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

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Cathleen Carlen-Lindauer, RN, MSN, CEN Clinical Nurse Specialist Department of Emergency Medicine Johns Hopkins Hospital Baltimore, MD Formerly from The Lehigh Valley Hospital and Health Network Allentown, PA Susan McDaniel Hohenhaus MA, RN, CEN, FAEN Executive Director Emergency Nurses Association and ENA Foundation Des Plaines, IL Formerly of Hohenhaus & Associates, Inc. Wellsboro, PA and Chicago, IL David Eitel, MD, MBA Physician Advisor, Case Management Wellspan Health System York, PA Jessica Katznelson, MD Assistant Professor Division of Pediatric Emergency Medicine School of Medicine Department of Pediatrics University of North Carolina at Chapel Hill Contributors iv Nancy Mecham, APRN, FNP, CEN Clinical Nurse Specialist Emergency Department and Rapid Treatment Unit Primary Children's Medical Center Salt Lake City, UT Valerie Rupp, RN, MSN Lehigh Valley Health Network Allentown, Pennsylvania Anna Waller, ScD Associate Professor Department of Emergency Medicine School of Medicine University of North Carolina at Chapel Hill Richard Wuerz, MD (deceased) Attending Physician Associate Research Director Department of Emergency Medicine Brigham and Women’s Hospital Boston, MA and Assistant Professor of Medicine (Emergency Medicine) Harvard Medical School Boston, MA The ESI Triage Research Team would like to thank Dr. David Eitel for his foundational contributions to the ESI, including development of the algorithm and the conceptual model, and his continued focus on translating ESI research into practice, especially in emergency department operations. Thank you, Dave.
Preface The Emergency Severity Index (ESI) is a tool for use in emergency department (ED) triage. The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs. Emergency physicians Richard Wuerz and David Eitel developed the original ESI concept in 1998. After pilot testing of the ESI yielded promising results, they brought together a number of emergency professionals interested in triage and the further refinement of the algorithm. The ESI Triage Group included emergency nursing and medical clinicians, managers, educators, and researchers. The ESI was initially implemented in two university teaching hospitals in 1999, and then refined and implemented in five additional hospitals in 2000. The tool was further refined based on feedback from the seven sites. Many research studies have been conducted to evaluate the reliability, validity, and ease of use of the ESI. One of the ESI Triage Group's primary goals was to publish a handbook to assist emergency nurses and physicians with implementation of the ESI. The group agreed that this was crucial to preserving the reliability and validity of the tool. A draft of this handbook was in progress in 2000, when Dr. Wuerz died suddenly and unexpectedly. The remaining group members were committed to the value of ESI and carrying out Dr. Wuerz's vision for a scientifically sound tool that offers emergency departments a standardized approach to patient categorization at triage. The group completed the first edition of The Emergency Severity Index (ESI) Implementation Handbook in 2002 (published by the Emergency Nurses Association [ENA]). The group then formed The ESI Triage Research Team, LLC, and worked with the Agency for Healthcare Research and Quality, which published the second edition in 2005. This 2012 edition has been significantly updated. ESI Version 4 is presented in the current handbook. Supporting research is presented in Chapter 2. Pediatric validation research led to the addition of a new pediatrics chapter to this edition. The handbook is intended to be a complete resource for ESI implementation. Emergency department educators, clinicians, and managers can use this practical guide to develop and conduct an ESI educational program, implement the algorithm, and design an ongoing quality improvement program. This edition of the book includes: • background information on triage acuity systems in the United States. • a summary of ESI research. • an overview of triage acuity systems in the United States and research reports using ESI. • an overview chapter describing ESI in detail: identifying high-risk patients, predicting resources, and using vital signs. • The new pediatric chapter. • Chapters on ESI implementation and quality monitoring. • Chapters with practice and competency cases, including many new cases. The handbook can be used alone or in conjunction with the training DVD, Emergency Severity Index, Version 4: Everything You Need to Know, also produced by AHRQ. The ESI represents a major change in the way triage is practiced; implementation of the ESI requires a serious commitment from education, management, and clinical staff. Successful implementation of this system is accomplished by committing significant resources during training and implementation. A myriad of benefits may result from a successful ESI implementation: improvements in ED operations, support for research and surveillance, and a standardized metric for benchmarking. v
Page 1 and 2: Emergency Severity Index (ESI) A Tr
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Page 5: Note From the Director The Agency f
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 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
Page 41 and 42: Chapter 4. ESI Levels 3-5 and Expec
Page 43 and 44: Chapter 5. The Role of Vital Signs
Page 45 and 46: those triaged as ESI level 3. The r
Page 47 and 48: A 72-year-old patient presents to t
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Table 6-6. Examples of Pediatric Tr
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Children with Co-Morbid Conditions
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Chapter 7. Implementation of ESI Tr
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The ED leadership team will ultimat
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will help assure reliability and va
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• The patient's rating of pain is
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• E-mails to remind staff of the
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Chapter 8. Evaluation and Quality I
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The cases in this chapter are provi
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28. “I just need another prescrip
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56 EMS arrives with a 42-year-old m
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84. EMS arrives with a 75-year-old
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14. ESI level 2: High risk. A tempe
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46. ESI level 4: One resource. The
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77. ESI level 5. No resources. No r
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Chapter 10. Competency Cases This c
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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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