ESI Sample Cases 2

Summary

This script discusses various patient scenarios in an emergency department, focusing on triage assessment and prioritization using the Emergency Severity Index (ESI). It highlights the importance of recognizing high-risk patients, such as those with trauma, disorientation, or severe symptoms, and the need for immediate interventions.

Takeaways

• 👨‍⚕️ The script discusses the Emergency Severity Index (ESI) triage system, emphasizing the importance of accurately assessing patient conditions to determine the level of care required.
• 🚑 It highlights the need for caution with repeat patients or those with substance abuse, as they can be high risk despite appearing stable, and their conditions should not be minimized.
• 📝 The dialogue includes various patient scenarios to illustrate the triage process, showing how different presentations affect the assigned ESI level.
• 🤕 The script emphasizes that patients with visible signs of trauma, disorientation, or alcohol consumption meet criteria for ESI Level 2, indicating a high-risk situation.
• 🧐 The importance of not relying solely on vital signs for all patients is stressed, with examples given where specific symptoms necessitate checking blood pressure or other measures.
• 👶 The triage of pediatric patients is highlighted, with different age groups having distinct criteria and considerations for fever and potential serious infections.
• 🏥 The script touches on institutional differences in protocols and how they can affect triage decisions, such as the handling of urine samples or eye exams.
• 🤔 The dialogue suggests that triage nurses must use their judgment, experience, and knowledge of standard care to predict patient resource needs, which may vary based on physician practice.
• 🏃‍♀️ The urgency of certain conditions like chest pain and hypotension is underscored, with the need for immediate intervention and physician assessment for such cases.
• 🧠 The script addresses the unique ways women may present with cardiac disease, often with atypical symptoms like upper GI discomfort, and the importance of recognizing these signs.
• 🌟 The importance of patient education is highlighted, especially for cases that do not require extensive medical intervention but can benefit from guidance on self-care and over-the-counter treatments.

Q & A

What is the significance of Glasgow Coma Scale score in the patient scenario involving Joe?

The Glasgow Coma Scale score is an important indicator of a patient's level of consciousness. In Joe's case, his score of 14 suggests that he is not fully conscious but is not in a state of severe unresponsiveness, which helps in determining the urgency of his condition and the level of care required.

Why is Joe considered a high-risk patient despite not requiring immediate life-saving interventions?

Joe is considered high-risk due to his disorientation to time, visible signs of trauma to the head, no recollection of events, and obvious alcohol consumption. These factors, combined with his known history with the emergency department, suggest potential for serious underlying issues that need attention.

What is the importance of not minimizing the presentation of well-known patients to the emergency department?

Well-known patients to the emergency department are often high-risk and may have complex health histories. Minimizing their presentation could lead to overlooking critical symptoms or conditions, potentially resulting in adverse outcomes.

Why is it crucial to maintain a high index of suspicion with patients who present with substance abuse?

Patients with substance abuse may have altered mental states or may not accurately report their symptoms, making it difficult to assess their condition accurately. A high index of suspicion ensures that the healthcare provider considers all possible complications and does not miss any critical diagnoses.

What are the criteria for assigning a patient to ESI Level 2 in the emergency department?

ESI Level 2 criteria include patients who are high risk and do not require immediate life-saving interventions. They may present with signs of trauma, altered mental status, or have a history that suggests potential for serious underlying conditions.

What is the potential consequence if a patient like Joe, who is disoriented and has signs of trauma, is not taken seriously?

If a patient like Joe is not taken seriously, there is a risk of missing a critical diagnosis such as a head injury or internal bleeding, which could lead to severe complications or even death.

How does the triage process differ for a patient with a known history of medical issues like Robert Douglas?

For patients with a known history of medical issues, the triage process involves a careful assessment of their current symptoms in the context of their medical history. This helps in identifying any changes or potential complications that may require immediate attention.

What is the rationale behind assigning Robert Douglas an ESI Level 2 instead of Level 1?

Robert Douglas is assigned an ESI Level 2 because he does not require immediate life-saving interventions. However, his significant medical history and current symptoms of weakness and dizziness warrant a high level of attention and timely assessment by the medical team.

Why is it important to consider a patient's medical history during the triage process?

A patient's medical history provides crucial context for their current symptoms and can help identify potential risks or complications. It allows the triage nurse to prioritize patients more effectively and ensure that high-risk patients receive timely care.

What factors contribute to a patient being classified as high risk in the emergency department?

Factors contributing to a patient being classified as high risk include known medical history of serious conditions, presenting symptoms that suggest potential complications, signs of trauma, altered mental status, and substance abuse.

How does the emergency department prioritize patients who are assigned to the same ESI level?

Within the same ESI level, patients are prioritized based on the urgency of their condition, the need for immediate interventions, and the potential risk to their health if not attended to promptly.

Outlines

00:00

🚑 Disoriented Patient Encounter

The scenario depicts a disoriented patient, Joe, found by the police on the sidewalk with facial injuries and under the influence of alcohol. Despite not requiring immediate life-saving interventions, his presentation raises concerns due to visible trauma, memory loss, and substance abuse, qualifying him as an Emergency Severity Index (ESI) Level 2 patient. The dialogue emphasizes the importance of maintaining a high index of suspicion for repeat ED visitors, especially with substance abuse or trauma, and not to underestimate their risk.

05:00

🤔 Dialysis Patient with Weakness

Robert, a 62-year-old with a history of renal failure, hypertension, and heart attacks, presents with weakness and dizziness. Although not requiring immediate intervention, his complex medical history and current symptoms make him an ESI Level 2 patient. The discussion highlights the need for triage nurses to consider the patient's medical background and not to overlook potential cardiac issues or electrolyte imbalances that could escalate the situation to ESI Level 1.

10:00

🚑 Pediatric Trauma with Hypotension

An 8-year-old girl is rushed to the ED after being hit by a bus, showing signs of hypotension and tachycardia. She requires immediate life-saving interventions such as fluid resuscitation and possible intubation, marking her as an ESI Level 1 patient. The case underscores the urgency required in pediatric trauma cases and the need for prompt action to stabilize the patient's condition.

15:01

😣 Severe Hypertension with Headache

A 33-year-old woman with a severe frontal headache and extremely high blood pressure is referred to the ED by an ophthalmologist. Her symptoms, combined with the alarming blood pressure reading, suggest a potential risk of stroke or other serious complications, categorizing her as an ESI Level 1 patient. The summary stresses the importance of immediate medical attention to address the dangerously high blood pressure.

20:01

👦 14-Year-Old with Possible Poison Ivy

A 14-year-old boy with symptoms of poison ivy is brought to the ED by his mother. Despite the discomfort, the boy has no significant medical history and stable vital signs, leading to a determination that he does not meet the criteria for ESI Levels 1 or 2. The case illustrates the importance of patient education and appropriate guidance for home care instead of emergency intervention.

25:02

😨 Chest Pressure and Shortness of Breath

A 52-year-old male, Larry, experiences chest pressure and shortness of breath, accompanied by nausea. With risk factors like obesity and high cholesterol, and presenting symptoms that suggest a possible acute myocardial infarction (AMI), he is classified as an ESI Level 1 patient. Immediate interventions such as IV access, fluid administration, and hemodynamic support are required, emphasizing the critical nature of his condition.

30:02

🤒 Epigastric Pressure with GI Symptoms

A 57-year-old female with a history of high cholesterol and recent heartburn presents with epigastric pressure and a sense of fullness in her stomach. Although her vital signs are stable, her symptoms and risk factors for cardiac disease qualify her as an ESI Level 2 patient. The summary highlights the atypical presentation of cardiac issues in women and the necessity to consider underlying cardiac conditions despite initial gastrointestinal symptoms.

35:05

🔪 Suicidal Ideation and Elderly Dizziness

The script presents two cases: a 21-year-old female with recent suicidal ideation after a breakup and a 76-year-old female experiencing dizziness and weakness. The young woman, despite denying suicidal thoughts, is considered high risk and an ESI Level 2 patient due to the potential severity of untreated mental health issues. The elderly woman's symptoms suggest a possible cardiac event, making her an ESI Level 1 patient requiring immediate intervention.

40:06

👶 Pediatric Fever and Asthma Medication

An 11-month-old infant with a high fever and an ear infection is triaged according to the pediatric guidelines, which consider age and appearance as key factors. Meanwhile, a 10-year-old girl with asthma requires a prescription refill, placing her in the ESI Level 5 category. The summary emphasizes the importance of following evidence-based guidelines for pediatric patients and ensuring appropriate care for those with chronic conditions.

45:08

🤧 Common Cold and UTI Symptoms

Adult patients presenting with common cold symptoms and a suspected UTI are discussed. The cold patient, without any need for specific interventions, is categorized as an ESI Level 5. The UTI patient, requiring a urine sample and possibly a pregnancy test, is also considered an ESI Level 5 unless the urine requires lab analysis, which would escalate her to Level 4. The discussion clarifies the distinction between bedside testing and lab testing in determining resource allocation.

50:09

👀 Eye Complaints and Triage

The final paragraph addresses eye-related complaints, such as conjunctivitis, foreign body sensation, and trauma. It distinguishes between high-risk situations requiring immediate intervention (ESI Level 2) and common complaints that can be managed with minimal resources (ESI Level 5). The importance of visual acuity assessment at triage for eye complaints is highlighted, emphasizing its significance over traditional vital signs.

Keywords

💡Triage

Triage is the process of determining the priority of patients' treatments based on the severity of their condition. In the video, triage is central to the theme as it guides the categorization of patients into different Emergency Severity Index (ESI) levels, ensuring that those most in need receive immediate care. For example, a patient with a Glasgow coma score of 14 and disorientation to time is categorized as ESI Level 2, indicating high risk.

💡Emergency Severity Index (ESI)

The Emergency Severity Index is a five-level triage system used to categorize patients based on the urgency of their need for treatment. The script discusses various scenarios where the ESI level is determined, such as a patient with a severe headache and extremely high blood pressure being considered ESI Level 1 due to the potential risk of stroke.

💡Glasgow Coma Scale

The Glasgow Coma Scale is a neurological assessment tool that helps in determining a patient's level of consciousness after a brain injury. In the script, Joe's Glasgow coma score of 14 indicates a moderate level of consciousness impairment, contributing to his ESI Level 2 classification.

💡Disorientation

Disorientation refers to a state of being confused about one's surroundings or the passage of time. In the video, Joe is disoriented to time, which is a sign of a potential serious condition and a factor in his ESI Level 2 categorization.

💡Alcohol Consumption

Alcohol consumption is a factor considered during triage as it can influence a patient's condition and treatment. In the script, Joe's alcohol consumption is noted, which may have contributed to his disoriented state and the need for a thorough assessment.

💡Substance Abuse

Substance abuse is the excessive use of a substance, often leading to health problems. The video script mentions substance abuse as a factor that requires a high index of suspicion and careful triage, especially in repeat ED visitors like Joe.

💡Dialysis

Dialysis is a medical procedure that removes waste products and excess fluids from the blood when the kidneys are no longer able to do so. In the script, Robert, a patient with a history of renal failure, missed his dialysis appointment and presents with weakness and dizziness, leading to his ESI Level 2 categorization due to his high-risk medical history.

💡Hypertension

Hypertension, or high blood pressure, is a chronic medical condition that can lead to various health complications. In the video, Robert's history of hypertension, combined with his other medical issues, contributes to his high-risk status and ESI Level 2 categorization.

💡Pediatric Trauma

Pediatric trauma refers to injuries sustained by children that require medical attention. The script describes an 8-year-old female who was struck by a bus, representing a high-priority case that meets ESI Level 1 criteria due to the severity of the trauma and the need for immediate life-saving interventions.

💡Conjunctivitis

Conjunctivitis, commonly known as pink eye, is an inflammation of the conjunctiva, often causing redness and discharge. In the script, a patient presents with symptoms of conjunctivitis, which is categorized as ESI Level 5 due to its non-urgent nature and the patient's otherwise stable condition.

💡Urinary Tract Infection (UTI)

A urinary tract infection is an infection that affects any part of the urinary system. In the video, a 19-year-old patient with symptoms of a UTI is categorized as ESI Level 4, requiring a urine sample and possibly a pregnancy test, but not immediate life-saving interventions.

Highlights

Joe Joe's case demonstrates the importance of not minimizing presentations of well-known ED patients, especially with substance abuse and trauma.

Disoriented patients with visible signs of trauma and alcohol consumption meet criteria for ESI Level 2, indicating high-risk status.

Repeat ED visitors can be prone to triage errors due to over-familiarity, leading to missed diagnoses such as heart attacks.

Robert's case illustrates the triage of a patient with chronic illnesses and new-onset weakness, emphasizing the need for prompt assessment.

Patients with significant medical histories and concerning symptoms should be assigned ESI Level 2 for high-risk prioritization.

The necessity of EKGs in triage for patients with cardiac symptoms is discussed, highlighting the evolution of triage practices.

Triage nurses must prioritize patients effectively, even within the same ESI level, based on the urgency of their conditions.

An 8-year-old female with severe trauma and hypotension meets ESI Level 1 criteria, requiring immediate life-saving interventions.

A 33-year-old with a severe headache and extremely high blood pressure is categorized as ESI Level 1 due to potential stroke risk.

EMS notification of a 78-year-old male post-cardiac arrest requires ESI Level 1 triage for continuous resuscitation efforts.

A 14-year-old male with poison ivy is triaged as ESI Level 5, indicating a low-acuity case suitable for home care and patient education.

Larry's case of chest pressure and multiple cardiac risk factors meets ESI Level 1 criteria, necessitating immediate medical attention.

Louise's case of epigastric pressure and shortness of breath, despite stable vitals, is categorized as ESI Level 2 due to cardiac risk.

The importance of recognizing atypical presentations of cardiac disease in women is emphasized in Louise's case.

A 21-year-old female with expressed suicidal ideation is considered high risk and categorized as ESI Level 2, despite her denial.

A 76-year-old female with symptoms of presyncope, bradycardia, and hypotension meets ESI Level 1 criteria for immediate intervention.

An 11-month-old with a high fever and ear tugging is triaged considering age-specific guidelines and potential serious infections.

A 10-year-old asthmatic needing a prescription refill is triaged as ESI Level 5, highlighting the need for efficient patient flow.

Triage assessment of a patient with UTI symptoms involves determining resource needs, typically a urine sample for analysis.

Eye complaints like conjunctivitis are often triaged as ESI Level 5 unless accompanied by high-risk factors or severe pain.

Visual acuity measurement is recommended at triage for eye complaints, serving as a crucial vital sign for these patients.

Transcripts

but why don't we watch another patient scenario

Joe Joe

the police found you lying on the sidewalk

what happened okay

okay

why can't you just let me alone

you were here yesterday what did you do after you left

I went down to the square

and my buddies

we had a few and the next thing you know I'm here

okay so you were drinking

I noticed

you had this bruise and this little cut on your face

did you fall did you get into a fight

I don't know I can't remember

all right Joe

what's your date of birth

January 22nd, 1951 alright

what month is it right now

September

no Joe

it's April

where are you right now the hospital

um Brigham

in Women's Hospital okay

I need to take your blood pressure and your temperature

and put this on your finger

this patient

appears to be known to the emergency department staff

he was found on the sidewalk

and brought in by the police

he has bruises on his face and a small asseration

his Glasgow coma scores 14

and he is disoriented to time

Joe does not need immediate life saving interventions

so he is not an ESI level 1

but his presentation is concerning

he has visible signs of trauma to the head

and he has no recollection of what happened

and obvious alcohol consumption

he meets a criteria for ESI Level 2

his presentation is high risk

and he is disoriented to time patients

who are well known to an emergency department

are often high risk

and it is important not to minimize their presentation

a triage nurse should always maintain a high index

of suspicion

with well known patients to the emergency department

especially when they present with substance abuse

any signs of trauma or language barrier

this patient meets ESI Level 2 criteria

tell me something do you see patients like Joe

sure sure

do you agree he's high risk definitely

and you know

we need to be very careful with these type of patients

do you have any questions about that case

no but it's interesting

that's where with people who are drunk

are repeat visitors that's where I see mistakes

in my years in the Ed

that's where I've seen the most mistakes

in triageing patients that's really easy to do right

these people every day sometimes several times a day

sure and

it's very hard to keep that high index of suspicion out

but you're right that's when bad things happen

I seen a heart attack

and a couple of other things that were missed

both by the pre hospital personnel and by us

easy for these people that bad head injuries

exactly

and we need to assume at this point

that he had one of those

and that alcohol was just another factor

so he is definitely an ESI level too

what would happen if we couldn't wake him up

like if you shook him and he just

wasn't responding to or it took a painful stimuli

would that change this category at all

depends if he was handling his airway and everything

I don't know right if he's unresponsive your right

he becomes in your way issue

which could bump them up to level one

absolutely

that would definitely bump him up to a level 1 okay

he would need immediate life saving interventions

he would need to be intubated

he cannot protect his own airway

so remember that definition of ESI Level 1 right

okay let's do another case

m I Robert Douglas oh that's me

hi Robert come on in my name is Paul

I'm one of the nurses which have a seat

I'm gonna ask you a couple questions about

what brought you in here today okay

so what what's going on what brought you in here

oh

just feeling weak

have no energy

had trouble getting out of bed this morning okay

when did all this start

last night

I was supposed to go to dialysis this morning

but I just don't have any energy okay

so you're feeling fine yesterday

and today you're feeling really weak

yes

okay I'm gonna go ahead and get your blood pressure

how old are you Robert 62 okay

are you having any pain or problems breathing with this

no just feeling dizzy okay

so you're feeling dizzy

do you have a list of medications that you take oh yes

I think it might be right there yeah

great thanks

okay

so other than the renal failure and the hypertension

do you have any other medical problems

that we should know about

well I've had two heart attacks

okay I had bypass surgery in 2002

okay when was your last dialysis

three days ago I've got one of those catheters

cotton catheter yes

okay yes

another interesting patient

he does not need to be immediately rushed back to

the treatment area

he does not require immediate life saving interventions

he is not an ESI level 1 however

he is a high risk patient

the concern is his significant medical history

that includes chronic Wheeling failure

hypertension and significant cardiac disease

combined with his presenting complaint of feeling weak

there are several questions

the triage nurse cannot answer

a triage is his potassium markedly elevated

is he having another am I

what does his EKG look like

these are major concerns that warrant

assigning this patient ESI level 2

he is high risk and it would

not be safe for him to wait in the waiting room

I would give him my last dad

this patient meets the criteria for ESI Level 2

so do any of you think he looks a little bit too good

to be this dialysis patient

and given him a level 2 what do you mean by too good

does he look pretty okay he looks pretty good to me

really well

except that you have to consider he's chronically ill

so you know a lot of what he's experienced

he's experienced before so you know

it may be usual to him in some ways um

I mean one thing that came to me right away um

I don't think they do it in that yard

that they were showing there

but we do EKGs in our triage area

that would be something

he could get in our triage area

that would right away tell you

there was anything going on

cardiac at that moment

okay but

would you get an

EKG before you assign a triage category

or with the triage category

kind of dictate the fact that you need to get that EKG

well yeah you go ahead and sign him a category however

as an adjunct

along with all the other information you're gathering

and EKG could be part of that

alright that's a good point

cause

a lot of people are doing more and more at triage now

but I think you still

are gonna have to make a decision on

the triage category before you

um have any other interventions or do anything else

and I think he just looks pretty good

but it's important to remember he's high risk

he's due for that dialysis patient

and all those things that we talked about

he's dizzy he's having chest pain

you really don't have any idea right

so if you did is EKG

then that's sort of a process thing afterwards

but you're still not gonna know his potassium level

so I wouldn't I mean

don't you see all these patients with weakness

coming in with that chief complaint

and I think the thing

the triage nurse has to do is sort out

what are the what I will call high risk situations

you know is he a diabetic

is I mean

this particular gentleman told you

he was a renal patient but what is this history

um it could be so many different things

and many of these are high risk patients

because they have chronic medical problems

and many of them don't have the classic symptoms

even if they're having a heart attack

if they've had an incision in their chest

or if they're diabetic sometimes

they won't have classic chest pain

as a presenting complaint

that's an excellent point

and then in a lot of ways

you know I consider it like a puzzle

I mean he starts out with the dizzy weakness part

well then he adds the dialysis part

and he has a hypertension part

then he had two MI's

and you're like adding all these pieces to the puzzle

and they're giving you a picture

because of that history especially

um I would make a room for him

and I you mentioned in the video

that you would give him your last bed

but even if that was not available

I would have to pull somebody that was more stable

and put them in why I do that

because he's weak I

saw him walking with a cane to you

I would go ahead and get a wheelchair

or a stretcher

to push him back into the treatment area

that's what I would do

great excellent points

on this case he was a level 2

he was very very like up there and upwards

a level two that's a good point too

what if you had five level twos now

what if you had we can do it all

a little prioritization of twos

so you have somebody now with

let's put that subarachnoid that we talked about

with a headache

female with severe headache after a bowel movement

that we're thinking is a subarachnoid

and then you have this patient with dialysis

and then you have somebody who has chest pain

and some shortness of breath

so who would you want to put first

certainly want to do the EKGs to see if I slide

don't have that at this

I did the Paul socks on the shortness and bra

and Paul socks on the

I mean that right I mean

I think what you need to look at is who needs

who's requiring intervention immediately

and so that would be one tell tale

in terms of a life saving intervention

is the pulse ox let's say that that we have none

and that's absolutely true

no level 1 criteria for any of these patients to have

three level twos chest pain

short of breath this man who's weak and dizzy

on dialysis and your maybe subarachnoid

I'd have a hard time between the chest pain

short of breath and the subarachnoid

gotta have to see him but say that you know

your distress pain doesn't look very good

yeah that's what I was gonna say the subarachnoid

we'd wanna get her back

but she looked good at that moment right um

but again you know

we don't have the information on the shorter breath

chest pain

but you know things like how he looked physically

is he diaphratic no

it's okay what's his color

like what's his age group

any past history any factors that you know

are making us think part right

I think what Paul is saying

part of it is

you're basing your judgment on your across the room

assessment as well as that information

you gathered during your triosh assessment

and really figuring out who's the circus

who is really needs to go back first

and who can safely wait for a few minutes

until another bed becomes available

you know this era of Ed overcrowding

finding beds is becoming increasingly more difficult

and I really liked your point about pulling somebody

out of her room into the hallway and creating a bed

yes cause you're gonna face the situation all the time

and you still do that

and people ask us that question a lot too

so just because you have five levels

within those levels

you're still gonna have to prioritize your twos

and you're still gonna have to prioritize your threes

so time ordering

your chart according to categories is not a good idea

so you're still gonna have to do a lot of assessment

great

so let's do the next case

you're notified by EMS

that you're receiving an 8 year old female

who was struck by a bus while crossing the street

bystanders report she was thrown across the street

her initial vital signs her heart rate was 1:48

respiratory rate 36 her blood pressure 70 over palpable

and her rumere saturation 91%

so does this patient meet ESI level 1 or 2 criteria

probably probably what

yes I love a 1 or 2

well I want her in the trauma room

she's a bad pediatric trauma

I think she's hypotensive and tachycartic for her age

so level 1 or 2 I think level 1

okay um great

she is hypotensive and

she does require immediate life saving interventions

what specifically do you think she'll need

well lines for fluid resuscitation

a fluid bolus possibly blood

possibly intubation depending upon what they find

perfect you aren't just starting a line to have a line

she needs immediate life saving interventions

she needs hemodynamic resuscitation

now let's talk about this

what if this were an adult with the same vital sign

same scenario I don't think it would change anything

you're right just checking let's move on

okay next case

we have a 33 year old that comes to triage from her

doctor's office um

she complains of a severe frontal headache

10 over 10 for about 4 days

she went to her eye to eye doctor's office

cause she thought she needed glasses

the ophthalmologist performed an eye exam

and sent her directly to the emergency department

for further evaluation she's alert oriented times three

her blood pressure is 260 over 160

her heart rates 82 and her aspirations are 16

s P O 2 and her temperature are fine

so what do you not like the most about this case

well the blood pressure is off the charts

so how does this work

if the blood pressure isn't part of the vital science

criteria for the ESI that's a good question

all patients probably should get vitals

especially adults

who are going to go to the waiting room

this is a perfect case to

demonstrates the need for vitals

well it's true that vitals are usually not helpful

a patient with a headache

or a nosebleed are really two examples

when you need to take the blood pressure

make sure you check it so let's go back to this case

what do you think the ophthalmologist saw

and why do you refer her to the emergency department

well maybe she had papillodema

and then I guess he checked her blood pressure great

so what triage level is this patient

well she's tolerated this pressure for four days

so I would make her a level 2

she is high risk

could she be a level one

well

does she require immediate life saving interventions

I would air on the cautious side with this case

she is going to require immediate access for medication

administration to start lowering that blood pressure

well it is true

she may have had this elevated blood pressure

for 4 days you don't know that for sure

it may have just started today

it's really hard to tell

well

I would make her an ESI level 1 and get her care going

two sixty over one 60 is really high

she is symptomatic and you can bet she has paplodema

she has the potential for stroke

what if she was you know

symptom free and this was a by chance blood pressure

you know she came in for a minor unrelated complaint

I guess you can make her a level 2 or a level 3

I wouldn't make her a level 3 though

she's too high risk

but that high of blood pressure even if she is stable

agree okay time to move on

okay now we have a case

you're notified by EMS

that you're receiving a 78 year old male

who collapsed in the garden

his daughter called 9 1 1 and immediately started CPR

he was defibrillated three times in the field

and he was brought into the emergency department

in Sinus berticcardia

and his pressure was 88 systemic

so what do you wanna do with this gentleman

ESI level 1 he's post arrest

and will require continuation of the resuscitation

he's also gonna be going on event and will need drugs

absolutely he's still hypotensive

he's sprayed a cardiac

and he's gonna need some IV vasopressors

probably dopamine

he may deter back into VFIB for all we know

so he is definitely a level 1

and there is really not much more to say about that

let's do the next case a 14 year old male

is brought to the emergency department

by his mother

who tells you she is concerned her son has poison Ivy

he was doing some yard work for a neighbor

and two days later developed itching

redness and little blisters on his arms

she's concerned that he will

spread it to the whole family

he's healthy takes no medications

has normal vital signs okay

do you think he needs level 1 or level 2 criteria

no way they need to go home

they should have gone to see their doctor

okay so maybe home after some great patient education

so you saying

this patient is not gonna require any resources right

he is an ESI level 5

he's gonna be instructed to go home

to get some over counter medicine

that's right don't forget

this is a really good

opportunity for patient education

why don't we watch another vignette

Larry

why don't you have a seat

my name is Nikki I'm one of the nurses

and I need to ask a few questions about

what brought you to the emergency department today

I also need to take your blood pressure

and put this thing on your finger

my wife brought me to the emergency department

she's all worried she thinks I'm having a heart attack

because I have this pain it's not really pain

more like a pressure like something sitting on my chest

okay do you have this pressure right now yeah

now

do you have any medical problems that you see a doctor

regularly for

just my high cholesterol

but he put me on a medication and anti cholesterol drug

it's much better now

what were you doing when this pressure started

sleeping woke me right up

hasn't gone away all right

what time was that about 6 a m

to feel short of breath at all

kind of right

how about your stomach do you feel sick to your stomach

a little queasy a little queasy all right

I need a wheelchair to triage

and I'm going to be taking that last monitored bed

Larry how old are you 52

52 I have a wheelchair

and then I'm going to have you have a seat in

and your wife

can go ahead and get you

registered into the emergency department

This 52 year old male has multiple respecters

for cardiac disease obesity

smoking anti cholesterol

he presents to the emergency department

with chest pressure that woke him up from sleep

with nausea shortness of breath antiparesis

his heart rate is between 30 and 40 and irregular

his respiratory rate is rapid

and his blood pressure is low

90 over 76 this patient is probably having an acute MI

he needs to be seen immediately

and immediate life saving interventions initiated

he needs IV access fluid pacing

pads in place and other hemodynamic interventions

he meets criteria for ESI Level 1

interesting case what do you think

do you agree ESI level 1 absolutely he may not agree

but you know the denial is along with the diagnosis

oh that's an excellent point

she knows how diphoratic he was

yes my first thing yeah

that across this room assessment

really made you key in on that

he had so many risk factors

now why didn't I just walk him back to trio

you know to treatment wrong

because activity increases his mycardial oxygen demand

so you would want him to rest and get oxygen in

that's an excellent point

we really need to do that

he's also betacartic and I think his

he was also had a hypertense hypotension

his blood pressure was low too

so yes

that's another right flag

great and that's really the thing

that makes him a level 1 versus a 2

cause you really don't wanna make all your chest pains

level 2

if you start making all your chest pains level 2

and people really aren't gonna be attend

paying attention to level 1

this is he was a level 1 because he was bradycardic

most chest pains

the nurse can manage just fine for the first 10

15 minutes you put them on the monitor

you get your access you get your labs

you get your EKG

and you really don't need a physician at the bedside

this patient who's at Breta Cardiac and hypotensive

you want to bring the DOC to the bedside

because you may start doing more than those things

and the things we talked about

the pacer pads all that is really good

still with all that he looks pretty good

and I know

I would have been surprised when I found his hurry was

30 I would not have originally pictured

but I would have been making the level 1

that was

the one thing that would have made me change my mind

especially since he brought in that can of soda

he's pretty active

he had so many arrest factors and you know

it's true ESI level 1 you

my concern

would be getting him back into that resuscitation room

before he arrested so exactly

me too yeah good

why don't we watch another patient scenario

Louise what yes I come on in Louise

okay there to have a seat my name is Paul

I'm gonna ask you a couple questions about

what brought you in here today

and get your blood pressure okay

okay I feel really silly being here

but the girls where I work

insisted that I come over and get checked out

so what's going on

I have this pain

it's like a constant pressure

it's it's not like my heartburn

this makes me sick to my stomach

how long has this been going on

about 3 hours okay

have you taken anything for it

one of my co workers gave me an add acid

I didn't do anything I'm just so tired

okay I'm gonna get your blood pressure

and ask you a couple more questions

how old are you 57

okay and on a scale of 0 to 10

with 10 being the worst pain that you can imagine

how would you rate that pain right now

ah about us 7

okay and Jay Nurse

this isn't gonna take long

is it cause I've got to get back to work

I've got so much work to do

you know

I can't tell you exactly how long it's gonna take

but

it is really important that you see the doctor today

okay okay

do you have any medical problems

I have a high cholesterol

and I've had some heartburn lately

okay

do you take any medicines every day on a regular basis

yes it's here in my purse

okay can I see

great thanks

This 57 year old female

presents to the emergency department

with epigastric area pressure

she has a history of high cholesterol

and seems to be stressed about work

all risk factors for cardiac disease

we know from the research

that women with heart disease

do not present with the classic signs of chest pain

and shortness of breath usually their more

their discomfort is more upper GI

and many will complain of being tired

this patient is currently stable

and does not require immediate

life saving interventions

but she is high risk for cardiac disease

she meets the criteria for ESI Level 2

if her blood pressure was low

or her heart rate was high

low or irregular and her skin was cool and diaphratic

she would then be an ESI Level 1

this patient is currently ESI Level 2

interesting woman what do you think

do you agree with that yes

that really makes sense

women are different aren't they

yes one of the first things I noticed about her

is that she was very short of breath

and that kind of alarmed me

said the whole time that she was talking to you

um

it just that was what I was thinking about

okay that she showed her breath

you know I need to try to help

you need to do yes

intervene soon even if she was just being dramatic

right you know

which you know

obviously in the emergency department

we have patients who present that way

would that change your priority rating at all

would you still make her too

I would and

I was considering the question of

whether she was hysterical

and nervous

or whether she was actually short of breath

the other thing is that she did take an Anacid

and it didn't help at all

which is leans me still in the direction

further

in the direction of a possible cardiac condition

that's an excellent point

now women with heart disease

they tend to deny their pain

we know that so

a lot of things were learning in the last 10 years

about women

and how they present to the emergency department

you know we need to make sure that they get seen

simply

have any other questions about this particular patient

any anything they wanna say

no she was her vital signs were normal

they were

they were still pressure heart rate everything

she just as you said was a little to get neck and I

I didn't see her pulse socks

what was that um

I believe it was 100% it was normal cause I again

I thought the yeah

shortness of breath was was quite evident

I wanted to give her an nemesis basin

that's a good point

so had so much up against or disrupts

just watching the video

I was concerned and that bothered me a lot too

but we really tend to blow off women

and even in some of the teaching that we do

we still find a lot of nurses that

don't want to take females um

seriously with this kind of cheap complaint

and it's kind of surprising that still

there are people that wanna minimize women with um

up a gastric distress

and it's not something that you want to do

they're so vague and right

they are big

we're so big and how we speak about our complaints

we tell too much what would you have to look like

to make her a level one

well some instability in the vital signs

what if I said her heart rate was one eighty oh

then she knew yeah definitely

definitely if her color looked worse as well

if she had diaphoresis

as well as the epigastric distress

and the shortness of breath

either hypertension or hypertension

either one good

interesting case I think we Learned a lot from that one

okay let's do a suicidal scenario okay

we have a 21 year old female

who comes in with her parents

who said that her daughter express suicidal ideation

after the boyfriend broke up with her

the patient denies being suicidal

she's alert she's oriented times 3

and she's a little bit non cooperative

her vitals are 97 nine 82

20 and one 15 over 70 she is requesting to leave

after all she says she is 21 years old

so with everything you know about this scenario

what triage level is she

I know she's considered high risk and an ESI level 2

but I just don't get it

why is she given such a high priority

well that's a concern that many Ed nurses have

so let's just go ahead and talk about it

because we have a lot of these patients

this patient cannot be trusted

we must assume she's suicidal

therefore she is high risk

if she were to leave and kill herself

you and the hospital would be liable

you know she may not get to your next bed

but this case really illustrates process and trash

categorization subtle days

some institutions will have a place for these patients

others have protocols

that require the triage nurse to immediately call for

standby or for somebody to observe her

and possibly notify a crisis worker

or a psychiatric liaison

and other institutions

may draw labs for medical clearance

so

we are actually doing quite a bit for these patients

on arrival but the bottom line is she is high risk

and take credit for it don't sweat it

suicidal

homicidal and psychotic patients are very high risk

we now have a 76 year old female

that tells you

that she feels like she's gonna pass out

she says you know

I've been feeling weak and dizzy

ever since I got up this morning

and I don't usually feel like that

I usually feel fine

I'm really healthy and I don't even complain at all

her SPR2 is 96 her heart rate is 32

so what do you think about her a little weak and dizzy

do you got something that we never see

I think she's a level 1

how come what kind of interventions does she need

oh first off

she's beta cardiac um

and I don't know what her blood pressure is

but she is dizzy and weak

so most likely she could be hypertensive

so she needs an IV line

um possibly some atropine

and at least external pacer pads applied

right if her VP is okay

I just leave the pads on and go for IB access

but if she's hypotensive

she may need immediate external pacing

perfect she definitely is a level 1 patient

she needs immediate hemodynamic interventions

I think it's time for a pediatric case

all right here we go

parents rush into the emergency department

with your 11 month old child

he has a temperature of 103

8 reports the mom

he woke up from his nap

cranky and he keeps pulling on his left ear

the baby is sitting quietly on the mother's lap

sucking on a bottle of juice

he cries when you try to listen to his heart

his temperature is 1 0

2 6

his respiratory rate is 30

his heart rate is 1:28 his Romeo saturation is 100%

so what do you think is he high risk

I hate trashing the kids I just don't feel comfortable

oh we see kids all the time

this gets fine well

how do you know that well

look at him he's sitting there sucking down juice

he looks great

but he's got a fever of 102 secs

but an antipartic will take care of that

let's look at the algorithm under Decision Point d

this is section under Vital Signs that discusses PEDs

fever criteria

there's actually a lot of very good literature

on this topic

if we go through the guidelines that are evidence based

we'll see that

if this child was less than 28 days of age

no matter how good he looked

he'd be at risk for serious infection

and therefore would be at least an ESI level 2

if he looked flacid or lethargic

he'd be an ESI level one

so moving up in the age group

there is some controversy over how to manage a fever

in the 28 day to three month old

so depending on your institutional practice

you could make a child in this age group

a level 2 or three

finally the 3 to 36 month old child

the child in our scenario

will probably be triage as ESI level 5

in this age group the triage nurse

first considers fevers greater than 102.2

so you may uptriage for this high of a fever

you know you should also consider

if there's an obvious source of infection

this child is tugging on his ear

so there's a probable source of infection

the triagenurist must also

ensure

that the child is up to date on his immunizations

so this child could actually be an ESI Level 5

again it's the nurse's judgment

but all babies less than 28 days of age must be

at a minimum ESI Level 2

okay let's go back to the tape

and see what other kind of cases we've got on here

Kristen Kristen McKenzie

come on in have a seat

my name is Nikki I'm one of the nurses

I need to ask you a few questions about

what brought you here

to the emergency department today

I also need to put this on your finger

and we'll take your temperature

and your blood pressure okay

all right so what brought you here today

we're here in Boston on vacation

my daughter has a history of asthma

it's not bad

but she needs to use an inhaler when she plays sports

we're heading up north to go skiing

and she forgot her inhaler

I told her to pack it

even put it on the bed next to her suitcase

but she forgot okay

so you're here for prescription refill

yes all right

Kristen how are you feeling

any shortness of breath

you feel like you're wheezing at all

no okay good

a healthy 10 year old with a history of asthma

presents to the emergency department with her mother

requesting a prescription for an inhaler

this child meets ESI Level 5 criteria

she needs to be seen by a physician

have a prescription written

and be discharged by the nurse

if she had been wheezing a little

she would need a handheld nebulizer

treatment with a pre and post peak flow 1 resource

making her an ESI Level 4

a level 3

asthmatic would be one who required a chest X ray

or labs additional resources

if this patient was wheezing significantly

and in severe distress with a good oxygen saturation

she would be ESI level 2 however

if she was decompensating

tiring and had an SPO 2 less than 90%

and the triage nurse was concerned

she would require immediate intervention

she would meet ESI Level 1 criteria

so what do you think about that case

pretty straightforward what do you think

sure

okay I think the patient looks good

I know we get a lot of patients in the Ed um

that come in because either they ran out of medication

um or they didn't have it a lot of times um

we do see that and I do agree that she would

this case would be a level 5

you know I bet there's probably some nurses out there

and some of us

that wanna kind of read more into the case um

but she doesn't have any soreness of breath

she has absolutely no complaints

another kind of example of the same thing

as patients that come in with a different complaint

and have a blood pressure that's up

totally unrelated

so don't make things more than they are

she just wants a prescription refill that's a 5

well if I was triaging her

she told me she felt fine still

but I would still grab my stethoscope

and still listen to her just

you know in case

because of her history for asthma

and because she's in a new area

where the altitude or the weather is different

so I'd still be you know a little cautious about that

that's another great point

you know

can you think of any other patients who would be ESI

Level 5 what about suture

what about suture removal

that seems very simple

is that a procedure removing sutures

no we don't count that as a resource oh okay

that would be an ESA Level 5 definitely

and you were saying

I was gonna say a ration as an example

yes many of those patients come in

they just want to know what it is

they got a medical exam and they're perhaps given P O

medication and then discharged

many of the time you know

often it's discharge instructions

that's really what they need

what else couple more

what about like

adult that comes in with like a common cold

because they couldn't sleep in the middle of the night

they're tossing and turning

they have no place else to you know

they're not gonna sleep so they're gonna come in

yeah sure

as long as you don't think they're gonna need a lamp

if they're gonna send a culture or throw culture

and then they'd be one resource

and level 4

it's a couple more fives that are pretty common else

earrings and children

that's a good one okay

a wound check wound check is a great one

they come in all the time

doesn't require any resources to set physical exam

abrasion to the skin

that's a very good example

or minor cut that turns out not to need suturing

another good one you know

as I watch the scenario I felt bad for the mother

you know here she is on vacation

and has to bring her child to the emergency department

for a prescription refill

you know sometimes nurses need a really

you know why are you here

they question that and you know Paula

I think we both agreed that

you know there's nothing we can do about it

these patients we want to see them

and we want to try and streamline them

through the department

and I think it's nice to see a patient

where we can offer preventative care

for a change and also um

like you said

someone from from out of town that's stressed

you know any patient that comes in

we should look at

as an opportunity for customer service

good point and I felt kind of sorry for the little girl

because I think she's gonna hear about this a lot haha

even though it was her fault

good point

okay here's a new scenario

here's a patient with a UTI

so patient comes in and says

I think I have a UTI it burns when I go to the bathroom

and I'm going all the time and I only go a little bit

this is a 19 year old patient

who's had these symptoms for 24 hours

she denies abdominal pain

fever chills or any kind of vaginal discharge

she's healthy no medications

no allergies her vital signs are good 97

8 80

16 and 110 over 76

so do we need a life saving intervention here

I don't think so okay

how about high risk criteria

severe pain or distress

not hardly how about just a urine sample

uh sounds like a good plan

does anybody think she's gonna need anything else

well it depends on which physician is working wow

I'm so glad you brought that up

you know

ESI is based only on the triage nurses judgment

of how many resources

she thinks the patient will require

to get the patient to a final disposition

whether that's home admission or transfer

this judgment is based on her experience

and knowledge of emergency medicine

standard to care and institutional protocols

physician practice will bury

but ESI

has shown that triage nurses do really well

at predicting what patients will need

and remember

the purpose of predicting resources is only to help

assign a triage category to the lower acuity patients

the threes the fours

the fives so

if the story changes

and the patient requires more resources

that's okay

you shouldn't triage differently based on how

you know who's working

how busy the department is okay

so let's go back to the case

sounds like a urine is all we need

one resource level 4 patient

but wait she's gonna need a pregnancy test too

and we don't usually send our urines to the lab

we just dip it and then treat when necessary

let's talk about the pregnancy test first

bedside testing if that's what your institution does

doesn't count as a resource

adding a pregnancy test

doesn't change the number of resources

lab counts as one resource

regardless of the number of tests you send

or the type of specimen for example

blood or urine or stool

so this is another

great example of some institutional differences

that are handled without a problem

using the assign

if the case you just discussed

if the urine is never sent to the lab

it is considered a bedside test

does not count as a resource

and the patient is a level 5

if at any point that urine goes to the lab

then we're back to ESI level 4 one resource

let's do an eye case

do you have a patient who comes in and says

you know my eyes are just all red and crusty

she's a 19 year old female

she said she's had red itchy eyes for two days

she has no medical problems

she takes birth control pills

has no allergies her vitals are 98 six 72

16 and 1 22 over 76

her visual cuties are 20 20 in both eyes

so what do you think is going on with this patient

she probably has conjunctivitis

the red itchy

goopy eyes absolutely

now is that a higher situation

oh no it's a very common complaint

okay so now we have to move on to resources

how many research

do you think it's gonna take to get this patient

out of the emergency department

just one an eye exam

okay and does that count as a resource

well

I looked no

I guess not

why not it's pretty important

that's a great question when ESI was developed

the researchers made some

really thoughtful decisions about

what does and does not count as a resource

if everything that we did count as a resource

we wouldn't have any level 4 or 5 patients

every patient gets a physical exam

so it's decided that physical exam doesn't count

let me talk a little bit more about physical exam

the patient who comes in with an eye complaint

is going to need a slight lamp exam

that is part of their physical

it would be just like a woman with abdominal pain

she would require a pelvic exam

and again

that's part of the physical exam of that patient

so does this patient require any resources

I guess not so what level is she

well if no resources

then I guess she's an ESI level 5 great

so let's talk a little bit more about eye complaints

this patient most likely has conjunctivitis

which is a common complaint

in which patients often seek treatment

in the emergency department

most I complaints often end up being treated as

it's either yes I

level 5 or 2 because they represent a high risk

to the loss of eyesight

well in this particular case is

and this one's triage is an ESI level 5

conjunctivitis is not an acute eye problem

that is considered high risk

what's another example of an eye complaint

that might be an ESI

level 5 what about someone that comes in

complaining of something in their eye

but has severe pain that's an excellent question

so you have to actually ask two questions first

is this a higher situation

and second do they have severe pain

well it's certainly not high risk

people come in the Ed all the time

thinking they have something in their eye

but they have 10 out of 10 pain

so that makes them meet the ESI Level 2 criteria true

but you could put up pain in her eye

the protocol states that

in order to be level 2 criteria

you have to have pain of 7 out of 10 or greater

that you can't do anything about in triage

so in this case

we could put some topical anaesthetic in her eye

to make her feel much better

and then therefore we can make her a level 5

but if your hospital doesn't have such protocols

then I would make her a level 2 based on severe pain

okay good

let's talk about some examples of high risk

high situations can you guys think of any

how about a sudden loss of vision in one eye

absolutely

that could be central retinal artery occlusion

or retinal detachment

can you think of some other examples

chemical splash definitely

it's safe to

assume that most patients with a chemical splash

are going to require rapid irrigation

an eye problem that requires irrigation

but not necessarily high risk

would require one resource

and that would be an ESI level for a patient

so those are both great examples

but there's one more I'm thinking of

can you think of something else

how about trauma to the eye or foreign body like a nail

absolutely patients have obvious trauma

are at risk for a lot of injuries

and obviously foreign bodies are really bad as well

a high FEMA is another good example

that should be considered ESI level 2

another example of a patient with an eye complaint

that's considered ESI Level 5

would be someone with a foreign body

sensation and pain to the eye

often patients present

either with something that blew in their eye

or pain from contact lenses

these patients usually have a corneal abrasion

and again only require an eye exam

these patients also complain of severe pain

however

if the triage nurse can instill a few drops of topical

anaesthetica triage

and decrease the pain

then they meet ESI Level 5 criteria

and finally this is an aside

if possible

it is recommended to obtain visual acuities at triage

this is a really important

vital sign for patients with eye complaints

even more so than a temperature

a pulse and respirations