Journal Reviews

Tanabe P, Gimbel R, Yarnold PR, et al. The emergency severity index (version 3) five-level triage system scores predict ED resource consumption. J Emerg Nurs 2004; 30:22-29.

Triage scores assigned by ED nurses based on the Emergency Severity Index (ESI), a five-level triage system that was developed to improve reliability and validity of triage, can accurately predict both the amount of ED resources needed and the patient’s length of stay, says this study from Northwestern University in Chicago. The researchers retrospectively reviewed 403 ED patient records and found that the triage level assigned by ESI correlated strongly with the ED length of stay and amount of resources used — a benefit that is not possible with a three-level triage system. For example, when the ESI scale was used, it became clear that patients in the low-acuity triage levels required few ED resources, while Level 1 and 2 patients needed significantly more resources, and Level 4 and 5 patients experienced the shortest length of stay, whereas Level 2 and 3 patients had the longest length of stay. With a better understanding of ED acuity and resource needs, proactive, real-time interventions can reduce overcrowding, the researchers suggest.

"The ability to describe ED acuity that includes not only patients in the treatment process but also those in the waiting room is essential in today’s overcrowded environment," they wrote. "These data will give hospital administrators the ability to predict staffing needs and be alerted much earlier of a potential overcrowding situation."

Prina LD, Decker WW, Weaver AL, et al. Outcome of patients with a final diagnosis of chest pain of undetermined origin admitted under the suspicion of acute coronary syndrome: A report from the Rochester epidemiology project. Ann Emerg Med 2004; 43:59-67.

Patients who are discharged with a diagnosis of chest pain of undetermined origin with an initial abnormal electrocardiogram (ECG), pre-existing diabetes, or pre-existing coronary artery disease are at higher risk of a subsequent adverse cardiac event, according to this research from the Mayo Clinic and Mayo Foundation in Rochester, MN. The study’s authors reviewed 230 ED patients who were admitted with chest pain of undetermined origin and found that the above risk factors put patients at a significantly higher risk for having an adverse cardiac event within 12 months of the initial ED visit. In contrast, patients with a diagnosis of chest pain of undetermined origin and without identified risk factors are unlikely to experience a cardiac adverse event or die from a cardiac cause within the same time period, according to the researchers. They give the following recommendations, based on the study’s findings:

  • Patients presenting with a first episode of chest pain should be investigated to rule out an acute coronary syndrome.
  • Patients presenting with chest pain after a recent negative work-up for cardiac ischemic disease and without cardiovascular risk factors might warrant a period of observation in the ED with serial ECG and cardiac markers before being safely discharged.
  • For chest pain patients with any of the above risk factors, a period of observation with serial ECG and cardiac markers is important before concluding that the patient can be discharged safely, even after a recently negative evaluation for acute coronary syndromes.

Colman I, Dryden DM, Thompson AH, et al. Utilization of the emergency department after self-inflicted injury. Acad Emerg Med 2004; 11:136-142.

Patents who come to the ED with self-inflicted injuries were more likely to have return visits for mental disorders, substance abuse, unintentional injuries, assault, headache pain, and other complaints, says this study from the University of Alberta in Edmonton, Alberta, Canada. Researchers compared 478 patients with self-inflicted injuries with groups of asthmatics, which are commonly associated with heavy ED use, and a third group of patients with other complaints. Compared with the two control groups, patients with self-inflicted injuries returned to the ED more frequently for diverse reasons and were more likely to have more than three repeat visits a year to the ED. The ED visit is a good opportunity to direct these individuals to appropriate treatment programs, say the researchers. "Although mental health interventions in the ED may not be efficient, appropriate, or possible for all patients with self-inflicted injuries, interventions to assist with their problems are clearly required and imperative," they wrote. They give the following strategies:

  • Identify individuals at high risk for suicidal behavior and refer them for outpatient prevention services.
  • Schedule an appointment for follow-up referral while the patient still is in the ED.
  • Encourage patients to comply with follow-up treatment.