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Triage using the

EMERGENCY SEVERITY INDEX

Kailsy Hatch | Utah State Univeristy | Nursing Department | Capstone Project | NURS 4210

Learning Outcomes

  • The learner will be able to recognize the appriopriate level of triage by estimating which compnents of the ESI a patient will need for proper care.

  • Based upon patient complaint, and signs and symptoms, the learner will be able choose the correct ESI level of triage.

  • The leaner will be able to anticipate and distinguish an appropriate ESI level of triage based upon data gathered by patient assessments.

Emergency Severity Index (ESI)

"Triage is basically a categorization process to prioritze various treatmens for patients based on the types of disease, severity, prognosis, and resource availability" (Elsi et al., p. 101, 2019).

What is ESI?

The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs.

Level 1: Most Urgent

Patients with life-threatening or critical conditions and/or patients who are unresponsive.

  • Airway
  • Emergency medications
  • Hemodynamic interventions
  • Intubated
  • Apneic
  • Pulseless
  • Severe respiratory distress
  • SPO2 <90
  • Acute mental status changes
  • Unresponsive

Level 2: Very Urgent

High-risk patients with unstable vital signs. These patients are experiencing severe pain or sickness.

Level 2

  • Chest pain (stable)
  • Signs of stroke
  • Suicidal or homocidal
  • Suspected kidney stones
  • Dislocations
  • Severe burns

Level 3: Urgent

Stable vital signs but significant discomfort and/or sickness is present. Often more than two resources are needed to make patient disposition.

Level 3

  • Fainting
  • Allergic reaction
  • Head injury
  • Temperature over 100.4
  • Asthma attack
  • Stomach pain
  • Seizure

Level 4: Less Urgent

Low risk patients with stable vital signs. One resource is needed to make patient disposition.

  • Needs stitches
  • Broken ankle or arm
  • Sore ear, eye or throat

Level 4

Level 5: Not Urgent

Low-risk patient with stable vital signs. No resources are needed.

Level 5

  • Removal of stitches
  • Renewing a prescription
  • Cough or congestion

Resources

Resources

  • Specialty consultaion

  • Simple procedures = 1 (lac repair, foley cath)

  • Complex procedure = 2 (conscious sedation)

R

E

S

O

U

R

C

E

S

  • Labs (blood, urine)

  • ECG, X-rays

  • CT-MRI-Ultrasound-angiography

  • IV fluids (hydration)

  • IV or IM or nebulized meds

Non Resources

Non Resources

  • Prescription refills

  • Phone call to PCP

  • Simple Wound care (dressings, recheck)

  • Crutches, splints, slings
  • History & physical (including pelvic)

  • Point-of-care testing

  • Saline or heplock

  • PO medications

  • Tetanus immunization

Scenarios

Let's triage some patients. Use your handouts to supplement your decision.

Scenarios

A 4-year-old female is transported to the ED following a fall off the jungle gym at a preschool. A fall of 4 feet. A witness reports that the child hit her head and was unconscious for a couple of minutes. On arrival you notice that the child is crying and asking for her mother. Her left arm is splinted.

Vital signs:

-HR 162

-RR 38

ESI Level 2

This 4-year-old had a witnessed fall with loss of consciousness and presents to the ED with a change in level of consciousness. She needs to be rapidly evaluated and closely monitored.

"I have an awful toothache right here," a 38-year-old female tells you as she points to her right lower jaw. "I lost my dental insurance, so I haven't seen a dentist for a couple of years." No obvious swelling is noted. Vital signs are within normal limits. Pain 9/10.

ESI Level 5: No Resources

This patient will require a physical exam. She has no signs and symptoms of an abscess or cellulitis, so she will be referred to a dentist for treatment. In the emergency department, she may be given medications by mouth. On arrival she rates her pain as 9/10, but because she does not meet the criteria for ESI level 2, she would not be given the last open bed.

"It hurts so much when I urinate," reports an otherwise healthy 25-year-old. She denies fever, chills, abdominal pain, or vaginal discharge.

Vital signs:

T 98.2°F

HR 66

RR 14

BP 114/60

ESI Level 4: One Resource

This patient will require one resource—lab. A urinalysis and urine culture will be sent, and depending on your institution, a urine pregnancy test. One or all of these tests count as one resource.

EMS presents to the ED with an 18-year-old female with a suspected medication overdose. Her college roommates found her lethargic and "not acting right," so they called 911. The patient has a history of depression. On exam, you notice multiple superficials lacerations to both wrists.

Vital Signs:

-RR 10

-SpO2 86% RA

ESI Level 1: Resuscitation

Requires immediate lifesaving intervention. The patient's respiratory rate, oxygen saturation, and inability to protect her own airway indicate the need for immediate endotracheal intubation.

A 60-year-old man requests to see a doctor because his right foot hurts. On exam the great toe and foot skin is red, warm, swollen, and tender to touch. He denies injury. past medical history includes type 2 diabetes, and psoriasis.

-T 99.4°F

-RR 18

-HR 82

-BP 146/70

-SpO2 99%.

ESI Level 3

Two or more resources. This patient has a significant medical history, and based on his presentation, he will require two or more resources, which could include labs and IV antibiotics.

Care Plan

Resources

Resources

Delnavaz, S., Hassankhani, H., Roshangar, F., Dadashzadeh, A., Sarbakhsh, P., Ghafourifard, M., & Fathiazar, E. (2018). Comparison of scenario based triage education by lecture and role playing on knowledge and practice of nursing students. Nurse Education Today, 70, 54–59. https://doi.org/10.1016/j.nedt.2018.08.006

Elsi, M., & Novera, I. (2019). Different triage categorization using Emergency Severity Index (ESI) method in emergency department. Enfermería Clínica, 29, 101–104. https://doi.org/10.1016/j.enfcli.2018.11.031

Fong, R. Y., Glen, W. S., Mohamed Jamil, A. K., Tam, W. W., & Kowitlawakul, Y. (2018). Comparison of the emergency severity index versus the patient acuity category scale in an emergency setting. International Emergency Nursing, 41, 13–18. https://doi.org/10.1016/j.ienj.2018.05.001

Ganjali, R., Golmakani, R., Ebrahimi, M., Eslami, S., & Bolvardi, E. (2020). Accuracy of the emergency department triage system using the Emergency Severity Index for predicting patient outcome; A single center experience. Bulletin of Emergency and Trauma, 8(2), 115-120. https://doi.org/10.30476/BEAT.2020.46452

Ivanov, O., Wolf, L., Brecher, D., Lewis, E., Masek, K., Montgomery, K., Andrieiev, Y., McLaughlin, M., Liu, S., Dunne, R., Klauer, K., & Reilly, C. (2021). Improving ed emergency severity index acuity assignment using machine learning and Clinical Natural Language Processing. Journal of Emergency Nursing, 47(2). https://doi.org/10.1016/j.jen.2020.11.001

Kwak, H., Suh, G. J., Kim, T., Kwon, W. Y., Kim, K. S., Jung, Y. S., Ko, J.-I., & Shin, S. M. (2018). Prognostic performance of emergency severity index (ESI) combined with QSOFA score. The American Journal of Emergency Medicine, 36(10), 1784–1788. https://doi.org/10.1016/j.ajem.2018.01.088

Shabrandi, N., Bagheri-Saweh, M. I., Nouri, B., & Valiee, S. (2022). Accuracy of nurses’ performance in triage using the emergency severity index and its relationship with clinical outcome measures. Emergency Care Journal, 18(4). https://doi.org/10.4081/ecj.2022.10638

Worth, M., Davis, L. L., Wallace, D. C., Bartlett, R., & Travers, D. (2019). Are emergency departments in the United States following recommendations by the emergency severity index to promote quality triage and reliability? Journal of Emergency Nursing, 45(6), 677–684. https://doi.org/10.1016/j.jen.2019.05.006

Wuerz, R. C., Travers, D., Gilboy, N., Eitel, D. R., Rosenau, A., & Yazhari, R. (2018). Implementation and refinement of the emergency severity index. Academic Emergency Medicine, 8(2), 170–176. https://doi.org/10.1111/j.1553-2712.2001.tb01283.x

Zacheri, H. (2022). Comparison the Emergency Severity index and Manchester Triage System in trauma patients. Bulletin of Emergency and Trauma, 10(2), 65–70. https://doi.org/10.30476/BEAT.2022.92297.1302.

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