Emergency Severity Index Triage Training UNION HOSPITAL EMERGENCY ROOM

What is ESI? Emergency Severity Index A five level triage scale that uses prioritization based on urgency (acuity) of condition but also considers resources needed to get the patient thru to ED disposition. Endorsed by ACEP and ENA. Rapid, accurate triage is key to successful emergency department operations. Undertriage leaves a patient at risk for deteriorating while waiting. Overtriage uses scarce resources limiting availability of an open ED bed for another more critical patient. Initial triage must be accurate. ESI is a tool for Emergency Department Triage. The Algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups-from Level 1 (Most urgent) to Level 5 (least urgent).

So, a 5 Level rating? 5 levels have meaningful differences between each level compared to previous 3 Level systems. ESI levels can be used to describe acuity levels. Not only # of visits annually but # of each level of patient. Can be used to justify staffing. 5 Level is research based, standardized and reliable between users. ESI levels can be used to describe acuity of patients. They are not dependent on changes in physicians, nurses, or protocols.

Emergency Severity Index ESI • Acuity assessment - Airway, breathing, circulation - Potential for life, organ or limb threat - How soon the patient needs to be seen • Expected resource assessment - Number of resources, as estimated by the triage nurse, that a patient is expected to consume in order for a disposition decision. Patients are categorized by evaluating both patient acuity and resources.

Emergency Severity Index ESI Five explicitly defined categories Mutually exclusive Allows for rapid sorting Differs from a complete assessment Gathering sufficient information to assign an ESI level Quick sorting

ESI ALGORITHIM Initially the nurses assess the acuity of the patient, if the patient does not meet high acuity criteria, then the nurse evaluates expected resource needs. Acuity is determined by the stability of vital functions and potential for life, limb, or organ threat. Resource needs are defined as the number of resources a patient is expected to consume in order for a disposition decision to be reached.

The first decision point is-Does this patient require life saving interventions?

Interventions not considered life saving are ones that are diagnostic or therapeutic. Life saving interventions are aimed at securing an airway, maintaining breathing, or supporting circulation.

An ESI Level 1 patient always presents with an unstable condition An ESI Level 1 patient always presents with an unstable condition. This patient requires immediate physician presence and interventions at the bedside and a team nursing response.

Examples of life saving interventions

Considered Diagnostic or Therapeutic.

What about mental status What about mental status? The patients level of consciousness is evaluated using the AVPU scale. Patients labeled a P or U are a critical concern.

An experienced triage nurse is able to recognize a patient in extremis with an across the room brief assessment. Level 1 patients comprise 1-3% of all ED patients.

Examples of Level 1 patients

Examples of Level 1 patients

Decision point B-Should the patient wait Decision point B-Should the patient wait? Pertinent subjective and objective information is utilized to quickly answer these questions.

The nurse utilizes experience to identify a patient at High Risk The nurse utilizes experience to identify a patient at High Risk. ESI level 2 patients are a high priority and placement and treatment should begin within 10 minutes of arrival.

Examples of level 2’s.

The concern is that whether the patient is displaying an acute change of level of consciousness.

Examples of confused, lethargic, or disoriented.

Pain is one of the most common reasons for visiting the ED Pain is one of the most common reasons for visiting the ED. Clearly all patients with a pain level of 7/10 do not need to be assigned a level 2 rating. The nurse uses all data to determine a level 2 rating.

Examples of level 2 for pain

Level 2 patients comprise approximately 20% of all ED visits.

Decision Point C- How may different resources is the patient going to consume to reach a disposition decision?

The estimation of resources has to do with standards of care and is independent of individual hospitals.

Note that it counts different TYPES of resources not individual tests.

Resource Examples CBC,BMP, PT/PTT=One Resource CBC, CXR=Two Resources CXR, ABD Series=One Resource CXR,CT Scan=Two Resources CBC,CT Scan, EKG=Three Resources Examples of counting resources

These patients have to be a reasonably healthy individual These patients have to be a reasonably healthy individual. Best suited to a Fast Track area.

Once again need to be reasonably healthy

Before assigning a level three the nurse must evaluate VS Before assigning a level three the nurse must evaluate VS. Are the VS appropriate for the age and are they meaningful? Consideration is then made to consider uptriaging the patient.

Temperature consideration for triage is only included with child under three. This will help identify a potentially bacteremic child and avoid them waiting a prolonged time.

Examples of level 3-5 patients.

Frequently Asked Questions Why isn’t a splint a resource? The application of a simple, pre-formed splint is not considered a resource. This is not being used to make the disposition decision. The Xray showing the injury makes the dispo decision. Why are the following considered resources? Eye irrigation, nebulized meds, and blood transfusion. All three are considered resources for the purposes of ESI. They tend to be used on patients that are more acute, require significant ED time, and are likely to have longer LOS.