Journal Article

The association between urgency level and hospital admission, mortality and resource utilization in three emergency department triage systems: an observational multicenter study

de Groot, Bas, Fransen, Laura F. C., Alexandridis, Georgios, Thijssen, Wendy A. M. H., van Wegen, Marit E.

2025

Overview

Background Effective triage systems are crucial for prioritizing patients based on urgency and optimizing resource utilization. An ideal triage system is expected to have low resource utilization, hospitalization and mortality among patients classified at low urgency levels. Furthermore, it should exhibit an increase in the risk of hospitalization and mortality as urgency levels increase, ensuring the most critically ill patients receive priority care first. However, it is unclear which triage system performs best. Objective To compare the performance of the Manchester Triage System (MTS), the Emergency Severity Index (ESI), and the Netherlands Triage Standard (NTS) by investigating the association between urgency levels and resource utilization, hospitalization and in-hospital mortality in Emergency Department (ED) patients. Methods Observational multicenter cohort study using data from the Netherlands Emergency department Evaluation Database, comprising seven representative EDs in six Dutch hospitals. All consecutive ED patients with a registered urgency level were included. Resource utilization, hospitalization and mortality were measured across all urgency levels. In each triage system, multivariable logistic regression was used to assess the association between urgency level and in-hospital mortality and hospitalization, adjusting for age, sex, presenting complaints and hospital type. Results A total of 696,518 ED visits (MTS 320,406 (46.1%), ESI 214,267 (30.8%), NTS 161,845 (23.3%) patients) were included. Resource utilization was substantially lower in the lowest urgency level of the ESI compared to the MTS and NTS. Hospitalization to a regular ward, cardiac, medium or intensive care unit in the least urgent level was 3.9% in the ESI, considerably lower than in the MTS (23.1%) and NTS (34.3%) ( P  < 0.05). Mortality in the lowest urgency level of the ESI was 0.8%, while in the MTS and NTS this was 6.3% and 12.4%, respectively ( P  < 0.05). In the ESI, the risk (Adjusted Odds Ratios) for hospitalization and mortality increased much more with increasing urgency levels compared to the MTS and NTS. Conclusion This study suggests that the ESI may be more effective in distinguishing between patients with low and high urgency, with a reduced risk of undertriage when compared to the MTS and NTS.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Admission and discharge / Adult / Aged / Emergency medical care / Emergency medical services / Emergency Medicine / Emergency service / Emergency Service, Hospital - statistics & numerical data / Female / Health care rationing / Health Resources - statistics & numerical data / Hospital Mortality - trends / Hospitalization - statistics & numerical data / Hospitals / Humans / In-hospital mortality / Male / Medical research / Medicine / Medicine & Public Health / Medicine, Experimental / Methods / Middle Aged / Mortality / Netherlands - epidemiology / Overtriage / Patient Admission - statistics & numerical data / Patient safety / Regression analysis / Statistical analysis / Traumatic Surgery / Triage / Triage (Medicine) / Triage - methods / Undertriage / Urgency level