Racial Disparities in Triage Acuity and Time to Provider in Adult Patients Presenting to the Emergency Department With Fever

Emergency department (ED) triage scores, such as the Emergency Severity Index (ESI), are assigned rapidly based on clinical severity, vital signs, and anticipated resource needs. ESI scores, ranging from 1 (most severe) to 5, influence how quickly patients are evaluated. While vital signs provide objective data in febrile patients, subjective components of triage may introduce bias. The objective of our study was to evaluate associations between sociodemographic factors and ESI assignment among adult ED patients presenting with a chief complaint of fever and to assess the effect of ESI assignment on time to provider.

We conducted a retrospective study of 45,090 patients ages 18-64 who presented to the ED of a tertiary care hospital between 9/1/2022 to 8/31/2023, identifying 854 patients with a chief complaint of fever. The primary outcome was ESI 2 versus ESI 3. Multivariable logistic regression was used to model the odds of ESI 2 assignment, while adjusting for age, race, sex, employment, insurance class, body mass index, temperature, pulse oximetry, and blood pressure. The secondary outcome was time to provider, defined as minutes to first physician or advanced practice provider contact.

Out of 854 identified ED visits of adult patients presenting with a chief complaint of fever, 26.5% were assigned ESI 2 and 69.6% were assigned ESI 3, with the remainder assigned other ESI levels. In multivariable analysis, Black patients had significantly lower odds of being assigned ESI 2 compared with White patients (OR 0.6, 95% CI 0.4–0.9). Other significant factors associated with ESI 2 included elevated heart rate (OR 59.6, 95% CI 10–353.7), respiratory rate (OR 100.1, 95% CI 9.2–1087.9) and age (OR 8.6, 95% CI 4.4–16.8). Patients assigned ESI 2 had a shorter mean time to provider compared with ESI 3 (60 vs 130 minutes).

Black race was independently associated with lower triage acuity assignment among adult patients presenting with fever, even when controlling for physiologic severity and sociodemographic factors. Because lower acuity scores lead to longer wait times, these triage disparities may contribute to inequities in timely ED care, including sepsis recognition. Future efforts will explore ED volumes, triage protocols, and other operational factors that may account for these disparities.