patients in real time Inter-rater reliability (reproducibility) measured by both case scenarios and patients in real time Prospective cohort study to identify outcomes associated with each triage level (predictive validity): Prospective cohort study to identify outcomes associated with each triage level (predictive validity): – Resource intensity – Admit rates – *ED length of stay – 60 day all-cause mortality – Case mix comparison between sites

65. “ESI V. 2… Is Reliable and Valid” “ESI V. 2… Is Reliable and Valid” NOTE: Pre-publication information Eitel, Travers, Rosenau, Gilboy, & Wuerz Seven EDs with > 350,000 annual visits Seven EDs with > 350,000 annual visits Mix of academic/community sites Mix of academic/community sites –Brigham & Women’s - Boston –Faulkner Hospital - Boston –Lehigh Valley - Allentown (3 sites) –University of North Carolina - Chapel Hill –York Hospital - York

66. Conclusion -Reliability: ESI © triage produces reliable triage classification assignments when used by experienced and trained nurses at EDs representing varied regions of the country, urban and rural areas, and academic and community hospitals.

67. Conclusion – Predictive Validity: ESI © classification by experienced nurses reasonably predicts at triage how many resources patients will require to reach disposition BUT MORE IMPORTANTLY successfully discriminates low versus high resource intensity patients. This differentiation by resources requirements allows for much more effective streaming of patients post-triage into alternative operational pathways and\or care delivery settings: that is, parallel processing BUT NOT triage away.

68. Conclusion – Predictive Validity: ESI © triage produces admission rates by triage level that make sense.

69. Conclusion – Predictive Validity: ESI © triage classification assignments result in ED LOS numbers that (made) sense by triage level.

70. Conclusion – Predictive Validity: The data suggests that ESI © triage results in 60 day all-cause mortality rates that match up with the triage levels (*numbers are too small, too many missing data points).

71. Conclusion – Predictive Validity: ESI © triage produces presentational case mix information that is more representative of the operational reality of an ED than traditional three-level triage data – that is, triage case mix “footprints” are produced that make sense for differing EDs.

72. Conclusion – Predictive Validity : Implementation of ESI © triage immediately provides reliable departmental case mix information that is useful to both clinical staff and ED & hospital managers for decision making. “Measurement as a language…” Kaplan

73. Conclusion – Predictive Validity : Definitions in ESI: face validity, explicit: understandable to everyone. Reliability drives predictability. (So what?)

74. 2 yes no High risk situation? Or Confused/lethargic/disoriented? Or Severe pain/distress? Step 3 Step 2:

75. Presentational Case Mix Data Presentational Case Mix Data (“can manage the waiting room…”) 8,063TOTAL 1.4 14%.003%812 (10%)Level 5 2.0 47%2%2,197 (27%)Level 4 3.4 73%24%3,173 (39%)Level 3 4.0 90%54%1,756 (22%)Level 2 2.4 80%73%125 (2%)Level 1 ED LOS (hours) Resource Intensity Admit Rate Case Mix (% total) Triage Level

76. Conclusion – Predictive Validity : Definitions in ESI: face validity, explicit: understandable to everyone. Reliability drives predictability. (So what?)

77. “The job of management is prediction.” Dr. Deming

78. What does the evidence indicate? ESI © triage by experienced and trained ED RN’s produces reliable (reproducible and repeatable) & valid (predictable outcomes) stratification of presenting patients into five classes that provides case mix data useful to both ED and hospital managers for clinical, operational, and other (financial) decision-making.

79. So what?

80. Driver of My Interest “Reengineering The ED – Fixing Triage”: Streaming, “Reengineering The ED – Fixing Triage”: Streaming, not just sorting not just sorting  Predictive management and modeling  Predictive management and modeling

81. Predictive Management and Modeling : Operational and Financial Because “Reliability begets validity” (Yarnold) we can be predictive operationally AND financially (U.S.) Because “Reliability begets validity” (Yarnold) we can be predictive operationally AND financially (U.S.) See “Stuff Happens” flow chart See “Stuff Happens” flow chart –Basic operational modeling could begin for the ED and other pertinent downstream hospital service units

82. Predictive Management and Basic Operational Modeling “Stuff Happens” flow chart “Stuff Happens” flow chart –What if the 4’s and 5’s do not go to the main ED? I.e. when predicted volume justifies it, why not PLAN ROUTINELY to have an EP and tech\nurse in an “AlternaCare” setting: and care for 45-60 patients (65,000 visit ED) with a two person doc-nurse team? –Parallel processing  unload the main (overcrowded) ED  and make a palpable difference operationally…

83. If your little girl falls and cuts her forehead and needs stitches - is that an emergency?

86. Predictive Management and Basic Financial Modeling (U.S.) What are the financial implications for alternative staffing considerations for decisions regarding operating AlternaCare? What are the financial implications for alternative staffing considerations for decisions regarding operating AlternaCare? –Understand professional side reimbursement by RBRVS and other 3 rd party payors, for EP’s (good) vs. Advanced Practice Providers – APP’s (often not so good) –Understand state licensing rules for APP’s for Allopathic vs. Osteopathic State Boards of Medicine (complex – doable) –Understand the credentialing hoops required by all your 3 rd party payors for reimbursement for services of APP’s in the ED setting (complex\very time consuming)

87. Predictive Management and Basic Financial Modeling (U.S.) “What are the financial implications for alternative staffing considerations for decisions regarding AlternaCare? “What are the financial implications for alternative staffing considerations for decisions regarding AlternaCare? –Payor mix: understand hospital side reimbursement for Medicare APC’s (3 year’s new) (good IF…) vs. all the other other 3 rd party payors: ? % are Medicare in “AlternaCare” –Service mix: understand that usually 65-70% or so are “boo- boo’s”, or trauma related »Are minor surgical procedures paid for fairly well by most 3 rd party payors?

88. Predictive Management and Basic Financial Modeling (U.S.) Because “Reliability begets validity” can be predictive Because “Reliability begets validity” can be predictive See “Medicare Fee Schedule”: visit and procedure codes – financial modeling also for the ED See “Medicare Fee Schedule”: visit and procedure codes – financial modeling also for the ED Note: RBRVS “E&M” approach for Emergency Physicians vs. “E&M” for all other physicians are different! Note: RBRVS “E&M” approach for Emergency Physicians vs. “E&M” for all other physicians are different!

89. Advanced Operational Modeling: Computer Assisted Design Once reliable case mix (service mix) information exists in any service setting Once reliable case mix (service mix) information exists in any service setting CAD with flow chart-based off-the shelf software can be brought to the shop floor to assist with resources deployment decision making CAD with flow chart-based off-the shelf software can be brought to the shop floor to assist with resources deployment decision making Activity analysis + operational logic + simulation Activity analysis + operational logic + simulation

90. YH ED Simulation Study Partial Question Set What is the optimal staffing pattern and skill mix by time of day and day of week for the emergency department? What is the optimal staffing pattern and skill mix by time of day and day of week for the emergency department? What are the performance characteristics of AlternaCare – financial, throughput times – when the primary provider is a Physician Extender versus an Emergency Physician What are the performance characteristics of AlternaCare – financial, throughput times – when the primary provider is a Physician Extender versus an Emergency Physician What are the optimal hours of operation for AlternaCare by day of the week? What are the optimal hours of operation for AlternaCare by day of the week?

91. YH ED Simulation Study Partial Question Set How will the performance of the ED and AlternaCare be affected by adding four additional care areas to AlternaCare? How will the performance of the ED and AlternaCare be affected by adding four additional care areas to AlternaCare? What is the impact on operations – flow, resource consumption, staffing and revenue – of holding admitted patients for 8, 16, and 24 hours by number of patients held – 5, 10, 15, and 20 patients? What is the impact on operations – flow, resource consumption, staffing and revenue – of holding admitted patients for 8, 16, and 24 hours by number of patients held – 5, 10, 15, and 20 patients? What is the impact of medical students on ED performance? What is the impact of medical students on ED performance?

92. Predictive Management and Advanced Operational Modeling “Pairing ESI © Five-level Triage Case Mix Data With Computer-Assisted Design To Improve ED Access and Throughput”: Mahapatra, Koelling, Eitel & Grove (In press) “Pairing ESI © Five-level Triage Case Mix Data With Computer-Assisted Design To Improve ED Access and Throughput”: Mahapatra, Koelling, Eitel & Grove (In press) –YH academic ED modeled in Process Model (low fidelity) & ARENA (high fidelity) models –Invited presentation @ The Winter Simulation Conference New Orleans December 2003 New Orleans December 2003 –BMLS 2004 course

93. What is triage? Why do we do it?

94. A principal goal of Triage should be: To determine who should be seen first. Right?

95. A second major goal should be: Not just to “sort” but to “stream” to get the right patient to the right resources in the right place and at the right time to get the right patient to the right resources in the right place and at the right time

96. Managing by flow, Not capacity! “The Goal”

97. To manage by flow, have to first decide how to stream incoming patients

98. What does the evidence indicate? ESI © triage by experienced and trained ED RN’s produces reliable (reproducible and repeatable) & valid (predictable outcomes) stratification of presenting patients into five classes that provides case mix data useful to both ED and hospital managers for clinical, operational, and other (financial) decision-making.

99. We suggest you acquire: *“The ESI © Five Level Triage Implementation Handbook” available the week of July 7, 2003 from the ENA ($50-100) www.ena.org. * Authored by The ESI Research Team Dedicated to the memory of Dr. Rich Wuerz

100. Read it. Talk seriously with your ED management team and senior hospital managers about the important downstream implications it could have for caregivers and managers in terms of predictive management and modeling. Then – thoughtfully – install ESI © five level triage in your ED and begin a movement towards a Hospital Emergency Care System.

101. In Memory Of: Richard Wuerz MD Associate Clinical Director Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School

103. On Behalf Of The ESI Triage Research Team: Nicki Gilboy Nicki Gilboy Alex Rosenau Alex Rosenau Debbie Travers Tom Stair (the database guru) Melissa Schlenker Dave Eitel Rich Wuerz Thank you for the invitation!

104. Triage: Fixing the Front End Emergency Nursing Seminar The 2 nd Mediterranean Emergency Medicine Congress David Eitel MD MBA daveitel@cyberia.com