• Scott Levin, Matthew Toerper, Eric Hamrock, Jeremiah S Hinson, Sean Barnes, Heather Gardner, Andrea Dugas, Bob Linton, Tom Kirsch, and Gabor Kelen.
• Emergency Medicine, Johns Hopkins University, Baltimore, MD; StoCastic LLC, Baltimore, MD. Electronic address: slevin33@jhmi.edu.
• Ann Emerg Med. 2018 May 1; 71 (5): 565-574.e2.

Study ObjectiveStandards for emergency department (ED) triage in the United States rely heavily on subjective assessment and are limited in their ability to risk-stratify patients. This study seeks to evaluate an electronic triage system (e-triage) based on machine learning that predicts likelihood of acute outcomes enabling improved patient differentiation.MethodsA multisite, retrospective, cross-sectional study of 172,726 ED visits from urban and community EDs was conducted. E-triage is composed of a random forest model applied to triage data (vital signs, chief complaint, and active medical history) that predicts the need for critical care, an emergency procedure, and inpatient hospitalization in parallel and translates risk to triage level designations. Predicted outcomes and secondary outcomes of elevated troponin and lactate levels were evaluated and compared with the Emergency Severity Index (ESI).ResultsE-triage predictions had an area under the curve ranging from 0.73 to 0.92 and demonstrated equivalent or improved identification of clinical patient outcomes compared with ESI at both EDs. E-triage provided rationale for risk-based differentiation of the more than 65% of ED visits triaged to ESI level 3. Matching the ESI patient distribution for comparisons, e-triage identified more than 10% (14,326 patients) of ESI level 3 patients requiring up triage who had substantially increased risk of critical care or emergency procedure (1.7% ESI level 3 versus 6.2% up triaged) and hospitalization (18.9% versus 45.4%) across EDs.ConclusionE-triage more accurately classifies ESI level 3 patients and highlights opportunities to use predictive analytics to support triage decisionmaking. Further prospective validation is needed.Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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