Download ESI Triage Vs 4 Overview

ESI Triage Overview
(Annual)
ESI Triage Quick Tips
• ESI Levels 1 and 2 are Emergent patients.
– Level 1 patients are seen immediately
– Level 2 patients can wait up to 10 minutes
• Determination is based on Acuity only:
–
–
–
–
–
–
ABC issues or unresponsive
High Risk Situations
Mechanism of Injury
Mental Status Changes
Level of Pain
Psychological or Physiological distress
ESI Triage Quick Tips
• ESI Level 3 are Urgent patients who are stable.
– Can wait an hour
• Vital signs and a good history play a significant role at this
level.
• Looks at number of resources needed to care for the patient.
• Examples:
– Medical problems
– Minor issues that comorbidities will require increased number of
resources.
– Abdominal Pain
– Moderate sedation
– Migraine Headaches
ESI Triage Quick Tips
• ESI Level 4 and 5 patients are non-urgent, clinic
type patients with only a single system problem.
• They can wait hours for treatment .
• Examples:
–
–
–
–
Laceration repair
Sprains/Strains
UTI
Ear Infection
ESI Triage Overview
• ESI has 4 decision points.
• To use the algorithm the triage nurse always starts
with decision point A.
• Does the patient require life-saving interventions?
• Is there a problem with their ABCs? Are they
unresponsive?
- If yes, the patient meets ESI Level 1 criteria.
- If no, the nurse moves on to decision point B.
ESI Triage Level I
• Answering “yes” to the following questions
would constitute assigning an ESI-Level I.
– Is their O2 sat under 90%?
– Is their B/P under 90 systolic and they are
symptomatic? (pale, diaphoretic,  HR, RR)
– Symptomatic low or high HR or RR?
– Unresponsive – responds to pain only or is totally
unresponsive
ESI Triage Level I
– Does the patient have an obstructed or partially
obstructed airway?
– Are they unable to protect their own airway?
– Are they apneic, or were they intubated prior to arriving
at the hospital?
– Does the triage nurse feel they need to be immediately
intubated?
ESI Triage Level I
• Is this patient pulseless?
• Is the pulse rate, rhythm or quality an immediate threat to life?
• Does the patient require immediate cardiac pacing, cardioversion,
defibrillation?
• Does the patient need immediate intravenous access and large amounts
of fluid or blood?
• Does the patient require immediate medications to reverse a threat to life
or limb?
• Does the patient have an acute change in mental status that requires
immediate life saving intervention?
–
–
–
–
Examples:
Hypoglycemic and require IV glucose
Heroin overdose who needs a reversal agent
Subarachnoid hemorrhage that cannot protect their own airway
ESI Triage Level I
• Examples of ESI level 1 patients:
–
–
–
–
Cardiac or respiratory arrest
Overdose with a respiratory rate of 6
Severe respiratory distress with agonal or gasping respirations
Acute Shortness of breath with an oxygen saturation of less
than 90%
– Anaphylactic shock
– Critically injured trauma patient – for example a gunshot wound
to the abdomen with a palpable blood pressure of 88
– Chest pain - pale diaphoretic – BP 90/palp
ESI Triage Level I
• If the answer to decision point A is No, the triage
nurse moves on to Decision point B
• Is this a patient who shouldn’t wait
• Would I give my last bed to this patient?
ESI Triage Level 2
• The triage nurse answers three questions to
identify the patient who meets ESI Level 2
criteria:
– Is this a high-risk situation?
– Is this patient newly confused, lethargic or disoriented?
– Is this patient in severe pain/distress?
ESI Triage Level 2
• Is this a high-risk situation?
– This is a situation where the triage nurse feels it
would be unsafe for the patient to wait for more
than a few minutes for a bed.
– The patient is presenting with symptoms that
could easily deteriorate or with a condition that’s
treatment is time sensitive or they have signs or
symptoms of a condition that has the potential for
major life or organ threat.
ESI Triage Level 2
• Examples of “high risk” situations include:
– The patient with chest pain, has a cardiac history who is
physiologically stable
– Patient with stroke symptoms who is phsiologically stable
– Rule out pulmonary embolus in a patient with multiple risk
factors, again physiologically stable
– Suicidal/homicidal patients
– Needle stick in a healthcare worker
ESI Triage Level 2
–
–
–
–
–
Falls from a significant height
High Speed MVC
Head injuries of the elderly or very young
Chemical Splash to the eyes
Babies under 28 days old with a fever of 100.2 or greater
ESI Triage Level 2
• Is the patient confused/lethargic or disoriented?
– The triage nurse needs to identify the patient with an
acute change in level of consciousness.
• Examples:
– New onset of confusion in an elderly patient. Example: the
family reports that this 86 year old female is usually awake
alert and oriented. She took a nap and woke up Confused.
– A 30 year old with a known brain tumor whose wife
reports that today he is confused.
– Adolescent who was found confused and disoriented.
ESI Triage Level 2
• Is this patient in severe pain?
– Many patients present to the emergency department complaining of
pain and it is important for triage nurses to assess a patient’s pain
using an appropriate pain scale.
– If the patient rates their pain as 7 or greater (0-10), the triage nurse
can assign the patient to ESI level 2 IF and ONLY IF:
• The triage nurse can do nothing to relieve their pain at triage AND
• The patient is in need of immediate interventions to relieve their
pain.
– Ask your self: Would I give my last open bed to this patient?
ESI Triage Level 2
• Not every patient who rates their pain as 7 out of
10 or greater will be assigned ESI level 2.
– For many patients the nurse can provide comfort
measures to relieve pain such as immobilization, ice,
elevation, and distraction.
– If the patient rates their pain as 9 out of 10 but has
had the pain for a few days, is laughing at triage or
eating chips, the nurse in good conscience will not
give the patient their last open bed.
• Remember: It is the patient in severe pain that cannot be
addressed at triage who will be given your last open bed.
ESI Triage Level 2
• Patients who would meet ESI Level 2 pain
criteria include:
– Patient with a suspected or known kidney stone who
cannot sit still, who is nauseous and needs IV pain
medication
– Patient with a severe burn
– The oncology patient whose pain regiment is no
longer working and they present to the ED for pain
management
– Patient with a possible dislocated shoulder who is
crying, diaphoretic and clearly in excruciating pain
– Patient with a suspected compartment syndrome
ESI Triage Level 2
• Is the patient experiencing significant physiological or
psychological distress?
– Some examples include:
•
•
•
•
•
•
A sexual assault victim
The combative patient
The homicidal or suicidal patient
The bipolar patient who is manic
The acute grief reaction
The frequent ETOH patient with signs of minor head trauma.
ESI Triage Level 2
• It is ideal for all ESI Level 2 patients to be placed in a
treatment area bed and evaluation by the emergency
nurse within 10 minutes of arrival.
• The triage nurse and the ED staff should be working
together to facilitate rapid placement of these
patients into an open bed.
– NOTE: The patient remains high risk, independent of
when they are assigned a bed.
Resources
• At decision point C, the triage nurse predicts how many
different resources a patient will need to reach a disposition
decision - Admission, Discharge, or Transfer.
– The prediction is based on the standard of care for a given
chief complaint or diagnosis.
– It is not dependent on:
• the type of hospital
• location of the hospital
• physician on duty, or
• acuity of the department.
Resources
Resources
When a patient comes to the ED it is expected
that they will have a history and physical exam.
– NOTE: Anything that is part of the H&P is NOT a
resource.
• Examples:
– Pelvic exam
– Cardiac Monitoring
– Eye exam
Resources
• X-ray counts as one resource whether you do 1 or 10 x-rays.
• Lab counts as one resource whether you do one blood test
and a UA, or two blood tests and a culture.
• A CT scan, a MRI, an ultrasound, and an angiogram
– each count as a resource
Resources
• Simple procedures count as one resource.
• Examples:
• inserting a urinary catheter
• Inserting a nasogastric tube
• laceration repair
• Moderate sedation counts as 2 resources
Resources
• NOTE: Resource predication is only used for less acute Urgent and
Non-urgent - patients
• ESI level 5 do not consume any resources.
– ESI level 4 consume one resource
– ESI level 3 consume two or more resources.
ESI Triage Level 5
• Examples of ESI Level 5 include:
– A healthy 10 year old with poison ivy on his arms
– A healthy 52 year old who ran out of his blood pressure
medicine yesterday
– A 22 year old involved in a car accident 2 days ago and
wants to be checked out, nothing hurts.
– A 46 year old with a cold.
ESI Triage Level 4
• Examples of ESI level 4 include:
– A healthy 19 year old with a sore throat and fever – one
resource a rapid strep screen
– A healthy 29 year old with a UTI – denies vaginal discharge
– one resource – lab – needs a urine, urine culture and a
urine pregnancy test which together are one resource
– A healthy 43 year old with a stubbed toe – “I think I broke
it” one resource an x-ray.
– A healthy 12 year old with a minor thumb laceration that
needs suturing –one resource.
ESI Triage Level 3
• ESI level 3 accounts for 30-40% of the patients seen in
Emergency Departments.
• These patients require an in-depth evaluation and have a long
length of stay in the ED.
• They will require a minimum of 2 resources.
• Once you have determined the patient will require 2 or more
resources, the triage nurse will move to Decision point D
– What are the patient’s vital signs?
ESI Triage Level 3
• The nurse needs to consider the vital signs.
– Are they outside the accepted parameters for age?
• If they are outside of those parameters the triage nurse
can up-triage the patient to ESI level 2.
• Vital signs outside the accepted parameters do not
automatically up - triage a patient – instead the nurse should
consider the vital signs and make a decision based on findings
from the assessment and history.
• This is an important point to stress. The triage nurse does NOT
have to up -triage every adult with a heart rate of 100 or
greater!
Pediatric Fever Considerations
• Decision Point D also includes temperature considerations for
children less than 3 years of age.
• The ESI triage follows the American College of Emergency
Physicians practice guidelines.
• The definition of fever is a rectal temp greater than 38.0 C
(100.4 F)
– 1 to 28 days old with a temp > 100.4 F are considered high
risk and assigned at least ESI level 2.
– 1-3 months old with a temp >100.4 F - consider assigning
ESI level 2.
Pediatric Fever Considerations
• A highly febrile child is defined as those with a fever greater
than 39.0 C (102.2 F)
• 3 months to 3 yrs old with a temp >102.2 F consider
assigning ESI level 3. Take into consideration:
– Are immunizations up to date?
– Is there an identifiable source of fever?
• Patients with incomplete immunizations or with no
identifiable source of fever should be assigned at least ESI
level 3.
Pediatric Fever Considerations
Frequently Asked Questions
Do I have to upgrade a patient’s triage level if the pain rating is 7
out of ten or greater?
– The answer is no you don’t have to.
Examples of patients who might be assigned ESI level 3, 4, or 5
criteria due to pain.
– ESI level 3 – abdominal pain, most migraines
– ESI level 4 – sprained ankle, simple lacerations, abscess
– ESI level 5 - toothache
Frequently Asked Questions
Do I have to upgrade the patient’s triage level if their heart rate
is 104?
– For the adult with a heart rate of 104 – the triage nurse
would consider this as part of the assessment – is there a
logical explanation of why the heart rate 104 the patient
does not have to be up-triaged to ESI level 2.
If the patient is always confused are they automatically assigned
to ESI level 2?
– No. ESI level 2 is for those patients with a new onset of
confusion, lethargy and disorientation.
Frequently Asked Questions
What if I assign someone ESI Level 2 and I can’t get them back
right away?
– As the triage nurse, you are required to identify the triage
level. It is desirable that level 2 patients be placed as
quickly as possible. Work with your charge nurse in
arranging for a bed, keep the patient close at hand and
reassess frequently, etc.
– You should never lower your triage category because you
know the patient must wait.
– You must be able to accurately represent the acuity of
each individual patient, as well as your department case
mix.
ESI Triage Quick Tips
Click on the link below to view/print the ESI Triage
Quick Tips sheet.
\\Rmpnetapp3\group\Lakeland University\Training and
Development\NETLEARNING\ESI Triage\ESI Triage
Quick Tips revised May2014.pdf
If you are done viewing the eLearning
you can now take the exam.
(Located on the left side of screen.)