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Ann Emerg Med. 2018 May;71(5):581-587.e3. doi: 10.1016/j.annemergmed.2017.09.036. Epub 2017 Nov 24.

Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment.

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Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Emergency Department, Hospital Moinhos de Vento, Porto Alegre, Brazil.
Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX.
Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
Emergency Department, Al-Rahba Hospital, Abu Dhabi, United Arab Emirates.
Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:



We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites.


This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed.


Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%).


In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.

[Indexed for MEDLINE]

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