Emergency Severity Index (ESI): A Triage Tool for Emergency ...

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Table 4-2. Examples of Resources for ESI Levels 3-5 33 Chapter 4. ESI Levels 3-5 and Expected Resource Needs Scenario Predicted Resources ESI Triage Category (ESI Resources in italic) Right lower quadrant pain: ESI Resources = 2 or more 3 22-year-old male, right lower quadrant abdominal Exam pain since early this morning, also nausea, Laboratory studies and no appetite. IV fluid Abdominal CT (possible) Surgery Consult Left lower leg pain: ESI Resources = 2 or more 3 45-year-old obese female with left lower leg pain Exam & swelling which started 2 days ago, after driving Laboratory studies in a car for 12 hours. Lower extremity non-invasive vascular studies (possible) Anticoagulant therapy Ankle injury: ESI Resources = 1 4 Healthy, 19-year-old female who twisted her ankle Exam playing soccer. Edema at lateral malleolus, hurts Ankle x-ray to bear weight. Ace wrap Crutch-walking instruction Urinary tract infection symptoms: ESI Resources = 1 4 Healthy, 29-year-old female with UTI symptoms, Exam appears well, afebrile, denies vaginal discharge. Urine & urine culture (possible) Urine hCG Prescriptions Poison ivy: ESI Resources = none 5 Healthy 10-year-old child with 'poison ivy' Exam on extremities. Prescription Prescription refill: ESI Resources = none 5 Healthy 52-year-old who ran out of blood pressure Exam medication yesterday. BP 150/84. No acute Prescription complaints.
Chapter 5. The Role of Vital Signs in ESI Triage Introduction In this chapter, we focus on decision point D—the patient’s vital signs. To reach this point in the ESI algorithm, the triage nurse has already determined that the patient does not meet ESI level-1 or level-2 criteria and that he or she will require two or more resources. Since the patient requires two or more resources, he or she meets the criteria for at least an ESI level 3. It is at this point in the algorithm that vital signs data are considered and the triage nurse must assess the patient's heart rate, respiratory rate, oxygen saturation, and, for children under age 3, temperature (see Chapter 6 for more detailed information concerning the use of ESI for pediatric triaging). If the danger zone vital sign limits are exceeded (as illustrated in decision point D, Figure 5-1, the triage nurse must strongly consider uptriaging the patient from a level 3 to a level 2. It is always the decision of the experienced triage nurse to determine whether the patient meets criteria for ESI level 2, based on his or her past medical history, current medications, and subjective and objective assessment that includes general appearance. This decision is based on the triage nurse's clinical judgment and knowledge of normal vital sign parameters for all ages and the influence of factors such as medications, past medical history, and pain level. Are Vital Signs Necessary at Triage? Prior to the advent of five-level triage in the United States, tradition dictated that every patient presenting to an emergency department should have a set of vital signs taken before triage-level assignment. Vital signs were considered an integral component of the initial nursing assessment and were often used as a decision-making tool. In a traditional three-level triage system, vital signs helped determine how long a patient could wait for treatment (i.e., if no abnormal vital signs were present, in many cases, the patient could wait a longer period of time). Essentially, ESI level-1 and level-2 patients often are taken to an area with immediate staff attention prior to the point in triage when vital signs would normally be taken. There is frequently discussion about why vital signs are not a more important part of ESI criteria. Vital signs are important; however, they are not always helpful in determining an initial triage level. An 35 Figure 5-1. Danger Zone Vital Signs objective assessment of the patient, including the patient’s chief complaint, is often sufficient to categorize the patient as a high-acuity patient (ESI level 1 or 2), or low-acuity patient (ESI level 3, 4, or 5). However, the ESI Triage Research Team recommends obtaining a full set of vital signs at triage, including temperature, heart and respiratory rates, and blood pressure. Nurses are accustomed to this practice, and we have found that when vital signs are not obtained at triage, in particular for lower acuity chief complaints, they may never be obtained during the ED stay. Furthermore automatic BP cuffs and pulse monitors rapidly accomplish this task in most emergency departments. More recently, newer triage models, including ESI, advocate selective use of vital signs at triage (Gilboy, Travers, Wuerz, 1999). Initial vital signs are not a mandatory component of other five-level triage systems and in general are not reported during the triage phase of a level-1 or level-2 patient (i.e., those patients with the highest acuity). For example, the Guidelines for Implementation of the Australasian Triage Scale in Emergency Departments states that “vital signs should only be measured at triage if required to estimate urgency, or if time permits” (Australasian College for Emergency Medicine [ACEM], 2000). Similarly, the Canadian Triage and Acuity Scale upholds the need for vital signs if, and only if, they are necessary to determine a triage level (in the cases of levels 3, 4, and 5) as time permits (Beveridge et al., 2002). The Manchester Triage Group uses specific vital-sign parameters as discriminators
Page 1 and 2: Emergency Severity Index (ESI) A Tr
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Page 5 and 6: Note From the Director The Agency f
Page 7 and 8: Preface The Emergency Severity Inde
Page 9 and 10: Contents Chapter 1. Introduction to
Page 11 and 12: Chapter 1. Introduction to the Emer
Page 17 and 18: Chapter 2. Overview of the Emergenc
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Page 29 and 30: Chapter 3. ESI Level 2 • Sepsis
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Page 33 and 34: Chapter 3. ESI Level 2 Table 3-1. E
Page 35 and 36: Chapter 3. ESI Level 2 2. Is the Pa
Page 37 and 38: Chapter 3. ESI Level 2 References E
Page 39 and 40: Chapter 4. ESI Levels 3-5 and Expec
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Page 47 and 48: A 72-year-old patient presents to t
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Page 51 and 52: to the safe care of a child. Method
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Page 55 and 56: ESI Level 2 As with assigning an ES
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Page 59 and 60: Children with Co-Morbid Conditions
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Set B Competency Cases 1. “Withou
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6. ESI level 2: High risk. Rashes a
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11. ESI level 2: High risk. An over
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Appendix A. Frequently Asked Questi
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Appendix B. ESI Triage Algorithm, v
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Appendix C. Abbreviations and Acron
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Notes: A. Immediate life-saving int
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