Chapter 7. Implementation of ESI Triage

Up to this point we have provided an in-depth discussion of ESI. The next step is implementation. A well-thought-out implementation plan is critical to the successful integration of the ESI into an emergency department. In a very real sense, poor implementation is worse than no implementation at all, since the ED is unlikely to realize any of the benefits of the ESI and will waste scarce resources.

Change of any sort is always challenging; however, change has become constant, pervasive, and persistent in health care. Nursing management literature has a wealth of information about how to facilitate change, which Sullivan and Decker (2001, p. 249) define as "the process of making something different from what it was." It is important to keep in mind that implementation of any change takes time, careful planning, and a group of professionals dedicated to a successful change process.

In this chapter, we present background information on the change process in health care organizations. The primary focus of the chapter is a step-by-step guide for successful implementation of the ESI. The implementation strategies successfully used by members of the ESI research team are also presented.

The decision to change from another triage acuity system to ESI may be based on multiple reasons. In many institutions one particular event may be the impetus for the change, such as a mis-triage or a sentinel event due to prolonged patient waiting time. The clinical or administrative staff may express concerns about patient safety. The nursing staff may find that they are, in fact, continuously re-triaging patients. In overcrowded EDs with many urgent patients waiting to be seen, nurses are forced to constantly reprioritize these patients for the scarce ED beds. The challenges associated with ED triage in the 21st century have been the subject of many journal articles and professional presentations (Gilboy, Travers, & Wuerz, 1999; SoRelle, 2002; Zimmermann, 2001). These sources have identified many potential solutions, including the ESI triage system. Changing the ED triage method, however, requires significant understanding of the planned change process.

Planned change is a process that results from a well-thought-out and conscious effort to improve something. Application of Kurt Lewin's theory of planned change is a frequently used approach to change in health care organizations (Nelson, 2002). Lewin identified three phases of change:

  1. Unfreezing.
  2. Movement.
  3. Refreezing.

The first step in implementing any change is to recognize that a problem exists and that there is a clear need for change. This unfreezing phase is often compared to assessment, the first step of the nursing process. During the assessment phase, data are gathered and the problem or problems are identified. Both informal and formal discussions may occur around both the problem and the need for change. In the ED this may occur at nursing and physician meetings or during informal discussions in the clinical area. In many cases one individual drives the push for change. This "champion" should take every opportunity to discuss the problem and explain why a change needs to occur.

As in the nursing process, during the movement phase the change agent or agents identify, plan, and implement suitable strategies. The last phase, refreezing, is similar to the evaluation and reassessment phase of the nursing process. At this stage, the champions of the new system need to ensure that the change has been successfully integrated into the day-to-day operations of the emergency department.

Once the decision is made to change to the ESI, a multidisciplinary implementation team needs to be identified. The implementation team becomes the change agent. Typically the team includes staff nurses, physicians and the clinical educator or clinical nurse specialist. If the department has a triage committee, the members should be included on the team. Other disciplines such as registration and information systems that will be affected by the change may also be asked to join the team.

Alternatively, the core team may choose to invite representatives from these disciplines to meetings on an as-needed basis. The group should consider asking one or more of the informal nursing leaders to be staff nurse team members. This will facilitate the informal leaders' "buy-in" of the change, which will be helpful when staff begins to raise concerns about the change to ESI. The implementation team leader is a key player in the successful implementation of the ESI and needs to have the respect of the department as well as strong skills in leadership, communication, problem solving, and decisionmaking.

It is important for the implementation team to meet regularly. Department leadership needs to arrange for staff to be available during meeting time. It is well established that without adequate planning, implementation will fail. Implementation is never a single action but involves a well-designed comprehensive plan, a stepwise process, and a variety of strategies and interventions (Grol & Grinshaw, 1999).

First, the team needs to consider all aspects of the change and identify exactly what must be accomplished and then strategies can be developed to bring about the change. For example, at Brigham and Women's Hospital in Boston, Massachusetts the team brainstormed to identify who and what would be affected by the change to ESI. The list generated by this process included:

Visiting other emergency departments that have already implemented ESI can be very informative. Start by contacting managers, educators or clinical nurse specialists at area emergency departments to determine what triage acuity rating system they are currently using. If the answer is ESI, determine how long the system has been in place. Visiting a department that has been using ESI for at least 6 months should be most beneficial. The leadership team may share valuable information about their own implementation experience, including issues they encountered and strategies that worked well.

If team members have questions that cannot be answered by the publications, this book, or others who have implemented ESI, they can always E-mail a member of the ESI research team at, and we will be happy to answer your questions.

Once the implementation team has identified an appropriate department to visit, it is important for the team to decide which members should participate in the visit. Because it is an original ESI implementation site, the Emergency Department at Brigham & Women's Hospital often hosts implementation teams from other institutions. With groups of less than four the tour guide is able to walk the group through all areas of the department and not interfere with patient care or staff activities. The group can spend time in the triage area watching the flow of patients and can see the triage process at work. With groups of five or more, these activities must be restricted.

It is important to plan these visits to make sure that all of the group's open issues are addressed. Prior to the visit make a list of questions and information the team needs. Be sure to request copies of policies and documentation forms.

The implementation team must decide what needs to be done, who will do it and what strategies will be used, as well as develop a time line. Other teams have found flow-charting helpful. A flow chart identifies the critical tasks that need to occur and links them with completion target dates. The team can regularly refer to the flow chart to see if they are meeting their target dates. Education for physicians, nurses, and support staff is one critical task the team needs to consider.

Implementing ESI demands a commitment to the education of all staff. In order for this change to be successful, ED leadership must commit the resources necessary to thoroughly prepare the ED staff to use ESI. Although the ESI algorithm looks simple, there are several key concepts that need to be well understood in order to maintain the reliability and validity of the instrument. Orientation to the ESI is not a straightforward in-service training that can occur at change of shift or during down time in the ED. The original ESI hospitals have found that successful implementation of the ESI requires that, at a minimum, every triage nurse attend a 2-hour education program. The ESI program is best conducted in a setting away from the ED that is free from the distractions of the clinical area and conducive to learning. Without this level of commitment to the necessary education, the implementation of ESI can either fail or be haphazard.

Changing to ESI takes several months of planning and timing is important. Once all the tasks associated with the change are identified and timeframes established, the group can choose a realistic implementation date. The team must consider what is happening within the hospital and within the ED and identify a time when the unit is able to support the change and the educational activities. The acuity system cannot be changed gradually. A definite start date and time must be set and shared with all staff affected by the change.

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Policies and Procedures

All policies related to triage must be reviewed in light of the change to ESI. Individual hospitals must decide how the ESI will be incorporated into their ED's existing policies and procedures and many policies may need to be rewritten.

Examples of policies and procedures that need to be addressed include:

The ED leadership team will ultimately make these policy decisions, but the implementation team should identify these issues and make recommendations.

The ESI research team is frequently asked if the ESI system includes criteria for time to reassessment by triage level. The ESI system does not include reassessment recommendations. This is a key difference between ESI and other five-level triage systems. The ESI triage research group has purposefully not identified reassessment times but has left that to individual departments to incorporate into their triage policy. We urge caution; in this era of ED overcrowding it is very difficult for busy triage nurses to reassess patients at set time intervals when they are busy sorting incoming patients, and falling short of the policy can become a departmental liability.

It would be unrealistic for the implementation team to assume that all staff will embrace the change to ESI. Resistance is expected. It is impossible to eliminate resistance; instead, the implementation team should put into place strategies to minimize or manage resistance. Major change can trigger a wide range of emotional responses such as enthusiasm, skepticism, stress, anxiety, and a sense of loss. The team needs to openly discuss the planned change, answer questions, and gather support.

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Planning ESI Education

Some form of education about the ESI should be provided to all staff who will utilize the ESI information. The staff may include ED nurses, physicians and other providers, nursing assistants and clerical staff. While the triage nursing staff will need a full orientation to the ESI, other staff will need less education. For example, at University of North Carolina Hospitals, clerical and nursing assistant staff members received a memo describing the five ESI categories and notice of the implementation date. The physician on the implementation team may choose to handle physician education. The duration of physician orientation to ESI will depend on how familiar they are with the algorithm. At teaching hospitals, the ED residency director needs to allocate time for a member of the implementation team to provide an orientation for the residents. It is helpful to give residents copies of key articles for review.

Two to 4 hours is a realistic timeframe for the triage nurses' mandatory ESI educational program. The educator or clinical nurse specialist should set the day and time for education. Plans should include one or two make-up classes for the staff that are ill, on vacation, or pulled back into clinical duties due to staffing issues.

The ESI Trainer

The implementation team must identify a trainer for the orientation to ESI. It may not be realistic to have an educator available to teach all classes. Many groups use a train-the-trainer program, which initially trains team nurses who feel comfortable teaching and confident dealing with questions and resistors in the group.

Experienced educators have found that reading the research publications can be particularly helpful in explaining why the change to ESI is so important.

The ESI Training DVD

Another training option is to use the Emergency Severity Index, Version 4: Everything You Need To Know DVD, produced by the Agency for Healthcare Research and Quality (AHRQ). This product is now free to all emergency departments and can be ordered from AHRQ by phoning 800-358-9295 or sending an E-mail to

The DVD is broken into segments that can be used by the team in several ways. The intent is to enable emergency departments to implement ESI using a standardized training program rather than each department having to create their own program. The first segment addresses the benefits of using a five-level triage system, the reliability and validity of ESI and some examples of how ESI triage data can be used. The introduction to the ESI and practice cases can be reviewed individually or in a group setting. This segment is directed at nursing and physician leadership. The next segment is an introduction to the ESI algorithm. The audience is walked through each of the decision points (similar to Chapter 3) and many examples are used to clarify each triage level. The next segment provides the audience with practice cases using a classroom setting and real patient scenarios. The last segment is for those departments that implemented ESI v. 3 and need information about ESI v. 4.

The DVD also includes 10 test cases that can be used as one segment of an ESI competency. The DVD also contains all slides and handouts from the cases and lectures, as well as a copy of the algorithm.

Another training option is to hire a consultant to conduct a train-the-trainer program or train all the staff. The advantage of this option is that the department does not need to spend the time and resources putting together a training program. This may also be an option for a department that does not have an available educator or staff that can effectively teach the content.

Implementation may also be an opportunity for collaboration. For example, two hospitals chose to change to ESI at the same time and decided to pool resources. They hired a consultant and offered joint educational programs. If a consultant is hired it is a good idea for future trainers to sit through a number of sessions to really learn the content, hear the types of questions that are asked and see how the trainer handles difficult participants.

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The ESI Training Course

The core content for the orientation to ESI is provided in this handbook. The first edition of this manual was written with the idea that experienced educators could use the materials presented to create their own implementation program. However, many emergency departments do not have a dedicated educator, so sometimes staff with less curriculum development experience is asked to create an ESI educational program. The following section meets the needs of this group. A detailed description of a typical training course is presented along with tips from experienced ESI trainers.

Using the ESI Training DVD

The training DVD was produced to help emergency departments implement ESI. The DVD has four sections that can be used in several ways:

For departments that develop their own educational program, the cases in the DVD can be used by staff having difficulty applying ESI. The nurse can independently review the appropriate section of the DVD and practice cases.

Emergency departments that used ESI v. 3 may find the explanation of v. 4 and the practice cases helpful. Instead of a formal class, staff may independently watch the v. 4 explanation and practice case segments of the DVD and complete the test cases.

The basic ESI training takes between 2.5 and 3 hours. Many hospitals use this opportunity to review other triage related information, such as high risk situations or policy and procedure changes. The following section provides a detailed description of a 2-hour training segment of ESI. It is advised that the trainers view the entire DVD prior to developing their own content. This will help assure reliability and validity of the ESI algorithm.

Section 1: Introduction

The purpose of the introduction is to let the staff know why the department has chosen to adopt ESI. The issues with the former triage acuity system should be briefly explained along with the advantages of ESI and how ESI will address them. The time allocated for this section will depend on what information has already been shared with staff. It is important for the trainer to focus on what ESI will do for the staff nurse and for ED administration.

A number of reasons can be cited to support a move to ESI (Go to Chapter 1 for additional information.):

At the end of the introduction trainers should discuss the issues with the current triage acuity rating system that the ED may have already identified. These may include:

While it is important to include specific examples of problems the department has experienced with the current triage system, it is also important that the trainer not let this become a "gripe" session. The facts should be presented and any comments or questions can be addressed at the end of the program.

If the staff is not convinced that a change in the triage acuity rating system is necessary they can play the Triage Game before discussing the importance of reliability and validity of triage systems.

The Triage Game. The original ESI orientation program included the Triage Game as a way to break the ice and illustrate the poor interrater reliability of the three-level triage acuity rating system. Each nurse in attendance is given a packet consisting of red, yellow, and green colored cards. The red card is labeled "emergent," the yellow "urgent," and the green "non-urgent." Three cases are read to the group and after each case participants are asked to rate the patient acuity and hold up the appropriate card. Each participant is able to see how other members of the group rated the patient. Resistance decreases as the group begins to notice that participants rate the same patient differently. The group begins to realize that with a three-level system, there is always some level of disagreement within the group.

Three cases that could be used for this game are presented below:

After the Triage Game, it is useful to highlight the research on poor interrater and intrarater reliability of conventional three-level triage systems, which is described in Chapters 1 and 2. At this point the group is about 15 to 20 minutes into the presentation and staff should be ready to hear about ESI. Participants should have a copy of the front and back of the algorithm and the trainer can now begin the discussion.

Section 2: The ESI Algorithm

This section of the presentation explains the algorithm in detail. It is important to stress to course participants that ESI was developed by a group of emergency nurses and physicians and has been in use at a number of hospitals since April 1999. Other important background information to discuss includes the following points about ESI:

Begin review of the algorithm with the conceptual version so that the four major decision points can be reviewed. Then begin a detailed description of the algorithm itself. The instructor should walk through each decision point slowly and not move on to the next decision point until all questions and concerns are addressed. This section will take from 40 to 65 minutes depending on the size of the group and the experience of participants. For each decision point the trainer should review the questions the triage nurse should be asking.

Decision point A: Does this patient require immediate life saving intervention? If the answer is yes, the patient is assigned to ESI level 1. It is imperative that the instructor spend time reviewing the A notes on the back of the card. The instructor should also include examples of ESI level-1 patients and the reason they fall into that triage level. Experienced ED nurses have no problems identifying this group of patients.

Decision point B: Is this a patient who shouldn't wait? The trainer needs to discuss in detail the three questions that are part of Decision Point B:

Is this a high-risk situation? Define the term high risk and have the participants identify chief complaints or diagnoses that are high risk. Participants will usually mention aortic abdominal aneurysm and ectopic pregnancy but the trainer needs to encourage the staff to think about other low volume, high-risk presentations. During this discussion knowledge deficits may become evident and the instructor will need to provide additional educational materials. For example, staff nurses may disagree on the need for immediate evaluation of a patient that presents with symptoms of central retinal artery occlusion. This is a perfect opportunity to explain why this is high-risk situation. A discussion of high-risk situations also provides the trainer with an opportunity to review triage red flags in the elderly and in children.

To prepare for this section of the course the instructor may want to review the Emergency Nursing Core Curriculum© and develop a list of high-risk patient situations. These situations are outlined in Chapter 4. The instructor needs to stress that a high-risk patient is safe to wait for 10 minutes while a bed is found. If the registration process takes less than 10 minutes then the patient or their family can finish this process.

Is there new onset confusion, lethargy or disorientation? This is the next question that needs to be reviewed using examples from various age groups. The definition of "acute" change in level of consciousness is important to clarify.

Is this patient in severe pain or distress? The concept of severe pain or distress elicits many opinions and questions from the audience. The instructor should not engage in a debate about pain scales and their use at triage. The discussion should focus on the intent of this question to identify the patient in extreme pain. It may be helpful to explain that there are actually three components to severe pain:

If the patient rates their pain as 7/10 or greater and the triage RN feels this patient cannot wait and needs intravenous analgesia, the patient will be assigned to ESI level 2. Participants may have many questions about this concept and the trainer needs to stress that it is not just the patient's pain rating that makes them an ESI level 2.

Nurses may say they feel uncomfortable documenting a patient's high pain rating and then leaving the patient in the waiting room. It is important for the instructor to stress that the patient's rating is one piece of an assessment and that the nurse should accurately document what he/she is observing. For example: "Rates pain as 10/10, skin warm and dry, laughing with friend at triage," "Generalized abdominal pain for 3 days, constant dull ache. Rates pain as 10/10."

The instructor should describe several patients that meet ESI level-2 criteria due to pain. Examples include sickle cell crisis, a cancer patient with breakthrough pain, and renal colic. At the same time the instructor needs to address patients who probably will not be assigned to ESI level 2 due to pain. Examples include toothache, eye pain, most headaches and extremity injuries. This is a great opportunity to discuss nursing interventions at triage to minimize or decrease a patient's pain. This discussion may also prompt the recognition of standing orders for analgesia at triage, (i.e., ibuprofen, opthane, and so on).

The next area to address is physiological or psychological distress. Examples are often the best method of explaining this concept. Examples of physiological distress include urinary retention and priapism. These patients are in acute distress and require immediate intervention. Many psychiatric emergencies fall under psychological distress. Examples include: sexual assault, domestic violence, paranoia, and manic behavior. The suicidal/homicidal patient has already been assigned to ESI level 2 because they are high risk. These patients should be assigned to ESI level 2 even if they come in every day stating they are going to hurt themselves or someone else. This is an excellent opportunity to review your ED psychiatric policy.

After discussing the three questions under decision point B it is helpful to review all the level-2 criteria together. Once again a list of examples is helpful.

Decision point C: How many different resources will this patient consume? It is important to clarify what is and what is not a resource. Reviewing the resource table on the back of the algorithm usually generates questions and discussion. The following discussion includes examples of typical questions the trainer should be prepared to discuss.

Once the group understands the concept of resources it is important to give multiple examples of patients who would be assigned ESI level 4 and 5. Before discussing ESI level 3, the trainer needs to review decision point D.

Decision point D: What are the patient's vital signs? It is important that participants understand that the triage nurse should consider the patients' vital signs. The triage nurse uses her judgment to determine whether the patient should be up-triaged to ESI level 2 based on abnormal vital signs. It is important to present examples of patients the triage nurse should up-triage to ESI 2, as well as examples of ESI level-3 patients that do not require up-triage based on abnormal vital signs.

At the end of this segment the participants should be quite comfortable with the type of patients that fall into each ESI level. Reviewing practice cases will reinforce use of the algorithm and answer many questions.

Section 3: ESI Practice Cases

After a thorough description of the ESI algorithm, patient scenarios are used as a group-teaching tool. Chapter 9 contains 30 cases specifically written for practice and intended to simulate an actual triage encounter. The cases encompass all age groups and the complete spectrum of acuity. In addition, these cases illustrate most of the important points in the algorithm. The instructor reads each case, and the participants are asked to use the algorithm to assign an ESI level. Each participant can be given an additional packet of colored cards labeled ESI levels 1 through 5 and asked to hold up the appropriate card as each case study is discussed. The advantage of using the cards is that participants will begin to notice a higher degree of agreement with ESI than they observed with the three-level triage system case examples.

Once everyone in the group has assigned an ESI level, the trainer can proceed with a step-by-step review of how the level was determined. The research group found it helpful to instruct nurses to always start with decision point A and work through the algorithm. If the case moves to decision point C, it is helpful to have the participants verbalize the expected resources. Many misconceptions can be cleared up with this strategy.

As previously discussed, staff may initially have difficulty with what is and what is not a resource, and with determining the number of resources. This is a perfect opportunity to re-emphasize the definition of resources in the ESI triage method and answer the "what about" questions. We have found that towards the end of the practice cases the staff becomes vocal about their level of comfort with the algorithm.

Section 4: Competency Cases

One question managers and educators frequently hear is "How do you know your staff is competent to perform triage?" Chapter 10 was written with this question in mind. The chapter includes many cases for each nurse to review and assign a triage acuity rating using ESI.

Each nurse should complete the competency cases individually and return them to the trainer to assess for accuracy. The ED management and educational staff of each hospital must define parameters for a passing score prior to assessing staff competency. In many institutions scoring 24 to 26 correct out of 30 is the standard. For the staff person whose score falls below the acceptable level, re-education is indicated and competency should be re-assessed at a later date with different cases. Paper case assessment of competency only addresses the staff nurse's ability to assign a triage acuity rating to paper cases. An evaluation of each triage nurse performing triage with real patients and using the ESI criteria should be performed with a triage preceptor or other designated expert.

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Strategies To Assist With Implementation

Strategies that the ESI triage research group have found useful for successful ESI implementation include the following:

Reinforcement is key to the successful implementation of ESI. At Brigham and Women's and the York Hospitals, the implementation team chose to have the algorithm preprinted on progress notes. For 2 months the triage nurse was required to use a progress note and record the patient's chief complaint and circle the assigned ESI level. The progress note served no purpose other than to make the triage nurse look at the algorithm each time a patient was triaged.

Questions and misinterpretation of the finer points of the algorithm will always arise after implementation and will need to be addressed with re-education. After implementation of ESI at Brigham and Women's Hospital, it was noted that the staff were not consistently assigning an ESI level 1 to intoxicated and unresponsive patients. This point was emphasized on a poster in the break room to bring attention to the problem.

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Implementation Day

The implementation team needs to be available around the clock to support the triage staff, answer questions, and review triage decisions. It is important that mis-triages be addressed immediately in a non-threatening manner. Making staff aware ahead of time that this will be taking place is less threatening. Reinforcing the efforts of the staff and being available will be important and help ensure ESI is appropriately integrated into the emergency department.

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Following implementation, it is important that triage nurses continue to be vigilant when assigning triage acuity ratings. Many nurses may complain that more patients are ESI level 2. Triage nurses should be reminded not to deviate from the original algorithm but instead understand the value of ESI as an operational tool. The staff should understand that deviations from the algorithm will threaten the reliability and predictive validity of the tool.

Staff efforts in making a smooth transition to ESI should be recognized and rewarded. This could include an article in the hospital newspaper, or a note of thanks to the staff from the ED leadership team. Successful implementation of ESI requires a dedicated team that recognizes the degree of change and effort needed to change triage systems. The team must be able to develop and carry out a specific, simple, and realistic plan. The team leader should have a clear vision, be able to clearly articulate it, be committed to the ESI implementation, and be able to energize the other members of the team and the staff. The team needs the support of the ED leadership and the resources necessary to make this planned change. For this change to be successful there must be broad-based support beginning with the most senior levels of the institution.

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Gilboy N, Travers DA, Wuerz RC (1999). Reevaluating triage in the new millennium: A comprehensive look at the need for standardization and quality. Journal of Emergency Nursing 25(6):468-73.

Grol R, Grinshaw J (1999). Evidence-based implementation of evidence-based medicine. Joint Commission Journal on Quality Improvement 25(10):503-13.

Nelson R (2002). Major theories supporting health care informatics. In S. P. Englebardt and R. Nelson (Eds.), Health care informatics: An interdisciplinary approach (pp. 3-27). St. Louis, MO: Mosby.

SoRelle R (2002, July). Triaging triage: Singling out a national standard. Emergency Medicine News, pp. 32-4.

Sullivan E, Decker P (2001). Effective leadership and management in nursing (5th ed.). New Jersey: Prentice Hall.

Zimmermann PG (2001). The case for a universal, reliable 5-tier triage acuity scale for U.S. emergency departments. Journal of Emergency Nursing 27(3):246-54.

Note: Appendix A of this handbook includes frequently asked questions and post-test assessment questions for Chapters 3 through 8. These sections can be incorporated into the ESI training course.

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