title: Lack of gender disparities in emergency department triage of acute stroke patients.
abstract: BACKGROUND
  Previous literature has shown gender disparities in the care of acute ischemic stroke. Compared to men, women wait longer for brain imaging and are less likely to receive intravenous (IV) tissue plasminogen activator (tPA). Emergency department (ED) triage is an important step in the rapid assessment of stroke patients and is a possible contributor to disparities. It is unknown whether gender differences exist in ED triage of acute stroke patients. Our primary objective was to determine whether gender disparities exist in the triage of acute stroke patients as defined by Emergency Severity Index (ESI) levels and use of ED critical care beds.
  
  
  METHODS
  This was a retrospective, observational study of both ischemic and hemorrhagic stroke patients age ≥18 years presenting to a large, urban, academic ED within six hours of symptom onset between January 2010, and December 2012. Primary outcomes were triage to a non-critical ED bed and Emergency Severity Index (ESI) level. Primary outcome data were extracted from electronic medical records by a blinded data manager; secondary outcome data and covariates were abstracted by trained research assistants. We performed bivariate and multivariate analyses. Logistic regression was performed using age, race, insurance status, mode of and time to arrival, National Institutes of Health Stroke Scale, and presence of atypical symptoms as covariates.
  
  
  RESULTS
  There were 537 patients included in this study. Women were older (75.6 vs. 69.5, p<0.001), and more women had a history of atrial fibrillation (39.8% vs. 25.3%, p<0.001). Compared to 9.5% of men, 10.3% of women were triaged to a non-critical care ED bed (p=0.77); 92.1% of women were triaged as ESI 1 or 2 vs. 93.6% of men (p=0.53). After adjustment, gender was not associated with triage location or ESI level, though atypical symptoms were associated with higher odds of being triaged to a non-critical care bed (aOR 1.98, 95%CI [1.03 - 3.81]) and 3.04 times higher odds of being triaged as ESI 3 vs. ESI 1 or 2 (95% CI [1.36 - 6.82]).
  
  
  CONCLUSIONS
  In a large, urban, academic ED at a primary stroke center, there were no gender differences in triage to critical care beds or ESI levels among acute stroke patients arriving within six hours of symptom onset. These findings suggest that ED triage protocols for stroke patients may be effective in minimizing gender disparities in care.
authors: Alpert Medical School of Brown University/Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island.
authors: Tracy E
authors: TE
authors: Madsen
authors: Alpert Medical School of Brown University/Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island.
authors: Esther K
authors: EK
authors: Choo
authors: Kaiser Permanente East Bay, Department of Criticial Care Medicine, Department of Emergency Medicine, Oakland, California.
authors: Todd A
authors: TA
authors: Seigel
authors: Emory University, Department of Epidemiology, Rollins School of Public Health Atlanta, Georgia.
authors: Danielle
authors: D
authors: Palms
authors: Alpert Medical School of Brown University/Rhode Island Hospital, Department of Neurology, Providence, Rhode Island.
authors: Brian
authors: B
authors: Silver
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data; D000368:Aged; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012737:Sex Factors; D020521:Stroke / Q000175:diagnosis* / Q000628:therapy; D013997:Time Factors; D014218:Triage / Q000706:statistics & numerical data*; D014481:United States