1. EMERGENCY SEVERITY INDEX (ESI)
Sarah Pelletier, BSN, RN-BC
Sarah Espin, MSN, RN-BC, VHA-CM
Julie Alban, MSN, MPH, RN-BC, VHA-CM
Updated by Tania McMillan, MSN, RN-BC
Adapted from the Emergency Severity Index (ESI) Refresher PowerPoint by William Alt, BSN, RN Dayle Ann McCary, MSN, RN, CEN

2. OBJECTIVES Identify the 5-level triage scale of the ESI
Describe the ESI Triage Algorithm
Identify resources that would affect the algorithm
Verbalize the process involved in patient transfers

3. Emergency Severity Index (ESI)
ESI is a five-level triage scale developed by ED physicians and nurses
Provides a reliable, valid tool for determination of acuity
Describes parameters for the rapid identification of those who need immediate care
Discriminates between patients that need to be seen emergently versus urgently
Improves patient flow based on rapid sorting with projected resource and operational needs
Get the right patient to right resources in the right place at the right time

4. Institute of Medicine (IOM)Aims
Safety
Avoiding injuries from care that is intended to help
Effectiveness
Providing services based on evidence and avoiding interventions not likely to benefit
Patient-Centeredness
Respectful and responsive to individual patient preferences, needs, values, in clinical decision making
Timeliness
Reducing waits and sometimes harmful delays for those who receive care
Efficiency
Avoiding waste, in particular of equipment, supplies, ideas, energy
Equitable Care
Care that does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status)

5. ESI Triage Algorithm Decisions are based on 4 key questions:
Is this patient dying?
Is this a patient who shouldn't wait?
How many resources are needed?
What are the vital signs?

6. ESI TRIAGE ALGORITHM

7. Decision Point Review
A. Determine if immediate life-saving intervention is required. B. Is this a High risk situation? For example… Is the patient confused or disoriented? Is the patient in severe pain? C. Consider the resources that the patient will require. D. Review Vital Signs. Are they Danger Zone Vital Signs?: Consider triaging up to ESI 2 if any vital signs are beyond patient’s normal parameters. Adult: HR >100 RR >20 Sa02 < 92% with clinically significant symptoms

9. RESOURCES NOT RESOURCES Labs (blood, urine) EKG, X-rays,
CT,MRI, Ultrasound, angiography
IV Fluids (Hydration)
IV, IM, nebulized medication
Specialty consultation
Simple procedure = 1
(Laceration repair, Foley cath)
Complex procedure = (Conscious Sedation
History and physical (including pelvic)
Point of Care Testing
Saline or heplock
PO Meds
Tetanus Immunization
Prescription Refills
Phone Call to PCP
Simple Wound Care
(dressings, recheck)
Crutches, splints, slings

10. SUMMARY Acute confusion, lethargy or disorientation
Level 1 Resuscitation: Highest Priority
Requires immediate life-saving interventions
Is unresponsive
May include suspected CVA with symptom onset < 3 hours
Level 2 Emergent : High risk situation
Severe pain/distress, or
Acute confusion, lethargy or disorientation
Level 3 Urgent :
Requires 2 or more resources as defined by Emergency Severity Index
Level 4 Less Urgent:
Requires 1 resource as defined by Emergency Severity Index
Level 5 Non-Urgent: Lowest priority to be seen
No resources required as defined by Emergency Severity Index
Levels 1 and 2 based on acuity
Levels 3, 4 and 5 based on anticipated resources

11. Case Scenarios
“I slipped on the ice, and I hurt my wrist,” reports a 58-year-old female with a history of migraines. There is no obvious deformity. Vital signs are within normal limits, and she rates her pain as 5/10.

12. Case Scenario
EMS arrives with a 45-year-old woman with asthma who has had a cold for week. She started wheezing a few days ago and then developed a cough and a fever of 103. Vital signs: T ̊F, HR 92, RR 24, BP 148/86, SpO2 97%.

13. Case Scenario
An 82-year-old resident of a local assisted living facility called 911 because of excruciating generalized abdominal pain and vomiting that started a few hours ago. The woman is moaning in pain but is still able to tell you that she had a heart attack 6 years ago. Vital signs: T 98 ̊F, RR 28, HR 102, BP 146/80, SpO2 98%. Pain 10/10.

14. Case Scenario
“I think I need a tetanus shot,” a 29-year-old female tells you. “I stepped on a rusty nail this morning, and I know I haven’t had one for years.” No past medical history, No known drug allergies, no medications.

15. Case Scenario
EMS arrives with a 76-year-old male found on the bathroom floor. The family called 911 when they heard a loud crash in the bathroom. The patient was found in his underwear, and the toilet bowl was filled with maroon-colored stool. Vital signs on arrival: BP 70/palp, HR 128, RR 40. His family tells you he has a history of atrial fibrillation and takes a “little blue pill to thin his blood.”

16. Ambulatory Care Triage &
Transfer Note

17. Nurse Ambulatory Care Triage (T)

18. Nurse Ambulatory Care Triage (T)

19. Nurse Outpatient Triage Note (T)

20. Nursing Ambulatory Care Triage (T)

21. Nurse Outpatient to Inpatient Hand-Off (T)

22. Nurse Outpatient to Inpatient Hand-Off (T)

23. Nurse Outpatient to Inpatient Hand-Off

24. Nurse Outpatient to Inpatient Hand-Off (T)

25. REFERENCES
Gilboy, N., Tanabe. P, Travers DA, Rosenau, A.M., Eitel, D.R. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality. May 2005.
Alt, W. and McCary, D.A. Emergency Severity Index (ESI) Refresher [PowerPoint slides].

26. QUESTIONS????