The findings of Sax et al., are concerning, but not surprising. Two recent systematic reviews revealed similar deficiencies.^3,14 They demonstrated that ESI, along with all other legacy triage scales in use across the globe, has poor sensitivity for critical illness and is subject to high variability. Sax et al.’s findings also add to a multitude of studies reporting inequity in triage under ESI, including those demonstrating lower triage acuity assignment for Black and Hispanic patient and under-estimation of illness severity in elderly populations.^9,15–19

In their supplement, Sax et. al. provide evidence that ESI, even if optimally applied, has limited capacity for patient differentiation in our current practice environment. Less than half of patients in their health system met objective ESI criteria for high (3.1 percent) or low (37.2 percent) acuity under ESI; the majority (59.7 percent) were left to a single category: Level 3.¹³ This is similar to the proportion of patients triaged to ESI Level 3 in a report that included 25 EDs from 11 different US healthcare organizations in 10 states.¹⁰ Majority allocation to a single ambiguous midpoint within a 5-Level triage system runs counter to the fundamental objectives of triage: to differentiate and prioritize.³

We can do better. It is possible to make triage more accurate and equitable. It is possible to distribute patients more effectively across triage levels, and to match those levels to operational capacity and needs of individual departments. All these things can be achieved, but they require charting a new course in our approach to ED triage.

First, we must abandon the notion that resource utilization is a sufficient proxy for illness severity, patient complexity or even ED care intensity. Instead, as with every other decision in emergency medicine, risk of adverse outcome should guide decision-making for ED triage. Under our current approach to triage, a 20-year-old with no medical problems and a 70-year-old with hypertension, hyperlipidemia, and diabetes who both present with chest pain and have similar vital signs would each be triaged to Level 3. In a crowded ED, they would wait with identical prioritization. This should not be the case; their clinical risk profiles are dramatically different. Protocolized front-end care pathways can be used to expedite diagnostic evaluation and without abnormal results, our 20-year-old with chest pain could be quickly treated and dispositioned in a ‘vertical care’ or ‘fast-track’ area. Often, less time in treatment space is required for such a patient than for an abscess, laceration, or strep throat. None of these patients should compete for care with an elderly patient with chest pain.