ESI Emergency Severity Index

Summary

This script offers a comprehensive review of the Emergency Severity Index (ESI), a triage system used to categorize patients into five levels based on their urgency and need for resources. It covers the history of triage, the importance of accurate acuity assessment, and the role of the triage nurse. The presentation also discusses the criteria for each ESI level, high-risk situations, and the importance of patient presentation in determining ESI, aiming to improve emergency department efficiency and patient care.

Takeaways

• 🚑 The Emergency Severity Index (ESI) is a triage system used to categorize patients into five levels based on the severity of their condition, with one being the most critical.
• 📚 ESI was updated in 2010 by the Emergency Nurses Association (ENA) to better reflect patient acuity and improve patient flow and staffing in emergency departments.
• 🧐 Triage nurses play a crucial role in greeting patients, providing reassurance, administering first aid, and offering emotional support during the initial assessment.
• 🏥 Overcrowding in emergency rooms is a nationwide issue, exacerbated by federal mandates requiring provider visits and a shortage of primary care providers.
• 🔢 ESI levels are assigned based on the number of resources a patient requires, with ESI 1 patients needing immediate life-saving measures and ESI 5 patients not requiring any resources.
• 🆘 ESI level 1 patients are considered most critical and require the provider's immediate presence for life-saving interventions.
• 🚨 ESI level 2 patients are unstable and should be seen within 10 minutes; they are not safe to wait in the waiting room.
• 🤔 The triage process involves assessing the patient's general appearance, work of breathing, and circulation to quickly identify those who are critically ill and cannot wait.
• 💊 High-risk situations, such as patients with severe pain, confusion, or signs of stroke, may require immediate attention and categorization as ESI 2.
• 📈 Triage nurses must consider various factors, including the patient's age, medical history, and presenting symptoms, to accurately assign an ESI level.
• 📝 Accurate triage is essential for ensuring appropriate resource allocation and timely care for patients, reflecting the urgency of their medical needs.

Q & A

What is the Emergency Severity Index (ESI) used for?

The ESI is a triage tool used in emergency departments to determine how sick a patient is and how long they can safely wait for a provider.

How many categories does the ESI system separate patients into?

The ESI system separates patients into five categories, numbered one to five, with one being the most life-threatening.

What does the term 'triage' originate from and what does it mean?

The term 'triage' originates from the French verb 'tier', which means to sort or choose, and it was used in the military to sort wounded soldiers who could return to battle and those severely injured.

What organization sets the standards for emergency practice and what do they recommend for triage nurses?

The Emergency Nursing Association (ENA) sets the standards for emergency practice. They recommend that triage nurses have a certain level of experience and qualifications, including diverse knowledge, the ability to provide patient education, work under stress, and collaborate with interdisciplinary team members.

What should ideally happen when a patient comes into the ER?

Ideally, a patient coming into the ER should be greeted by a nurse and triaged within 2 to 5 minutes, although exceptions may apply for certain populations like pediatric patients and the elderly.

What are some benefits of having a triage nurse?

Benefits of having a triage nurse include greeting each patient, providing reassurance, administering first aid, offering emotional support, and potentially teaching patients at the point of triage.

What is one of the reasons for overcrowding in emergency departments?

One reason for overcrowding in emergency departments is the federal mandate that any patient coming into the ER must see a provider, coupled with a shortage of primary care providers, forcing sick people to seek care in the emergency department.

What is the first level of the five-level triage system and what does it indicate?

The first level is the resuscitation level, indicated by ESI 1, which means the patient needs some kind of life-saving measure and cannot wait for a provider.

What type of patient would be categorized as an ESI 1 and why?

An ESI 1 patient is someone who requires immediate life-saving measures such as back-bouth ventilation, intubation, defibrillation, or medication administration that can stabilize their critical condition.

What is the difference between an ESI 1 and ESI 2 patient?

An ESI 1 patient requires immediate life-saving measures and cannot wait for a provider, while an ESI 2 patient is unstable and should not wait more than 10 minutes, but does not require immediate life-saving interventions.

Outlines

00:00

🚑 Introduction to Emergency Severity Index (ESI)

This paragraph introduces the Emergency Severity Index (ESI), a triage tool used in emergency departments to assess the severity of a patient's condition. It explains that ESI categorizes patients into five levels, with one being the most critical. The purpose of ESI is to determine how sick a patient is and how long they can safely wait for treatment. The paragraph also discusses the origin of the term 'triage' and its military roots, as well as the importance of accurate acuity assessment for staffing and patient flow. The Emergency Nursing Association (ENA) sets standards for triage, emphasizing the need for experienced and qualified triage nurses who can make rapid, accurate decisions while considering cultural and religious concerns.

05:01

🔍 Understanding ESI Categories and Triage Process

This paragraph delves into the specifics of the ESI triage system, explaining the different categories and the criteria for assigning them. It mentions that ESI1 patients require immediate life-saving measures, while ESI2 patients are unstable and should not wait more than 10 minutes. ESI3 patients are urgent but can wait, and ESI4 and ESI5 patients are less urgent and non-urgent, respectively. The paragraph also highlights the importance of the triage nurse's role in greeting patients, providing reassurance, first aid, and emotional support. It discusses the nationwide problem of emergency department overcrowding and its causes, including federal mandates and a shortage of primary care providers.

10:04

🏥 Triage Assessment and Examples of ESI1 Patients

The paragraph focuses on the initial assessment during triage and the identification of ESI1 patients. It emphasizes the importance of quickly determining if a patient is dying and needs immediate life-saving measures. Examples of ESI1 patients include those with airway or breathing problems, those requiring defibrillation, and those needing procedures like needle decompression. The paragraph also discusses the changes made by the ENA in 2010, expanding the criteria for ESI1 to include more patients requiring life-saving measures. It provides examples of such patients, including those with severe respiratory distress, hemodynamic instability, and critical injuries.

15:05

🩺 ESI2 Patients: Unstable and High-Risk

This paragraph discusses ESI2 patients, who are unstable and should not wait more than 10 minutes for treatment. It explains that these patients may not be actively dying but still require immediate attention. The paragraph provides examples of ESI2 patients, such as those with active chest pain, needlestick injuries, and signs of stroke. It also highlights the importance of not sending ESI2 patients to the waiting room and the need for providers to see them within 10 minutes of arrival. The paragraph emphasizes the potential for these patients to deteriorate quickly and the need for prompt assessment and treatment.

20:07

🏥 High-Risk Situations and ESI2 Criteria

The paragraph explores various high-risk situations and the criteria for ESI2 patients. It covers patients with chest pain, needlestick injuries, stroke signs, abdominal pain, and immunocompromised conditions. The importance of not sending these patients to the waiting room is reiterated, as they may deteriorate rapidly. The paragraph also discusses the need for providers to initiate protocols and treatments promptly, such as for needlestick injuries and potential ectopic pregnancies. The potential for severe complications in elderly patients with abdominal pain is highlighted, emphasizing the need for timely evaluation and treatment.

25:09

🏥 Chest Pain and High-Risk Triage Situations

This paragraph discusses the triage of patients with chest pain and other high-risk situations. It explains that not all chest pain cases are ESI1 or ESI2, and the triage nurse must assess the patient's overall health and symptoms to determine the risk level. The paragraph also covers high-risk situations such as epigastric discomfort, nosebleeds in patients on Coumadin, difficulty swallowing, and inhalation injuries. The importance of timely assessment and treatment for these patients is emphasized, as they may have life-threatening conditions that require immediate attention.

30:09

🏥 High-Risk Medical Complaints and ESI Criteria

The paragraph focuses on high-risk medical complaints and their corresponding ESI criteria. It discusses patients with symptoms such as fainting, weakness, testicular pain, and mental health issues. The importance of not sending these patients to the waiting room is highlighted, as they may have serious underlying conditions that require immediate evaluation and treatment. The paragraph also covers the triage of patients with ocular injuries, compartment syndrome, and other high-risk orthopedic situations. The need for prompt assessment and treatment is emphasized to prevent further complications.

35:14

🏥 Pediatric and Special Populations Triage

This paragraph addresses the triage of pediatric patients and special populations, such as pregnant women and organ transplant patients. It explains the importance of considering the patient's age and specific conditions when assigning an ESI level. The paragraph highlights the need for prompt assessment and treatment for pediatric patients with seizures, dehydration, and burns, as well as for patients with recent transplants or respiratory issues. The importance of notifying the CBC nurse for pregnant patients and considering the mechanism of injury for trauma patients is also discussed.

40:15

🏥 Triage Evaluation and Resource Allocation

The paragraph discusses the process of evaluating patients during triage and determining their ESI level based on the resources they will need. It explains that the triage nurse must consider the patient's presentation and the potential need for various resources, such as lab work, imaging, and consultations. The paragraph provides examples of how to determine the number of resources a patient might need and assigns them to the appropriate ESI category. It also covers the criteria for ESI3, ESI4, and ESI5 patients, emphasizing the importance of accurate triage to ensure appropriate resource allocation and patient care.

45:15

🏥 Final Thoughts on Triage and ESI

In this final paragraph, the speaker provides a summary of the key points discussed in the video script. It emphasizes the importance of triaging patients based on their presentation in the emergency department, considering both their current condition and their pre-hospital history. The speaker also encourages participants to complete the review questions to receive credit for the session. The paragraph concludes by thanking the audience for their participation and providing contact information for submitting the review questions.

Keywords

💡Emergency Severity Index (ESI)

The Emergency Severity Index (ESI) is a triage system used in emergency departments to categorize patients based on the severity of their condition and the urgency of the care they require. Defined as a tool that 'determines how sick the patient is or if not how long they can wait safely for a provider,' it is central to the video's theme of efficient and effective patient prioritization in emergency settings. The script discusses ESI's five levels, with ESI 1 being the most critical.

💡Triage

Triage is the process of prioritizing patients for treatment based on the severity of their condition relative to the resources and personnel available. Originating from the French verb 'tier,' meaning to sort or choose, triage is essential in emergency medicine to allocate care appropriately. The script emphasizes the importance of triage in quickly identifying patients who require immediate attention versus those who can safely wait.

💡Acuity

Acuity refers to the seriousness of a patient's condition, which is a critical factor in determining the level of care needed. In the context of the video, correct acuity assessment is highlighted as essential for proper patient flow and staffing decisions in the emergency department. The script mentions that the ESI system helps in 'choosing the Acuity for our patients correctly.'

💡Resuscitation Level

Resuscitation Level, or ESI 1, denotes patients who require immediate life-saving measures and cannot wait for care. The script provides examples of such patients, including those needing intubation, defibrillation, or urgent surgical intervention, emphasizing the immediacy and severity of their conditions.

💡Urgent Care

Urgent Care refers to the level of care needed for patients who are not immediately life-threatening but still require prompt attention. The script describes ESI 3 patients as those who 'will need at least two or more resources' and are safe to wait, although they require more resources than less urgent cases.

💡Less Urgent

Less Urgent patients, categorized as ESI 4, are those who can wait for care without significant risk. They typically require only one resource, such as a single test or procedure. The script mentions that these patients are safe to wait for up to 60 minutes in the waiting room, subject to re-evaluation.

💡Non-Urgent

Non-Urgent patients, or ESI 5, do not require immediate resources but still need to be seen by a provider. The script illustrates this with examples such as patients needing medication refills or follow-up consultations, indicating a lower level of urgency compared to other categories.

💡Overcrowding

Overcrowding in the emergency department is a nationwide problem discussed in the script, with statistics indicating a 52% overcrowding rate in New England. It is a critical issue because it affects patient flow and the ability to provide timely care, especially for ESI 1 and 2 patients who require immediate attention.

💡Provider

A provider in the context of the script refers to a healthcare professional, such as a physician or nurse practitioner, who delivers care to patients. The script emphasizes the importance of the provider's presence for ESI 1 and 2 patients, who need immediate and potentially life-saving interventions.

💡Cultural and Religious Concerns

The script mentions the triage nurse's need to understand 'cultural and religious concerns that may occur with patients and their families.' This refers to the importance of culturally competent care, which respects and accommodates patients' beliefs and practices, especially in an emergency setting where rapid decisions must be made.

Highlights

Introduction to the Emergency Severity Index (ESI) for triage decision-making in emergency departments.

ESI's role in reflecting patient acuity and department staffing and flow.

Historical origins of triage from military practices to sort wounded soldiers.

Qualifications and experience required for triage nurses according to the Emergency Nursing Association (ENA).

Ideal triage process including greeting, reassurance, and first aid within 2-5 minutes.

Nationwide problem of emergency department overcrowding and its causes.

Five-level triage system used in most emergency departments to categorize patient needs.

Criteria for ESI Level 1 patients requiring immediate life-saving measures.

Identification of ESI Level 2 patients who are unstable and cannot wait in the waiting room.

Differentiation between non-life saving measures and criteria for ESI Level 1 assignment.

Examples of patients that qualify as ESI Level 1 due to severe respiratory distress or hemodynamic instability.

Importance of rapid provider presence for ESI Level 2 patients to prevent deterioration.

Assessment strategy for assigning ESI levels based on patient's general appearance and vital signs.

Special considerations for high-risk populations such as pediatric patients, the elderly, and pregnant women.

Guidance on managing patients with non-life threatening conditions and assigning ESI Levels 4 and 5.

Importance of re-evaluating waiting room patients and adjusting ESI levels as necessary.

Tips for triage nurses on assessing patient presentations and determining appropriate ESI levels.

Transcripts

welcome to the emergency severity index

review for those of you that are new to

triage this will prepare you to decide

whether the patient is sick or not sick

and who is safe to wait for those who

have been triaging for years this is a

good review on the changes that the ENA

made in 2010 it's important that we are

choosing the Acuity for our patients

correctly because it will reflect the

Staffing in our department and patient

flow for the duration of this session I

will refer to emergency severity index

as

ESI so let's begin ESI is a tool that we

use at triage to determine how sick the

patient is or if not how long they can

wait safely for a provider it separates

patients into five categories one to

five one being the most life-threatening

this tool also allows us to rapidly

identify the small number of prior ones

and twos and then sort the remaining who

can

wait the word triage is derived from the

French verb tier which means to sort or

choose this system originated in the

military to sort the soldiers who were

wounded and those who could return back

to the battlefield and the ones that

were severely injured it's great when we

have open beds and anyone coming into

the ER goes straight into the night next

available room but when more than one

patient comes in simultaneously the key

question is are they dying and how long

can they wait and if they wait how many

resources will they

require the emergency nursing

association sets the standards for

emergency practice they state that the

triage nurse will see each patient and

determine their priority based on

physical Developmental and psychological

needs as well as factors influencing

access to healthcare and patient flow

through the Emergency Care System the

ENA also recommends that the tri aers

have a certain level of experience and

qualifications such as a diverse

knowledge mace the ability to provide

patient education the ability to work

under stress and collaborate with the

interdisciplinary team members they must

also have the ability to make rapid

accurate decisions while understanding

cultural and religious concerns that may

occur with patients and their

families ideally the patient coming into

the ER should be greeted by the nurse

and triaged in 2 to 5 minutes of course

there are always exceptions to the rule

such as with pediatric patients and the

elderly population which may require

more time

so what are the benefits of having a

triage nurse one of them is that they

greet each patient provide reassurance

that they came to the right place for

treatment and one of the most useful

actions a triage nurse can do is provide

first aid so whether it's an ice pack

dressing protocol for pain management or

other quick interventions it allows for

the care to start right at triage the RN

can also provide emotional support

people in ER come because they're in

pain or something concerning is

happening most times people come in with

family or other support people so the

nurse has the opportunity to provide

comfort and even teach right at triage

depending on the

situation you can see that the problem

of overcrowding is a nationwide problem

with New England being at a 52% of

overcrowding one of the reasons being

that

um it is a federal mandate that any

patient that comes into the emergency

room needs to see a provider and second

that the primary care providers are in

short supply so um this forces sick

people to come to the emergency

department because they have no other

resource so this is the five level

triage system used um in most emergency

departments the first level

is the resuscitation level so an esi1

patient needs some kind of life saving

measure and cannot wait for a provider

the provider needs to um be present in

the room as soon as the patient arrives

for those life-saving measures the

second level is an emergency which uh

patient is unstable the nurse can go

ahead and start some kind of treatment

but the provider needs to be in there

within 10 minutes so that the patient

doesn't continue to

deteriorate um and then uh or or

potentially go into a uh ESI 1 and need

life-saving measures the third one is

urgent which means that the patient will

um need at least two or more resources

and we'll discuss resources um a little

bit later on uh this patient is safe to

wait um potentially in the waiting room

um for a provider the nurse can go ahead

and start any kind of protocols that may

be standing depending on the um

complaint of the

patient the next level is four which is

a less urgent patient this is more of if

you can think of your clinic type

patient that may need just one resource

um they're safe to wait for 60 minutes

in the waiting room um ideally every

patient that's in the waiting room

should be um

re-evaluated uh periodically and any

time the patient can be upgraded to a

different Acuity or or downgrade it

every time they're reassessed and then

your fifth category is your non-urgent

patient this patient does not require

any resources but does need um still to

see a

provider perhaps it's something um easy

such as a medication refill they

essentially don't have any kind of

complaint

um but are there for some kind of

followup or um simple question um that

the provider needs to

answer so let's begin with assigning

Acuity so you have a patient that comes

into the emergency department and with

the initial encounter you're going to

notice the patients General appearance

their work of breathing and circulation

so before vitals are taken just by

looking at the patient you want to ask

yourself the first question and is is

this patient

dying if indeed this patient looks like

they're in stress they need life-saving

measures and this is something that's

comes with experience the triage nurse

ideally is one that has seen patients um

in life-threatening situation um so this

patient will be triage as an esi1 taken

straight into a room and um have the

provider go in there there to initiate

those life-saving measures the patient

will not stop at triage for Vital Signs

um they will not have any other

questions answered just based on their

appearance

Alone um will will become an ESI 1 and

we'll go into some examples as to what

an ESI 1 um is

considered okay so let's look at some

examples of what constitutes as an esi1

and patients needing life-saving

measures if the patient has an airway

breathing problem that requires um back

bouth ventilation if the patient needs

to be intubated any kind of surgical

Airway or they come in or need CPAP or

BiPAP they are an

esi1 if they need some kind of

life-saving measure where they need to

be defibrillated or emergently

cardioverted or have an external Pacer

placed that is also an

esi1 so the patient can essentially be

alert and um com able to verbalize their

discomfort but they um need these

life-saving measures they are an esi1 if

the patient needs procedures such as a

needle decompression a paroc cardiio

centesis an open thorocotomy or an

insertion of an intra access in order

to provide any medication that um is a

life-saving measure that is also an esi1

if the patient is hemodynamically

unstable where they need IV fluid

resuscitation they need blood

transfusion administered um or any

control of major bleeding they are also

an

esi1 if the patient requires

medications such as U nalaxone or Naran

to reverse their

respiratory depression they're in esi1

if they are

hypoglycemic and unstable where they may

be unresponsive or have any kind of

alter mental status that is a

life-saving measure to give somebody um

an amp of D50 because the brain cannot

function without

glucose so that would be considered a

life-saving measure a patient requireed

dopamine for unstable blood pressure

atropine for a unstable heart rate um

below normal or if they need a d or a

Denine for a unstable SVT this will all

be an esi1 patient this patient needs to

be in the room immediately with a

provider um as as well as the nurse to

provide life-saving measures so notice

on the non-life saving

side these are things that can be

initiated by the nurse this um is

something that perhaps could be

considered a um um treatment or um

diagnostic so this does not have any

kind of life

saving um capabilities so a patient just

being place in a nasel canola or a nonre

breather um it is not life- saving

putting somebody on the cardiac monitor

gives us a lot of information as to

what's happening but it is the actual

act of putting a person on the cardiac

monitor canot um save their life

doing an AKG lab work ultrasound uh

focused abdominal scan for trauma again

gives us information to help us diagnose

but does not have any life sa saving

capability um any patient needing IV

access or sailing lock although some of

the stuff will happen simultaneously

with your life- saving measured is not

the only reason why a person will be

assigned me a high level of one

before 2010 the standard for ESI 1 was

reserved for those cardiac arrest and

respiratory arrest patients but after

the ENA made changes they opened up that

ESI to more um type of patients that

were requiring life-saving measures the

concept is that the provider needs to be

in the room and initiating those

life-saving measures so patients that

come in with an SPO to less than 90

perhaps need uh definitive Airway should

be considered an ESI 1 critically

injured trauma patients who are

unresponsive will need life-saving

measures any overdose with a respiratory

rate of six um or below you would

anticipate them needing Naran so they

should be in

esi1 a sever respiratory distress

patient with agonal or gasping type

respirations will need a definitive way

severe Bic cardia may need a external

Pacer or atropine uh AIC cardia maybe um

unstable and um

hyperperfusion patient will need um

medication and uh perhaps uh fluid

resuscitation patients that are

hypotensive um may also need medication

to help with the perfusion trauma

patients who require um large amount of

uh fluid resuscitation or blood products

um any kind of um control bleeding needs

to be an esi1 if a patient comes in with

uh complaint of chest pain and they're

showing signs of hypop profusion um and

are peer pale and diaphoretic have a

unstable blood pressure should be an

esi1 a patient who is weak uh dizzy with

a heart rate of 30 will

need an Pacer or uh perhaps some

atropine to help them um with their

heart rate a patient with anaphylactic

reaction um can progress fairly quickly

so you want to stabilize this patient uh

perhaps um establish a definitive Airway

before swelling gets worse and get that

Epi on board as soon as

possible um so that the respiratory um

distress doesn't progress

a baby that appears to be FD needs to be

taken care of um immediately so they

would be an

esi1 a patient who is unresponsive with

a strong odor of eoh you have to assume

the worst um you cannot just assume that

the patient's intoxicated perhaps

there's something else going on that's

life-threatening such as

hypoglycemia or a head injury so you

have to kind of get the patient in the

room with the provider and initiate any

life-saving measures a patient that is

hypoglycemic and needs uh

dextrose um will also be considered an

ESI 1 because that life- saving measure

cannot

wait okay so let's try an example a

67-year-old male comes into the ER by

car he complains of severe abdominal

pain he says it feels like I'm ripping

apart the pain started about 20 minutes

ago and is a 10 out of 10 he is

hypertensive and takes diuretics the

patient is sitting in the wheelchair

moaning in pain his skin is cool and

diaphoretic So based on the general

appearance of this patient just by

looking at him you notice that he is in

distress circulatory is an issue with

his cool and diaphoretic skin he is

complaining of a ripping pain which

should alert you that perhaps this is an

AAA rupture so the patient needs to be

in ESI 1 and brought in right

away okay so let's try another one this

is a 25-year-old female that comes in

with complaint of the smoke was so bad I

just couldn't breathe she has aoar voice

and complains of sore throat and is

coughing you know she is working hard to

breathe she has history of

asthma so this patient should be an ESI

1 she has significant Airway injury from

the smoke and will need

intubation okay Okay so we've gone over

what constitutes an as an esi1 patient

so now let's go into the next category

which is your esi2 patient and this

patient is unstable and should not wait

more than 10 minutes so you've answered

the first question is this patient dying

the answer is no um but the next

question is um shouldn't shouldn't wait

in the waiting room essentially and if

they shouldn't wait

in the waiting room for either um

physical um distress any developmental

or psychological need then they need to

be an ESI too so the patient needs to

not St at triage for Vital Signs they

can go straight into the next available

room the team of nurses can certainly

start any type of treatment whether it's

their protocols to get blood work or um

put on the card

monitor um uh establish any uh maybe

start normal sailing or nasal Kenya non

breather such things or just provide a

safe environment if this is a um

psychological

issue so the provider ideally should be

in the room within 10 minutes um the

patient may be uh potentially worsening

so they should not wait more than 10

minutes so that the doctor can go ahead

and start any kind of additional orders

whether it's um Imaging or medication so

that the patient way to think about it

the um triage nurse knows that this

patient um should not wait um so they

make them a priority too so the idea is

that this could be a highrisk

situation um the patient may be confused

so if they're showing signs of um

inappropriate response to stimuli they

have a decrease in attention span and

memory if they're lethargic to the point

where they're drowsy or they're sleepy

more than usual um or just doesn't

respond appropriately when stimulated

they should be a esi2 they're high-risk

patient and should really be um going to

the next available

room and the patient disoriented and

this is new um the patient is unable to

answer questions you know simple

questions as time place or person um

then they should be in ESI

too so examples of confusion lethargy

and disoriented let's say this is a um

new onset confusion for an elderly

patient or a baby whose mom says they're

just not acting a appropriately or

sleepy all the time if it's an

adolescent that perhaps is uh confused

or disoriented we're going to assume

that there's either a structural or

chemically

compromised uh brain injury um so they

need to be seen uh within 10 minutes and

definitely not go into the waiting

room okay so some examples of an ESI

patient that cannot go back into the

waiting room a patient with active chest

pain but otherwise stable so they are

not showing any signs of hypo profusion

but if a patient comes in with complaint

of chest pain we need to get an EKG done

right away and read to make sure that

they're not having ANM or any other

unstable

life-threatening um cardiac um issue a

patient that comes in with a needle

stick um so somebody from the hosital

Hospital from another floor got stuck by

a patient um dirty needle they need to

be an ESI 2 and registered and seen um

by the provider within 10 minutes of

arrival the last thing we want is this

patient to think that getting a needle

stick is not a big deal and um we put

them into the waiting room cuz that's

kind of what the message implies is that

we're going to send you into the waiting

room room um because this isn't a um you

know a high-risk situation when indeed

it's the opposite this is a very

highrisk situation we want to not only

reassure the patients that we're going

to do everything that we can to take

care of them but we want to go ahead and

get um our protocol for needle stick

initiated and start any kind of

treatment if um it's warranted

a patient that comes in with signs of

stroke but not unresponsive which would

make them a category one um so a patient

that is exhibiting uh weakness or uh

facial

droop um they need to be seen by a

provider and have that NIH Stroke Scale

within 10 minutes of arrival so the uh

ideally the provider needs to get in

there and start their um

assessment um get that NIH Stroke Scale

and bring the patient to CAT scan for um

a head SE team the patient that is

complaining of abdominal pain and can

potentially be an ectopic

pregnancy um otherwise hemodynamically

stable should be an ESI too they need to

have a provider evaluate them um the

patient needs to have Vital Signs just

to make sure that there's no um rupt

sure or that they're not going to worsen

in the waiting room a patient that's on

chemo with a fever is immunosuppressed

and they really should not go into the

waiting room for the mere fact that they

will be exposed to everybody out there

um and can get U much sicker a patient

who is showing signs or has verbalized

that they are suicidal or homicidal are

not safe to go into the waiting room

they need to be put into a room where

they can be safe um and perhaps if they

are um needing medication that needs to

be um done as soon as

possible so abdominal pain is a common

complaint in the ER so the triage nurse

needs to um take a step back and ask

what makes this abdominal pain a

highrisk situation and there's a couple

of factors um pain rating may be a

factor or once you do Vital Signs

something is unstable that would make it

a high RIS situation we also have to

consider the elderly

population as a high risk because if

they're having abdominal pain they have

a high potential of perhaps a bowel

obstruction

a GI bleed or um other

complications that can um be significant

for a higher U morbidity and mortality

um when compared to your younger

patients so um

another uh a key kind of uh word that

may may make this a high risk if it's

the patient is complaining of a ripping

kind of abdominal pain um you want to

consider perhaps this could be an

abdominal aortic

aneurysm um and they should be in a high

risk and brought in for

evaluation um otherwise uh perhaps a

patient is vomiting blood or um

complaining of blood um uh in the stool

then um they should definitely kind of

um be considered along with their Vital

sign that this is not a patient that is

um stable to wait in in the waiting

room the next common uh problem or

complaint that the patient um in the ER

has is chest pain so not every chest

pain is an ESI to but we do need to

consider that sometimes it's difficult

to um determine if they're having a um

acute coronary um syndrome at triage so

if the patient is having complaints of

epigastric

discomfort um with or without symptoms

they usually will need an EKG to

determine whether they're having a acute

coronary syndrome um and be made an

esi2 otherwise the triage nurse has to

kind of um take a step back and see okay

is this patient um otherwise healthy

um has chest pain but cough and fever

you know the potential for acute

coronary syndrome is low so they don't

necessarily need to be made an ESI too

every patient is um individual so the

trian nurse kind of has to draw their um

in of their knowledge of acute coronary

syndrome also um think of women and

their kind of uh presentation and

unspecific um characteristics of heart

disease so perhaps you have a you know

female in their 50s that has epigastric

pain and

fatigue this is a

highrisk um situation and um they should

be in ESI

too another example of the highrisk

situation is those nose bleed patients

that are on cumin they have a potential

for losing a large amount of blood if

not controlled

um they also have a potential for um

their Airway to be compromised because

of the amount of blood if this patient's

having um a nose bleed and is

hypertensive they are also a highrisk

situation because the increase in blood

pressure is making the bleeding um

worse um if the patient um also has uh

history of of recent cocaine

use um they should be in ESI too because

they are considered a highrisk

patient um patients with complaint of um

difficulty swallowing perhaps this is an

epiglottitis they have a potential for

obstruction so if the patient says I'm

having difficulty swallowing or it hurts

to swallow um don't be afraid to kind of

look into their mouth and see what's

going

on in their throat you want to make them

an ESI to and get them to be seen um

perhaps they will need an U uh to have a

Airway

established if the patient has had any

kind of inhalation injuries they should

be considered high risk because again

they may have potential for their Airway

to be compromised and they may need a

definitive Airway

if the patient um has an environmental

or an inhalation injury that indeed is

showing signs of Airway distress and

this patient should be in

esi1 and have um a definitive if Airway

established right away if the patient

has a facial fracture this is a highis

situation because they can have an

airway compromise

and um swelling can get worse so if they

are not having any Airway compromise um

they should still be an ESI too just

because of the high risk if they are

having any signs of difficulty breathing

or compromise then they should be an

esi1 other General Medical complaints

that should be considered a high risk is

patient that you are suspecting maybe in

dka perhap perhaps hypo or

hyperglycemic or if they meet sepsis

criteria then they should be a ESI

too some more high risk situations let's

say a patient comes in complaining of

fainting or passing out or feeling like

they had a temporary loss of

consciousness um they should be uh H

situation uh rule out Syncopy patient

and brought into a room for

evaluation a patient that perhaps is

sent in from their doctor's office um

where they were called in because they

had lab work and um they had hyperemia

they should also be uh brought into a

room and placed on the Monitor and have

repeated blood work quickly they should

not go into the waiting room a patient

with um weakness that happens to be a um

chronic renal failure patient should

also be U brought into the next

available room because they have a high

risk of having electrolyte

imbalances the oncology patient as I

mentioned earlier is imuno compromised

so they should not be in the waiting

room a male that complains of testicular

pain um this patient needs to be

evaluated um to make sure that they

don't have a um testicular torsion um

that could have um

long-term um effects they need a Urology

consult and um treatment um as soon as

possible to um avoid worsening or any

tissue destruction if they are having a

a AIC

torsion a patient that is brought in uh

from dialysis because they became

hypotensive or hypertensive or um

complain of dizziness or weakness any

kind of

interruption of that

treatment um needs to be

evaluated um because they are

potentially still fluid overloaded and

they have of electrolyte

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imbalances any um urinary

obstruction should also um be seen

fairly quickly within 10 minutes the um

patient can be U very uncomfortable with

that urinary

obstruction um and uh can become very

unstable um the progression can worsen

they can go into a um poon nephritis um

and have other complications so they

should be seen within 10 minutes a

patient that has um mental health issues

such as um saying that they're suicidal

or homicidal or having any kind of

psychotic event um they're violent or um

an alotment risk with a potential for

harming self or others um needs to be an

ESI too and placed in a safe place safe

room a patient that's

intoxicated um is not a reliable source

so they can't tell you with 100%

certainty that they didn't in fact hit

their head um or that they fell so

there's potential for them to have um

confusion or slurred speech um because

of a head injury and not just because

they're

intoxicated a patient that complains of

that worst headache of their life um

needs to be a high-risk um ESI patient

um any change in mental status high

blood pressure um

lethargy fever or rash they should also

be in ESI too because of the potential

of having a um medical problem that can

worsen um in the waiting

room moving on to more high-risk

situations a patient with an ocular

injury can have severe debilitating

effects from um such um injuries like a

chemical Splash so although this is not

a lifethreatening

situation um it is highrisk because of

the potential for disability an

orthopedic um highrisk situation is um

suspicion of a compartment syndrome so

if a patient with cast is complaining of

um pain that's increasing paresthesia if

the skin appears to be U pale there's um

decreased CMS of paralysis

pulselessness then um this patient is at

high risk for compartment syndrome and

um injury to the extremity and

potentially could need surgery a

pediatric patient that has um had a

seizure appears to be dehydrated and dka

I child that you may suspect is um child

abuse um needs to be placed in a safe um

in a safe place a pediatric Burns needs

to be an ESI to um or a one depending on

the severity of their injuries if they

potentially will need large amounts of

fluid

resuscitation um a pediatric with um

head injury especially if they're

withdrawing or just not acting like

themselves they be any si2 uh pediatric

with any type of vitamin or iron um

ingestion needs to be treated right away

a baby that's under 28 days old with a

fever needs to be in ESI 2 and made a um

high-risk patient a patient with a

recent transplant of any organ or is on

the list um cannot wait in the waiting

room needs to be placed in a room and

treatment started any

respiratory issues such as an asthma

exacerbation potential for PE plural

diffusion a num numo thorax a foreign

body

aspiration um any type of a toxic

inhalation um or short of breath with

chest pain is an ESI too although they

don't need any really life um saving

measures initially the potenti is there

so they need to have a provider see them

fairly

quickly patients with known or

suspected overdose whether they admit to

what they've taken or maybe they're not

sure um needs to be an ESI to we need to

um get a good story and um determine

what they've taken and how much um we

also need to determine whether this was

accidental or perhaps uh suicidal

ideation which would definitely make

them a high risk situation um other

patients such as trauma patients even

though they don't have um any obvious

injuries we need to U make them in ESI 2

based on their mechanism of injury so if

the um acceleration deceleration force

is significant we need to consider that

and um get them evaluated ated to make

sure that they don't have any um

injuries that we're were missing um

motor vehicle and motorcycle crashes

Falls um any gunshot stab wounds um that

would be um you know blunt or

penetrating trauma need to be

assessed uh fairly

quickly a patient that comes in with a

wound injury um if they need some kind

of um controlling in the bleeding so if

it's something like an arterial bleed or

a partial

amputation um they should be made an ESI

to um and treated for their injury so

that it they don't continue to bleed out

and have um Circ circulatory

compromise so let's look at a special

population which is our pregnant females

um any patient that comes in and um says

that they are pregnant regardless of the

complaint we should give CBC a call and

just let them know hey I have this

patient they're coming in for such and

such complaint and um they will

determine whether they want to see the

patient or not so let's say that this

patient is a above 20 we trauma patient

and they come in um through the front

door

so we um need to make sure that they are

stabilized and then um once a patient um

is determined that they don't have any

life-threatening injuries they can then

go to

CBC um or the CBC nurse can come to the

Ed um to check any fetal um heart rate

or um have the obstetrician take a look

at the patient um so even if it's not

a uh pregnancy complaint whether it's

the patient um coming in for

congestion um or chest pain any kind of

complaint um our policy is that we do

give the nurse arriage gives the CBC

nurse a call and just run it by them and

say hey I have this patient um do you

want to see them after we do our

part if it is a patient that is above um

20 weeks with any kind of trauma we

would stabilize and then ship to a

facility that can um take care of a

trauma patient a pregnant trauma

patient okay so let's say that you have

done your across the room evaluation the

patient's General appearance um work of

breathing and

circulation look like it's not

life-threatening um they indeed can wait

for a provider you can go ahead and

bring them into your triage room start

doing vital signs if while you're doing

vital signs you notice that there is um

danger zone vital signs or there

something is out of um normal range you

can change your ESI and upgrade them to

an ESI 2 based on your abnormal Vital

Signs so you can go ahead and get the

patient into the next available room and

let the provider know that they need to

get in there within 10 minutes um and

the nurses can start any kind of um

treatment so some of your danger zone

vital signs that you'll want to consider

upgrading to an ESI 2 is if your

pediatric patient um 1 to 28 days of age

um has a temperature of above 100.4 fit

if your um one to three Monon old uh

baby has a temperature above 100.4 you

also want to consider um ESI to a 3month

old to a

three-year-old um can be safely made in

ESI 3 if they have a fever because one

of the things that you could do at

triage is offer Tylenol or um Motrin

depending on whether the patient got

anything at

home um if while you're getting the

history uh the P the parents say that

they have incomplete

immunizations um or maybe there's no

obvious source of fever um then this is

a high-risk situation and the patient

should be in ESI 2 and brought back to

see a

provider I mentioned to severe pain as

one of the criteria for ESI 2 so let's

look more into pain pain is subjective

so it's whatever the patient tells you

it is so if they're telling you that

it's a 10 out of 10 pain that's what you

document but pain is just one part of

your assessment or one part of the

information that you're Gathering you

want to document their appearance so if

the patient is otherwise sitting

comfortable able to talk um in normal uh

without distress they're sitting

laughing or munching on potato chips

then you know document that so you're

basically

stating why you are considering putting

this patient in the waiting room um and

why they're not in severe pain the other

part of pain is that if you can

Implement any kind of comfort measure at

triage and document that you did that

and then state that that is the reason

why you're safely um putting the patient

in the waiting room um then you don't

have to make that patient in ESI too so

this is something that you kind of have

to recall on previous

experiences if it's a patient who is

having um renocolic there's very very

little you can do at triage because this

patient essentially needs an IV place

they need

analgesia so you would make this an ESI

tube um level um you want to ask

yourself would you use your last bed for

this patient is the pain severe enough

that you would give this patient the

last bed otherwise is there something

that you could do at triage to help them

with their pain perhaps you can offer

them an ice pack perhaps you can

position um their extremity to a point

where they feel a little bit more

comfortable perhaps you can give some

tylon or Motrin at triage so you can

Implement things that um address their

pain even if it's above a seven um but

you are also documenting why they're um

able to wait in the waiting room and and

basically you're not using your last B

said for this

patient okay so this is the next

scenario EMS arrives with 80-year-old

male with a

self-inflicted laceration to his neck

the bleeding is controlled and he's

tearful and tells you that his wife died

last week

because of the type of injury to the

neck this patient has a potential for

Airway compromise although the bleeding

is controlled um he does tell you that

he is suicidal so he needs to be an ESI

too so in order to determine whether the

patient is an ESI 3 versus 4 versus 5

five we want to count how many resources

is it going to take for this patient to

have a disposition made so this is where

nursing experience um is very important

because they will recall you know what

is typically done for a patient who

presents with this type of complaint so

for example let's say a patient comes in

with abdominal pain you have established

that they are not having a

life-threatening event that they are not

high risk so what are we going to do

typically for this patient um let's say

it's a 20-year-old male with complaint

of abdominal pain perhaps they'll need

um a he block with IV um medication for

pain and um some lab work okay that is

considered two resources so you would

make that patient an ESI

three um lab work regardless of how many

things go to the lab whether it's a

combination of urine and blood that

counts as one

resource images such as x-rays EKGs CTS

MRIs ultrasound that is all bunched into

one resource IV fluids is another one IV

and IM or nebulized medications is one

resource so excluding a tetna shot in

the IM am a tnis shot is not considered

a resource if the patient needs a

specialty consult such as they need

neurology to see them or cardiovascular

consult that is a

resource if the patient will need a

simple procedure such as a lack repair

or ficap that is considered one resource

so if the patient comes in with a

urinary obstruction and you're going to

put in an IV

um for fluids and you're going to put in

a Foy catheter typically um that will

constitute as an ESI 2 because it's two

resources so two or more is considered a

category

three if the patient um you anticipate

that they will only need

one um item from the not resources list

so if the patient um just needs um po

medication or a tetna shot or we need a

call back from their PMD those are not

considered resources um and they would

not be made in ESI uh 3

so one

resource is an ESI 4 so if the patient

is only going to need lab work then

there there'll be an ESI for if the

patient has um have no

resources um they have no complaints you

anticipate um none of your resources

being used then they will be an ESI 5

patient so notice that obtaining a

history in physical is not considered a

resource any point of care

testing um some facilities do pregnancy

tests in the ER or um um acutex that is

not considered a resource uh a heac by

itself is not considered a resource peel

medications um a technicia even though

it's an IM is not considered a resource

a simple phone call to a PCP is also not

considered any simple wound care so if a

patient just needs

addressing um they would not be

considered as a resource um or crutch

education or splint that is also not

considered a resource so patients again

that need two or more of your resources

will be in ESI 3 if they only require

one resource then they are in ESI 4 and

if they don't require any resources they

are considered an ESI 5

patient the next scenario is a

25-year-old female that comes in with

complaint of abdominal pain for 4 days

she's been spotting denies NOA vomiting

or diarrhea and has no urinary symptoms

her last menstrual period was 7 weeks

ago she has a history of an ectopic

pregnancy and her vital signs are a temp

of 98 a heart rate of 66 respirations at

14 and a blood pressure of 106 over 70

So based on her complaints she's going

to need at least two resources she's um

definitely going to need confirmation

whether um she's pregnant or not she may

need an ultrasound blood work she's

hemodynamically stable so this patient

can be an ESI 3 and can safely wait for

the next available

bed so if you take home tips you want to

triage based on the presentation of the

patient to the Ed

so if they came in by EMS and they were

say unresponsive or had some

life-threatening situation the EMS

addressed and now at arrival the patient

is much more stable you want to face

your ESI based on the presentation of

the patient in the Ed now you do want to

consider the backstory and what happened

prehospital because that can contribute

to whether your patient is a high RIS

risk

situation but you want to remember that

you are basing your ESI on how the

patient appears when they come to the

Ed thank you for taking the time to

review ESI if you would like to get

credit for participating in this review

simply fill out the questions and email

them back to me at J Munos at Griffin

health.org thanks