Emergency Severity Index and Triage Tips for New Emergency Nurses

Summary

The video from Emergency Chaos provides essential tips for new ER nurses, focusing on the Emergency Severity Index (ESI) and triage processes. It explains how to prioritize patients based on the severity of their condition, from life-threatening (ESI level 1) to non-urgent (ESI level 5). The guide highlights the importance of accurate assessment, understanding resource needs, and utilizing protocols for effective patient management. It also emphasizes the value of experience, advocating for patients, and offering practical tips to ensure efficient care in the emergency department.

Takeaways

• 🚑 Triage is the process of sorting patients based on their severity to prioritize those who need immediate care in situations where resources are limited.
• 🏥 The Emergency Severity Index (ESI) is a 5-level algorithm used to categorize ER patients based on the urgency of their condition and the resources they may require.
• 🔴 ESI Level 1 patients are in critical, life-threatening conditions (e.g., cardiac or respiratory arrest) and require immediate intervention.
• 🟠 ESI Level 2 patients have potentially life-threatening conditions (e.g., chest pain or stroke symptoms) and should be seen within 10 minutes of arrival.
• 🟡 ESI Level 3 patients have stable vital signs but need prompt evaluation and at least two resources for diagnosis and treatment (e.g., abdominal pain or fractures).
• 🟢 ESI Level 4 patients are stable and only require one resource (e.g., minor burns or lacerations needing sutures) and can wait longer for care.
• 🔵 ESI Level 5 patients are non-urgent cases (e.g., medication refills or minor cold symptoms) that don’t require immediate attention or any resources.
• 🔬 Resources include diagnostic tests, imaging, IV medications, IV fluids, and consultations but exclude oral medications, history taking, and simple wound care.
• 👩‍⚕️ Nurses performing triage should have a solid foundation in clinical skills, critical thinking, and experience (ideally over a year in ER) to make accurate decisions.
• 📋 Always follow the hospital's protocols for specific conditions like chest pain or pediatric fever and clearly communicate expected wait times to lower patient anxiety.

Q & A

What is the purpose of triage in an emergency setting?

Triage is the process of sorting patients based on the severity of their condition to prioritize those who need urgent care. It helps allocate limited resources effectively, ensuring that the most critical patients are treated first.

What are the five levels of the Emergency Severity Index (ESI)?

The five levels of the ESI are: ESI Level 1 (immediate, life-threatening conditions), ESI Level 2 (emergent, potentially life-threatening conditions), ESI Level 3 (urgent, stable but requiring prompt assessment), ESI Level 4 (less urgent, stable patients who can wait), and ESI Level 5 (non-urgent, patients with minor conditions).

What kinds of patients are classified as ESI Level 1?

ESI Level 1 is assigned to patients with life-threatening conditions that require immediate intervention, such as cardiac or respiratory arrest, severe trauma, active hemorrhage, or acute myocardial infarction.

What distinguishes an ESI Level 2 patient from an ESI Level 1 patient?

While both levels involve critical patients, ESI Level 2 patients are unstable and at risk of deteriorating without prompt treatment, but they are not in immediate life-threatening danger like ESI Level 1 patients. Level 2 patients should be seen within 10 minutes.

What are examples of patients who would be assigned an ESI Level 3?

ESI Level 3 patients are stable but require two or more resources to diagnose and treat their condition. Examples include patients with abdominal pain, exacerbations of asthma or COPD without changes in vital signs, or possible fractures.

What resources are considered when determining an ESI level?

Resources include diagnostic tests like blood work, imaging studies, IV medications, consultations, and procedures such as laceration repairs or chest tube placement. Simple wound dressings and oral medications do not count as resources.

What is a key question to ask when determining if a patient should be classified as ESI Level 1?

The key question is: 'Is this patient dying right now?' If the answer is yes, the patient is classified as ESI Level 1 because they need immediate life-saving interventions.

How does a nurse differentiate between an ESI Level 2 and Level 3 patient?

A nurse should ask whether they would feel comfortable sending the patient back to the lobby. If the patient has time-sensitive issues or unstable vital signs that prevent them from waiting, they are likely an ESI Level 2. Otherwise, they are an ESI Level 3.

Why is it important for nurses to have experience when working in triage?

Triage requires nurses to make critical decisions based on clinical skills, patient assessments, and critical thinking. Experience helps nurses recognize patients at high risk for deterioration and confidently advocate for timely care.

What is the recommended protocol for pediatric patients with a fever under 28 days old?

Newborns under 28 days old with a fever are automatically classified as ESI Level 2 because of their high risk for serious conditions. Accurate weight measurement is critical for proper medication dosing.

Outlines

00:00

🩺 Understanding Triage and the Emergency Severity Index (ESI)

The introduction explains triage as the process of sorting patients based on their illness severity to prioritize critical cases. It also introduces the Emergency Severity Index (ESI), a five-level system used in emergency rooms to determine patient priority based on condition severity and resource needs. ESI level 1 represents the most critical patients needing immediate intervention, such as cardiac arrest or severe trauma. The importance of using resources efficiently in the emergency room is emphasized, as well as the goal of addressing the most life-threatening conditions first.

05:02

⏱️ ESI Levels 2-5: Differentiating Patient Priorities

This section describes ESI levels 2-5, which cover less severe but still urgent cases. ESI level 2 patients have potentially life-threatening conditions like chest pain or asthma attacks and must be seen within 10 minutes. ESI level 3 patients are stable but need prompt attention, such as those with abdominal pain or fractures. ESI level 4 patients are stable and require only one resource, like laceration repair or a UTI. ESI level 5 patients have non-urgent conditions, such as cold symptoms or medication refills, and can wait longer for care.

10:02

🔍 What Counts as a Resource in Triage?

Resources in triage include diagnostic tests (like blood work, x-rays, or CT scans) and treatments (like IV fluids or medications). Some procedures, such as laceration repair or chest tube placement, also count as resources. However, oral medications, point-of-care glucose testing, simple wound dressings, and history assessments do not count as resources. The importance of determining resource needs helps classify patients within ESI levels 3-5 based on the number of resources they will require for diagnosis and treatment.

🛏️ Making ESI Decisions and Nursing Tips for Triage

Nurses are guided on how to assign an appropriate ESI score. If a patient is dying or requires life-saving interventions (such as intubation), they are classified as ESI 1. Patients who are unstable but not dying are classified as ESI 2. For ESI 3 patients, nurses should assess whether they would feel comfortable allowing them to return to the waiting area. Nurses should also rely on clinical experience to advocate for their patients and ensure they get the necessary resources or bed assignment. The importance of efficient vitals checks and weight measurements for pediatric patients is also highlighted.

🤔 Trusting Your Gut in Triage and Communicating Wait Times

This section emphasizes trusting gut instincts when something feels off with a patient and seeking a second opinion when needed. Experience in triage is crucial for recognizing deteriorating conditions. Nurses should prepare patients with ESI levels 4 and 5 for long wait times, helping manage expectations and reduce frustration. The SAMPLE mnemonic (Signs and symptoms, Allergies, Medications, Past medical history, Last meal, and Event of the situation) is introduced as a helpful tool for asking patients relevant questions.

📚 Knowing Protocols and Learning Resources for ER Nurses

The final paragraph encourages nurses to be familiar with their hospital’s protocols for handling chest pain, pediatric fevers, fractures, strokes, and traumas. It mentions nurse-initiated orders for certain conditions, such as ordering tests for UTI symptoms or medications for fevers. Nurses are encouraged to continue learning and mastering emergency nursing basics through available books and resources. The script closes with a reminder that teamwork and a proactive approach are essential in emergency nursing.

Keywords

💡Triage

Triage is the process of sorting patients based on the severity of their condition, with the goal of prioritizing those who need immediate medical attention. In the context of the video, it is essential for emergency care in situations with limited resources, helping ER staff allocate attention efficiently. The video emphasizes that triage happens both in prehospital settings and in the ER.

💡Emergency Severity Index (ESI)

The Emergency Severity Index (ESI) is a five-level triage algorithm used in emergency departments to categorize patients by the urgency of their conditions. Level 1 represents the most critical cases requiring immediate intervention, while Level 5 involves non-urgent cases. The video discusses how the ESI helps prioritize patients based on their acuity and the anticipated resources needed.

💡ESI Level 1 (Immediate)

ESI Level 1 refers to the most critical patients with life-threatening conditions requiring immediate intervention. Examples include cardiac or respiratory arrest, severe trauma, and acute myocardial infarction. In the video, these patients are described as needing immediate attention and multiple resources to stabilize their condition.

💡ESI Level 2 (Emergent)

ESI Level 2 patients have potentially life-threatening conditions that require urgent medical care, typically within 10 minutes. The video gives examples like chest pain with suspected acute coronary syndrome (ACS) and stroke symptoms, emphasizing that these patients may become unstable without prompt treatment.

💡ESI Level 3 (Urgent)

ESI Level 3 patients have stable vital signs but require prompt evaluation and treatment. Their condition is not immediately life-threatening but could worsen without intervention. The video mentions examples like abdominal pain or exacerbation of chronic conditions like asthma, highlighting that these patients usually need two or more resources.

💡Resources

In the context of ESI, 'resources' refers to the diagnostic tests, treatments, and consultations required to manage a patient’s condition. These can include lab tests, imaging (e.g., CT scans), IV fluids, or procedures like laceration repair. The video stresses the importance of understanding what counts as a resource when assigning ESI levels, as it impacts prioritization.

💡Critical Thinking

Critical thinking is an essential skill in emergency triage, allowing nurses to assess situations quickly and make informed decisions about patient care. The video emphasizes the need for nurses with experience to work in triage, as critical thinking helps them recognize when a patient is deteriorating or when something feels 'off.'

💡Pediatric Patients

Pediatric patients, especially newborns with fevers, are given special attention in the ESI system. The video highlights that infants under 28 days old with a fever are automatically assigned an ESI Level 2 because of their high risk of deterioration, underscoring the importance of accurate weight measurements for administering weight-based medications.

💡ESI Level 4 (Less Urgent)

ESI Level 4 patients have stable conditions that do not require immediate attention and can wait longer for care. These patients only require one resource, such as a diagnostic test or minor treatment. Examples from the video include lacerations requiring sutures and minor burns, illustrating that while they need care, it is not time-sensitive.

💡ESI Level 5 (Non-Urgent)

ESI Level 5 is assigned to patients with non-urgent conditions that do not require resources or immediate care. They can wait for extended periods without risk of deterioration. The video provides examples such as cold symptoms and medication refills, noting that these cases do not typically need diagnostic tests or treatments.

Highlights

Introduction to Emergency Severity Index (ESI) and its importance for ER nurses.

Triage is the process of sorting patients based on how critical their condition is, prioritizing those who need immediate intervention.

ESI is a five-level triage algorithm, with level one being the most acute and level five the least urgent.

Level 1: Immediate, life-threatening conditions that require immediate intervention, such as cardiac or respiratory arrest, severe trauma, and acute myocardial infarction.

Level 2: Emergent cases requiring prompt attention, within 10 minutes, including chest pain with suspected ACS, moderate trauma, and stroke-like symptoms.

Level 3: Urgent cases that require evaluation within 30 minutes, including abdominal pain, syncope, or exacerbation of chronic conditions like asthma or COPD.

Level 4: Less urgent cases that can wait over an hour, including lacerations requiring sutures, sprains, and mild pain.

Level 5: Nonurgent cases that can wait for an extended period and do not require immediate attention, such as cold symptoms or medication refills.

Resources are defined as diagnostic tests and treatments, including lab work, imaging, IV medications, and procedures like laceration repairs or chest tube placement.

Oral medications, medication refills, and simple wound dressings are not counted as resources in the ESI system.

Questions to determine the correct ESI level: Is the patient dying? Are they unstable? Are they experiencing time-sensitive issues?

Level 1 patients require life-saving interventions like intubation, defibrillation, or needle decompression.

Nursing tips: Nurses should have at least one year of experience before handling triage due to the critical nature of patient prioritization.

Experience in triage helps nurses recognize high-risk patients and advocate for their care when resources are limited.

Use the SAMPLE mnemonic (Signs and symptoms, Allergies, Medications, Past medical history, Last meal, Event of the situation) to guide patient assessments.

Transcripts

welcome to emergency chaos where we

provide tips and tricks to make you a

better earners today we are going over

the emergency severity index and

providing triage tips for new ER nurses

thank you for your time so what is

triage it's the process of sorting

patients based on how ill they are with

the goal of prioritizing patients who

are more critical so that these patients

receive interventions first as you are

aware Staffing and resources are often

Limited in the ER triage helps us use

our limited resources more effectively

so triage occurs in the prehospital

setting and in the ER in the prehospital

setting EMS decides where and how to

transport patients base on their needs

in the ER trial can occur in the

designated triage area where patients

are seen after they walk into the ER or

in each individual room after they're

brought in by

ambulance so the sever the emergency

severity index is is a five level trial

algorithm algorithm ranging from again 1

to five with level one being the most

acute most ill patient so again it's a

five level Tri algorithm used to

prioritize patients in the emergency

department based on the Acuity of their

condition and the anticipated resources

needed again this anticipated resources

needed is very important we'll cover

what the resources are shortly so for an

ESI level one it's known as immediate

it is assigned to patients with

life-threatening conditions requiring

immediate interventions these patients

should be seen immediately and will need

many many resources examples of ESI

level ones can include cardiac and

respiratory arrest severe trauma severe

burns active severe Hemorrhage and acute

myocardial in inection the key is that

these patients need to be seen

immediately and be placed at a higher

priority than all other patients the ER

now an ESI level two is known as

emergent it is assigned to patients with

potentially life-threatening conditions

these patients are unstable and may

deteriorate without prompt medical

attention these patients should be seen

by a provider within 10 minutes examples

can include chest pain with suspected

ACS an asthma exacerbation moderate

trauma or even stroke like symptoms the

key is that these patients will have

unstable Vital Signs and or have a time

sensitive issue that

need prioritization above other patients

to prevent further deterioration again

these patients must must be seen within

10 minutes of arrival and will also use

again many resources and we'll cover

what the resources are in a little bit

now for an ESI level three it's known as

they're known as urgent patients it's

assigned to patients with stable Vital

Signs who do not require prompt who do

I'm sorry who do require prompt

assessment and interventions but their

condition is not lifethreatening at this

moment again these patients should be

seen somewhere within 30 minutes

examples can include abdominal pain

Syncopy or near Syncopy exacerbation of

a chronic issue like asthma or COPD

without changes in their Vital Signs

possible fractures skin infection

likeitis again these patients with an

ASI ESI level of three they they're

stable but they do require two or more

resources to diagnose and treat their

condition these patients should be seen

within 30 minutes again now for an ESI

level four they're known as less urgent

it's assigned to very stable patients

who can wait for an hour or longer these

patients do not have lifethreatening

conditions examples can include

lacerations requiring sutures sprains or

strains UTI minor burns and mild pain

these patients will only require one

resource and now for level five these

are known as nonurgent patients it it is

assigned to patients who do not require

immediate attention have no

life-threatening conditions and may wait

for an extended period of time examples

can include cold symptoms work noes

medication refills and even suture

removal these patients do not require

any resources and are able to wait for

an extended period of time so now what

does count as a resource resources

refers to diagnostic tests and

treatments again resources refers to

diagnostic tests and treatment included

can can be laboratory studies such as

blood work and urine Imaging studies

such as x-ray CTE ultrasound or MRI

medication such as IV meds IM meds and

subcutaneous medications here it's

important to know that oral medications

typically do not count as a resource

other resources include IV fluids such

as normal sailing or lactator ringers

and even consultation such as Cardiology

or or Ortho procedures also count such

as a laceration repair or an incision in

drainage or more complex procedures like

chest to placement Central lines align

and even

reductions now what is not count as a

resource typically oral medications do

not count as a research medication

refills point of care glucose testing

simple wound dressings assessments like

a history and physical and suture

removal do not count as a resource so

how do you go about selecting the

appropriate ESI score for a patient some

of the questions that you can ask

yourself is after you've done your

assessment you got a history you got a

set of vital signs you ask yourself is

this patient dying right if the answer

is yes they're an ESI of one for example

is this patient not breathing are they

severely hypoxic do they have a pulse

are they hypotensive but it's also

accompanied with signs of poor tissue

profusion like decreas mentation their

pale diaphoretic and so forth those

would be an ESI of one also if they need

life-saving intervention such as like

intubation defibrillation cardiov

version needle decompression or even PCI

if so these are going to be esis of one

because they need to be prioritized

above all other patients right because

they're dying now if they're not dying

are they unstable to the point where

they should not wait in the lobby or do

they have a time sensitive issue if the

answer is yes then they should be an ESI

of two for example are they experiencing

sense of a stroke is it a newborn with a

fever or an immuno compromised cancer

patient with infection symptoms are they

suicidal is it a shorter breath asmatic

patient that is hynic and sating

91% or another example can be a patient

endorsing uh vomiting blood who is also

teic cardic and hypotensive in the '90s

but they're still oriented they're still

maintaining what helps me differentiate

and determine the difference between ESI

level one and and two is asking whether

they're dying right now if they're not

dying then they're in ESI 2 because

they're still unstable now to

differentiate between an ESI 2 and an

ESI 3 what helps me figure this out is

if I ask myself would I be comfortable

with this patient going back to the

lobby and and or should they get my last

beted in the ER if I don't feel

comfortable with them going back to the

lobby because of a Vital sign or just

something is time sensitive and they

should I think they should take the last

bed they're most likely an ESI level too

now when it comes to the esis level

three four and five this is where we

need to focus on the resources

an ESI level of three patient will

require two or more resources as they

have a complaint that will require an

in-depth evaluation but they're deemed

stable and they're safe to wait for a

bit an ESI level four will only require

one resource and in ESI level five will

require no resources right so remember

these are what count as resources lab

studies Imaging studies most medications

IV fluids consultations and procedures

so you got to be mindful of these when

you're looking at the E size levels

three four and five now let's go into

specific nursing tips when it comes to

triage you have to advocate for yourself

you should not be in the triage area if

you do not have at least one year of

experience ideally too although we have

the ESI and protocols in place a huge

part of keeping patient safe in triage

comes from experience you you should

have a solid foundation in clinical

skills critical thinking and patient

assessments as these are essential for

making accurate decisions experience

helps you recognize when patients are at

high risk for deteriorating with

experience also comes confidence often

with high senses in the ER there aren't

many open bets and if your patient needs

a bed you need to confidently get your

point across to the charge to nurse as

to why this patient you're calling for

needs a bed right another exam another

tip is always obtain an accurate weight

for Pediatric patients medications uh

for peas are weight based so you need to

have an accurate weight um newborns with

the fever are automatically in isi of

two so anybody any any kid under 28

years under 20 uh 28 days old they need

to be and they have a favor they need to

be in ESI of too next uh connect

everything for the vitals like the blood

pressure the P socks everything you need

while you're speaking to the patient so

you can be more efficient so you don't

do one and then the other do both at the

same time and you need to always check a

point of care glucose for diabetics

other tips include that if you have a

gut feeling that something is off or

just the patient does not look right to

you get a second opinion a buddy nurse

the charge or even the provider you can

never be too safe and with time you will

get better and you will have a better

grasp for things but again if something

is off trust it but this is why

experience to be out in triage is a must

with esi's levels of four and five I let

patients know that the weight times are

going to be long and that we are doing

our best but they do need to anticipate

being in the ER for several hours this

helps a little with preventing patients

from getting too irritable you let them

know early on that the weight is going

to be long don't forget the pneumonic

sample to help you to help guide your

questions it stands for signs and

symptoms allergies medications past

medical history last meal and event of

the situation again know your

organization's protocols for chest pain

for Pediatric fevers for possible

fractures for strokes traumas and nurse

initiated orders such as ordering and

your analysis for UTI symptoms for

example your chest pain protocol your

Hospital May indicate that you order an

EKG a chest x-ray a troponin a CBC and a

chemistry and that's part of the

protocol when a patient comes to triage

the Pediatric protocol may say uh that

you get the accurate that you get the

accurate weight and that you medicate

this patient based on their weight for

their fever right keep it in mind things

making sure that the that the parents

didn't already give that medication

before arrival so make sure you know

your organization's

protocol and here if you would like to

continue learning and master the basics

of emergency nursing check out our books

on Amazon with the view inside option

you can take a look at the table of

contents to see what is included in the

book links are

below as always Teamwork Makes the Dream

workor and here at emergency chaos we

are proactive not reactive