1. Christine Chao Northeastern University
Emergency Severity Index, 4th ed: Introduction to the five-level Triage Scale
Christine Chao
Northeastern University

2. Table of Contents Triage Overview and Refocus
Current Triage Statistics
Emergency Severity Index (ESI)
ESI Triage Algorithm
A) Does this patient require immediate life-saving intervention?
APVU Scale
B) Is this a patient who shouldn't wait?
Level 2 Indications
C) How many resources will this patient need?
D) What are the patient's vital signs?
ESI Reliability and Validity
References

3. Triage: Overview and Refocus
Triage is used to systematically prioritize patients No standardization of triage acuity rating systems
Three-level triage systems resulted over triage or under-triage
In 2002, Joint Triage Five Level Task Force released the following statement: “Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid five-level triage scale such as the Emergency Severity Index (ESI).”
ESI takes into account patient’s physical, developmental, psychosocial needs, patient flow in the emergency care system, and health care access.
Triage is the initial clinical sorting used in hospital emergency departments (ED) in order to systematically prioritize patients according to determine how urgently patients need care, including triage of requests for acute medical treatment. Historically, EDs in the US did not use standardized triage acuity rating systems. A variety of three-level triage systems were in use (1-emergent, 2-urgent, 3-non-urgent). The former triage system, consisting of three levels, has resulted in the tendency to over triage, resulting in scarce resources, or under-triage, putting a patient at risk of deterioration.
In 2002, Emergency Nurse Association and the American College of Emergency Physicians force Joint Triage Five Level Task Force released the following statement: “Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid five-level triage scale such as the Emergency Severity Index (ESI).” Reliable triage is critically important to help ensure patient safety and accurate identification of the patients needs. The nurse will assess and determine priority of care using ESI not only based on the patient’s physical, developmental, and psychosocial needs but also on patient flow in the emergency care system and health care access.

4. CURRENT Triage Statistics
In 2009, 57% of US hospitals have adopted the five-level Emergency Severity Index (ESI) system.
After implementation of five-level triage systems in Germany and Switzerland, the proportion of patients who leave the ED due to a long waiting time is lowered by 50%.
Of the million visits to the U.S. emergency departments in 2008, only
Statistic # 2: Increases patient safety
18% were seen in the first 15 minutes.
Several studies have demonstrated poor inter- and intrarater reliability of conventional three-level triage in the United States.

5. Emergency Severity Index
Three-level triage resulted in
tendencies toward early discharge of patients
minimizing readmission rates
reducing the use of an overburdened health care system is changing the face and function of triage.
Emergency Severity Index (ESI) was developed to increase accuracy. According the the ESI guidebook, “The ultimate goal of ESI implementation is to accurately capture patient acuity to optimize the safety of patients in the waiting room by ensuring that only patients stable to wait are selected to wait.”
Three-level triage was once considered the exclusive domain of the emergency department. However, tendencies toward early discharge of patients, minimizing readmission rates, and reducing the use of an overburdened health care system is changing the face and function of triage.
Due to the poor validity of three-level triage, the Emergency Severity Index (ESI) was developed as new five-level triage instrument to increase accuracy. According the the ESI guidebook, “The ultimate goal of ESI implementation is to accurately capture patient acuity to optimize the safety of patients in the waiting room by ensuring that only patients stable to wait are selected to wait.”
As with the three-level triage, assessing the ABCs of any patient is the primary concern but determining the disability of the patient aids the triage nurse in upgrading any triage decision. Therefore, observing the patient and doing a visual survey is the first step in the process. In addition, other aspects of triage include obtaining a good history of the patient’s presenting symptoms, obtaining a good medical history of the patient, and completing an assessment have been completed, the triage nurse can make a decision about the patient’s disposition.

6. ESI Triage Algorithm
This algorithm is designed to help triage nurses differentiate the critically ill from a large population of patients. ESI uses several quality indicators to monitor a patient’s health: life-saving intervention, abnormal disposition/behavior, resources, and vital signs.
All quality indicators aim to improve patient care through safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity, the six aims of the Institute of Medicine.

7. A) Does this patient require immediate life-saving intervention?
QUICK CHECKLIST
already intubated
apneic
pulseless
severe respiratory distress
SpO2 < 90 percent
acute mental status changes
unresponsive
To determine if a patient is classified as ESI level 1, the patient requires an immediate lifesaving intervention such as resuscitation, immediate medication or another intervention such as a blood transfusion. The patient may need an intervention if there is any concern about the following:
ability to deliver adequate oxygen to the tissues
breathing, maintaining a patent airway
detectable pulse
abnormalities in pulse rate, rhythm, and quality
chest pain including patients who are pale, diaphoretic, in acute respiratory distress or present unstable blood
Just like three-level triage, ESI level 1 patients cannot wait for medical attention. To determine if a patient is classified as ESI level 1, the patient requires an immediate lifesaving intervention such as resuscitation, immediate medication of another intervention such as a blood transfusion. A triage nurse will consider if a patient has the ability to deliver adequate oxygen to the tissues by identifying a patent airway.
In addition, chest pain must be evaluated within the context of the level-1 criteria to determine whether the patient requires an immediate life-saving intervention. Some patients presenting with chest pain may require a diagnostic electrocardiogram (ECG) within 10 minutes of arrival, but these patients do not meet level-1 criteria. However, patients who are pale, diaphoretic, in acute respiratory distress or present unstable blood levels do meet level-1 criteria and will require immediate life-saving interventions.

8. AVPU SCALE
AVPU (alert, verbal, pain, unresponsive) scale: The goal is to identify the patient who has a recent and/or sudden change in level of conscience or are non-verbal or require noxious stimuli to obtain a response.
Alert
Verbal
Pain
Unresponsive
Alert, awake, responds to voice, oriented to surroundings
Responds to verbal stimuli by opening eyes, not fully oriented
Does not respond to voice but responds to painful or noxious stimuli
Nonverbal and does not respond when painful stimuli is applied
In addition to assessing factors such as breathing and chest pain, a triage nurse much also assess level of responsiveness. The ESI algorithm uses the AVPU (alert, verbal, pain, unresponsive) scale. The goal for this part of the algorithm is to identify the patient who has a recent and/or sudden change in level of conscience or are non-verbal or require noxious stimuli to obtain a response.
Patients scoring a P (pain) or U (unresponsive) on the AVPU scale meet level-1 criteria. Unresponsiveness is assessed in the context of acute changes in neurological status, not for the patient who has known developmental delays, documented dementia, or aphasia. Any patient who is unresponsive, including unresponsive intoxicated patients, meets level-1 criteria and should receive immediate evaluation. An example of a recent mental status change that would require immediate intervention as would a patient with decreased mental status who is unable to maintain a patent airway or is in severe respiratory distress.
Patients scoring a P (pain) or U (unresponsive) on the AVPU scale meet level-1 criteria. Unresponsiveness is assessed in the context of acute changes in neurological status, not for the patient who has known developmental delays, documented dementia, or aphasia

9. B) Is this a patient who shouldn't wait?
QUICK CHECKLIST for level-2 criteria:
Is this a high-risk situation?
Is the patient confused, lethargic or disoriented?
Is the patient in severe pain or distress?
At decision point B, the nurse needs to decide whether this patient is a someone that should not wait to be seen.
If the patient should not wait, the patient is triaged as ESI level 2.
If the patient can wait, then the user moves to the next step in the algorithm.
Missing a high risk situation may result in a longer waiting period and potential deterioration of the patient’s health.
ESI does not specify the time frame to physician evaluation, unlike many other triage systems. However, it is understood that level 2 patients should be evaluated as soon as possible.
At triage nurse will look at the three criteria detailed on the next slide. Patients who meet the ESI level 2 criteria should have their placement rapidly facilitated.

10. Confused, lethargic, disoriented
level 2 Indications
High Risk Situation
Confused, lethargic, disoriented
Pain or Distress
Abnormal vital signs
Abdominal pain/bleeding, bloating
Vomiting, bleeding, etc
Chest pain (considered with other health factors i.e. drug use)
Airway compromise or inhalation injuries
Third degree burns
Electrolyte disturbances
High or low glucose levels in patients with diabetes
Oncology patient
Altered mental status – new upon injury
Chronic dementia and chronic confusion does not meet criteria; only acute changes are considered
Assess pain using pain scale - all patients who have a pain rating of 7/10 or greater should be considered for meeting ESI level-2 criteria (but not automatically triaged)
Assess for severe distress, defined as either physiological or psychological
Pain: Also consider chief complaint, past medical history, physiologic appearance of patient, and what interventions can be provided at triage to decrease pain

11. C) How many resources will this patient need?
Labs (blood, urine)
ECG, MRI, ultrasound
IV fluids for hydration
Specialty consultation
Simple and complex procedures
Not Resources
Physical exam
Saline
Prescription refills
Phone call to PCP
Simple wound care
Crutches, splints, slings
A patient is considered for ESI level 3, 4 or 5 is a triage nurse determines the patient is out of any immediate or oncoming threat by implementing the following information:
brief triage assessment
past medical history
medications
age
gender
to determine how many different resources will be needed for the ED provider to reach a solution.
Considering resources allows patients to be separated into more complex or resource intensive (level 3 or above) from those with simpler cases (level 4 or 5).

12. D) What are the patient's vital signs?
In ESI, vital signs, while important, may not always be helpful in determining initial triage level.
Only absolutely required for patients classified as ESI level 3. If the danger zone vitals are reached, a triage nurse can consider up-triaging to the patient from a level 3 to a level 2.
In the cases of urgency such as ESI level 1 and 2, vital signs may not be needed unless there is enough time.
Vital signs are ideally only taken if needed to estimate urgency or if time permits
In a three-level system, vital signs are taken to help determine how long a patient can wait for treatment. In ESI, vital signs, while important, may not always be helpful in determining initial triage level. Vital signs are only absolutely required for patients classified as ESI level 3. If the danger zone vitals are reached, a triage nurse can consider up-triaging to the patient from a level 3 to a level 2. In the cases of urgency such as ESI level 1 and 2, vital signs may not be needed unless there is enough time.
It is not wrong to obtain vital signs when triaging a stable patient. However, there is limited evidence showing abnormal vital signs have the ability to predict a serious illness. As such, vital signs are ideally only taken if needed to estimate urgency or if time permits. Automatic BP cuffs and pulse monitors accomplish this task rapidly in most emergency situations.

13. ESI Reliability and Validity
The Emergency Severity Index has shown high reliability and validity through the following studies:
Reliability and validity of a five-level triage instrument
Five level triage: A report from the ACEP/ENA Five Level Triage Task Force
Accuracy of the Emergency Severity Triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention.
Five-level triage system more effective than three-level in tertiary emergency department.
Validation of the Emergency Severity Index (ESI) in self-referred patients
If implemented widely in the US, ESI can has the ability to become the standard triage acuity assessment in EDs.
For further information, please refer to the Emergency Severity Index (ESI) Implementation Handbook, 2012 Edition online at
ESI offers 12 different analyses of adult emergency patients, more than other five level triage systems. It has been shown to be reproducible across several settings: rural and urban settings, academic hospitals, and community hospitals. Additional studies have demonstrated a high level of reliability and validity.
1. Wuerz R., Milne LW, Eitel D R, Travers D, Gilboy N (2000). Reliability and validity of a new five-level triage instrument. Academic Emergency Medicine 7(3):
2. Fernandes C, Tanabe P, Gilboy N, Johnson L, McNair R, Rosenau A, Sawchuk P, Thompson DA, Travers DA, Bonalumi N, Suter RE (2005). Five level triage: A report from the ACEP/ENA Five Level Triage Task Force. JEN 31(1):39-50.
3. Platts-Mills TF, Travers D, Biese K, McCall B, Kizer S, LaMantia M, Busby-Whitehead J, Cairns CB (2010). Accuracy of the Emergency Severity Triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention. Acad Emerg Med 17:
4. Travers DA, Waller AE, Bowling JM, Flowers D, Tintinalli J (2002). Five-level triage system more effective than three-level in tertiary emergency department. JEN 28(5):
5. Elshove-Bolk J, Mencl F, van Rijswijck BTF, Simons MP, van Vugt AB (2007). Validation of the Emergency Severity Index (ESI) in self-referred patients in a European emergency department. Emerg Med 24:

14. References
Aacharya, R., Denier, Y., & Gastmans, C. (2011, Oct 7) Emergency Department Triage: An Analysis. BMC Emergency Medicine, 11(16), Christ, M., Grossman, F., Winter, D., Bingisser, R., & Platz, E. (2010, December 17). Modern Triage in the Emergency Department. Dutsch Arztebl Intl, 107: Retrieved from Emergency Nurses Association and American College of Emergency Physicians. STANDARDIZED ED TRIAGE SCALE AND ACUITY CATEGORIZATION: JOINT ENA/ACEP STATEMENT. Emergency Nurse Association. Emergency Nurse Association, Web. ESI Triage Algorithm, v. 4. Digital image. Welcome to the Emergency Severity Index (ESI). Emergency Nurse Association, Web. < Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. (2012, January 1). Emergency Severity Index (ESI): A Triage Tool for Emergency Department. Agency for Healthcare Research and Quality, 4. Retrieved from systems/hospital/esi/esi1.html. Green, N., Durani, Y., Breecher, D., DePiero, A. (2012 Aug 28). Emergency Severity Index version 4: a valid and reliable pediatric emergency department triage. Pediactric Emergency Care, 28(8): Retrieved from pubmed/ Pitts, S., Pines, J., Handrigan, M., & Kellermann, A. (2012 Dec). National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity. Annals of Emergency Medicine, 60(6): Retrieved from Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. (2002 Mar 7) Reliability and validity of a new five-level triage instrument. Acad Emerg Med, 7:236;–42. Retrieved from

15. Notes
Reflective Note: This presentation is intended for emergency medical professionals who are operating emergency departments with a two-, three- or four- level triage assessment. The Emergency Severity Index has proven to be more accurate and efficient in providing better patient care than other systems. The intention is to bring to attention the benefits of a more comprehensive system of classification. The language is geared towards a population with a strong medical background, reducing explanation of several medical terms. This PowerPoint is has a very simple design. Because the topic is more serious, I did not include any extra photos or comics as I intend to for project 4. Important points and key words for different slides are bolded or highlighted to make this an easy reference guide. I also included easy to read lists to show the breakdown of ESI. This also allows for easy comparison to other triage systems. Personal Note: I think this would make a great addition for my portfolio. I had a good time learning about triage and emergency departments as well as putting myself in the shoes of a medical professional. Project 3 demonstrates my ability to present information in a professional way.