Emergency Department Undertriage: Using Multidisciplinary Case Review to Drive Quality Improvement

Introduction: Triage determines the priority of evaluation. Undertriage, the underestimation of patients’ acuity, poses a safety risk. Undertriaged patients in the pediatric emergency department (PED) experience longer times to intravenous placement, nebulization therapy, and disposition. We described a multidisciplinary, team-based case review process to decrease our rate of clinically important undertriage. Methods: We defined clinically important undertriage as patient visits with an Emergency Severity Index (ESI) triage score of 4 or 5 in which the patient required admission or received aerosolized medication, oxygen, or intravenous medication. Cases were identified by an electronic health record tool, and then, a sample of cases was randomly assigned for review. Nurse–provider dyads and a multidisciplinary team reviewed undertriage cases monthly to determine whether a different ESI level should have been assigned based on information available at triage. The primary outcome measure was the proportion of patients triaged as ESI 4 and 5 with clinically important undertriage. The balancing measure was overtriage, defined as patients triaged as ESI 3 requiring fewer than 2 resources. Results: A total of 543 visits identified by electronic health record query were reviewed from September 2023 to September 2024. Interventions resulted in a decrease in the rate of clinically important undertriage by 14%, resulting in a centerline shift. Conclusions: Clinically important undertriage serves as a valuable quality metric to improve triage processes within the PED. Multidisciplinary team-based interventions successfully decreased the undertriage rate in the PED.