ESI Emergency Severity Index
Summary
TLDRThis 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
🚑 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.
🔍 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.
🏥 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.
🩺 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.
🏥 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.
🏥 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.
🏥 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.
🏥 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.
🏥 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.
🏥 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.
Mindmap
Keywords
💡Emergency Severity Index (ESI)
💡Triage
💡Acuity
💡Resuscitation Level
💡Urgent Care
💡Less Urgent
💡Non-Urgent
💡Overcrowding
💡Provider
💡Cultural and Religious Concerns
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
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