The Emergency Severity Index
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The Emergency Severity Index

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The Emergency Severity Index, ESI, v4

The Emergency Severity Index, ESI, v4

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  • 1. Emergency Severity Index, Version 4: Implementation Handbook Agency for Healthcare Research and Quality: Pub. No. 05-0046-2, May 2005
  • 2. “Triage” is derived from the French verb “trier,” to “sort” or “choose.” Originally the process was used by the military to sort soldiers wounded in battle for the purpose of establishing treatment priorities.
  • 3. Emergency Nurses Association (ENA) Standards of Emergency Nursing Practice The emergency nurse triages each patient and determines the priority of care based on physical, developmental and psychosocial needs as well as factors influencing access to health care and patient flow through the emergency care system. The goal is to rapidly gather “sufficient” information to determine triage acuity. (ENA, 1999, p. 23).
  • 4. It is recommended that comprehensive triage is to be completed in 2 to 5 minutes, Travers (1999) demonstrated at one tertiary center ED that this goal was only met 22% of the time. The triage nurse is expected to obtain a complete history, take vital signs and complete department- specific screening questions.
  • 5. In 2003, the National Center for Health Statistics found that 47% of EDs used 3-level triage systems, while 20% used 4-level and 20% used 5- level systems (personal communication, Catharine Burt, Nov 1, 2004). 5-level triage 20% 4-level triage 20% 3-level triage 47%
  • 6. Recent Trends Affecting ED ED overcrowding The American Hospital Association (2002) reported 90% of hospital ED perceive they are at or over operating capacity. The average waiting time to be seen by an EP in 2001 was 49 minutes, which represented an increase of 11 minutes from 1997 (McCaig & Ly, 2002).
  • 7. Triage Systems in the United States Though many U.S. hospitals still use a 3- or 4- level triage system, the trend is toward the use of 5-level systems. Both ENA and the ACEP have come out in support of 5-level triage systems for U.S. EDs.
  • 8. Triage Systems in the United States 3 levels 4 levels 5 levels • Emergent • Life-threatening • Resuscitation • Urgent • Emergent • Emergent • Nonurgent • Urgent • Urgent • Nonurgent • Nonurgent • Referred
  • 9. Emergency Severity Index Conceptual Algorithm, v. 4 yes patient dying? 1 no yes shouldn’t wait? 2 no how many resources? non one many consider 5 4 vital signs no ©ESI Triage Research Team, 2004. 3
  • 10. 1 requires immediate life-saving yes intervention? no high risk situation? yes or confused/lethargic/disoriented? 2 or severe pain/distress? no how many different resources are needed? non one many consider danger zone vitals? 5 4 <3 m 3 m~3 y 3y~8y HR >180 > 160 >100 RR >50 > 40 > 20 SaO2 <92% ©ESI Triage Research Team, 2004. no 3
  • 11. Immediate Life-Saving Intervention airway, emergency medications, hemodynamic interventions (IV, O2, monitor, ECG or labs DO NOT count); and/or any of the following clinical conditions: intubated, apneic, pulseless, severe respiratory distress, SpO2 <90, acute mental status changes, or unresponsive.
  • 12. High Risk Situation Put patient in your last open bed. Severe pain/distress is determined by clinical observation and/or patient rating of ≧ 7 on 0-10 pain scale.
  • 13. Resources  Count the number of different types of resources, not the individual tests or X-rays (examples: CBC, electrolytes and coags equals one resource; CBC plus CXR equals 2 resources). Resources Not Resources • Labs (blood, urine) • History & physical (including pelvic) • ECG, X-rays • Point-of-care testing • CT-MRI-ultrasound-angiography • IV fluids (hydration) • Saline or heplock • IV or IM or nebulized medications • PO medications • Tetanus immunization • Prescription refills • Specialty consultation • Phone call to PCP • Simple procedure =1 (lac repair, foley cath) • Simple wound care • Complex procedure =2 (dressings, recheck) (conscious sedation) • Crutches, splints, slings
  • 14. Danger Zone Vital Signs Consider up-triage to ESI 2 if any vital sign criterion is exceeded. Pediatric Fever Considerations:  1 to 28 days of age: assign at least ESI 2 if temp >38.0 C  1-3 months of age: consider assigning ESI 2 if temp >38.0 C  3 months to 3 yrs of age: consider assigning ESI 3 if temp >39.0 C, or incomplete immunizations, or no obvious source of fever