Tanabe and Colleagues Publish Article in the Journal of Emergency Nursing

Paula Tanabe, associate dean for research development and data science, recently published an article entitled "Implementing the Emergency Severity Index Triage System in Jamaican Accident and Emergency Departments" in the Journal of Emergency Nursing. Co-authors include Simone French from the University of the West Indies, Georgiana Gordon-Strachan of the University of the West Indies, Kevon Kerr of the University of the West Indies, Jacquiline Bisasor-McKenzie of the Ministry of Health in Jamaica and  Lambert Innis of the Ministry of Health in Jamaica.

Accident and Emergency Departments (A&Es) in Jamaica are overcrowded; in 2017, a total of 620,058 ED visits were recorded islandwide.1 The potential for negative outcomes is high as patients experience long waits for a full physician evaluation and diagnostic workup. The Ministry of Health (MOH) recognized the need to implement a valid and reliable triage system in Jamaica to ensure patient safety.

There are 19 local hospitals across Jamaica with 24-hour A&Es across the island. The health system is organized into 4 geographical regional health authorities: South East Region (SERHA) containing 7 24-hour hospital emergency departments; North East (NERHA) and Western Region (WRHA), each containing 4; and Southern Region (SRHA), containing 5 A&Es. Historically, Jamaica has used a wide variation of 3-, 4-, and 5-level triage systems across these hospitals. Many of these triage systems are poorly defined. The use of 5-level systems began to appear in the literature in the 1990s. Systems included the Australasian, Manchester, Canadian Triage and Acuity System (CTAS), and the Emergency Severity Index (ESI). Evidence of reliability and validity for all systems has been documented, with the largest literature existing for the CTAS and the ESI. Inter-rater reliability (agreement among different raters) of ESI ranges from 0.69 to 0.89.2, 3, 4 Validity with respect to the proportion of patients admitted to the hospital per ESI triage category, 60-day all-cause mortality by ESI level, as well as number of resources used, has also been demonstrated to be very good.3, 4, 5, 6 Emergency nurses have reported high levels of satisfaction with use of ESI.7 In addition to being used in over 57% of emergency departments in the United States,8 ESI has been implemented in Germany, Greece, Netherlands, Iran, Brazil, Taiwan, France, Saudi Arabia, and Abu Dhabi.9, 10

One hospital on the island, The University Hospital of the West Indies (UHWI), the primary teaching hospital in Jamaica, implemented the ESI in 2007. Beginning in 2004, nurses and physicians in the emergency medicine training programs were taught the ESI at UHWI. Training materials were used that are available online at no (books) or low (web course) cost, minimizing the barriers to learning ESI.11 After the successful implementation of ESI at UHWI in 2016, the MOH decided to implement the ESI as the triage system of choice across Jamaica. Several factors influenced the decision to implement the ESI. To prevent medical deterioration in the waiting room, acuity must be assessed accurately at triage. It was determined that using a 5-level system with good reliability and validity would allow a more accurate picture of A&E acuity in each hospital. The MOH could use these statistics to describe acuity across all A&Es. This comparison could guide resource allocationand policy development. The ESI triage system was selected because it meets all these criteria.

Given the mixed results of inter-rater reliability of the ESI internationally, we developed a comprehensive and thoughtful approach to implementation. The purpose of this paper is to report a project implementation and the detailed planning process to implement the ESI triage system throughout Jamaica using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) model as an organizing framework. We briefly discuss our plans for maintenance of implementation.