Patient Safety, 2012

Woodhull Medical and Mental Health Center Implements Triage System to Improve Care

May 2012

The emergency department at Woodhull Medical and Mental Health Center in Brooklyn, New York, implemented AHRQ's "Emergency Severity Index" (ESI) triage system to better manage incoming emergency patients. This triage system made it easier to differentiate the priority cases and standardized Woodhull's emergency care. Woodhull is a member of the New York City Health and Hospital Corporations.

AHRQ researchers developed the ESI in the late 1990s to prioritize patients into five groups based on patient acuity and the resources needed to treat them. The ESI Triage Group, a group of medical clinicians, managers, educators, and researchers, further refined the algorithm. Triage levels range from Level 1, which includes patients who are unresponsive, not breathing, or intubated to Level 5, which includes patients who are predicted to require only the taking of a history and a physical.

Former Medical Director of the Woodhull emergency department, Maurice Wright, MD, says, "Implementing [ESI] is the best thing that we ever did. We had approximately 65,000 emergency visits in 1998 and have since increased to around 100,000 annual visits. The growing number of patients meant we had to improve our systems' efficiency. The ESI enabled us to do that."

Prior to implementing AHRQ's ESI, Woodhull's emergency department had used a three-level triage system that classified patients as urgent, emergent, and nonurgent. This system made it difficult for triage nurses to differentiate between emergent and nonurgent patients. Furthermore, nurses working on the day shift tended to triage patients differently from nurses on duty at night. The lack of standardization in the way patients were triaged decreased the number of patients seen and also led to physicians not seeing the appropriate patients.

Wright, now Medical Director at Harlem Hospital, notes that changing triage systems was not easy. "This was a revolutionary move and it was a 'hard sell' to the staff. The nursing staff had become invested in the three-level system." To implement the ESI, Woodhull nurses and physicians took training courses that explained how the five-stage triage system works. This training emphasized differentiating between patients who, under the previous system, would be in the same group.

Since adopting the AHRQ ESI system, Woodhull's emergency department has embraced the ESI as a significant improvement and created what Wright calls "true believers" out of the nursing staff. The department has seen its patient satisfaction score rise, waiting room times decrease, and overall quality improve. By using the ESI triage system, Woodhull Medical Center improved the emergency department's patient flow, prevented care delays, and saved patient care costs by becoming more efficient.

Ten other New York City Health and Hospital centers are in the process of implementing or have implemented the ESI triage system since its adoption at Woodhull Medical and Mental Health Center.

Impact Case Study Identifier: CQuIPS-12-07
AHRQ Products: Emergency Severity Index
Topic(s): Emergency Medicine
Scope: New York

Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7:236-242. (HS10381)

Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 12-0014. Rockville, MD: Agency for Healthcare Research and Quality; 2011. http://www.ahrq.gov/research/esi/

Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care. AHRQ Pub No. 12-0014. http://www.ahrq.gov/research/esi/esi1.htm

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