No, it is a factor to consider.
No, again this is one factor to consider.
No, an ESI level 2 is assigned to patients with an acute change in level of consciousness.
For any patient who meets ESI level-3 criteria. Vital signs are always obtained if the triage nurse determines they may be useful.
Assign an ESI level to each of these patients.
| Level | Patient |
|---|---|
| 1. _________ | A 62-year-old with CPR in progress. |
| 2. _________ | A 53-year-old with 30% BSA burn. |
| 3. _________ | A 22-year-old who needs a work note. |
| 4. _________ | A 12-year-old with an earache. |
| 5. _________ | A 45-year-old involved in MVC, ejected from vehicle, BP 100/60. |
| 6. _________ | An unresponsive 14-year-old. EMS tells you he and his friends "had been doing shots." |
1. ESI level 1
2. ESI level 2
3. ESI level 5
4. ESI level 5
5. ESI level 2
6. ESI level 1
No. With stable vital signs and no other factors that would meet high-risk criteria, this patient should be assigned ESI level 3. She will most likely need labs, and either x-rays, an IV, or pain medications, i.e., two or more resources. You would not use your last open bed for her.
No. The new onset of confusion, lethargy, or disorientation meet criteria for ESI level 2.
Not all patients with chest pain meet ESI level-1 criteria. If they are unresponsive, pulseless, apneic or not breathing, or require immediate life saving intervention, they meet level-1 criteria. A chest pain patient that is pale, diaphoretic, hypotensive, or bradycardic will require immediate IV access to improve their hemodynamic status is level 1. Stable patients with active chest pain usually meet high-risk criteria and should be categorized ESI level 2; immediate placement should be facilitated.
Read each case and determine whether the patient meets the criteria for ESI level 2. Justify your decision.
1. A 40-year-old male presents to triage with vague, midsternal chest discomfort, occurring intermittently for one month. This morning, he reports a similar episode, which has now resolved. Currently complains of mild nausea, but feels pretty good. Medical history: Smoker. He is alert, with skin warm and dry, does not appear to be in any distress.
2. A 22-year-old female on college break presents to the triage desk complaining of sudden onset of feeling very sick, severe sore throat, and feels "feverish." She is dyspneic, drooling at triage, and her skin is hot to touch.
3. A 68-year-old male brought in by his wife for sudden onset of left arm weakness, slurred speech, and difficulty walking. Symptoms began 2 hours prior to arrival. PMH: Atrial fibrillation. Meds: Lanoxin. The patient is awake, oriented, mildly short of breath. Speech is slurred; rightsided facial droop is present. Left upper-extremity weakness noted with 2/5 muscle strength.
4. A 60-year-old male complains of sudden loss of vision in the left eye that morning. Patient denies pain or discomfort. PMH: CAD, HTN. The patient is slightly anxious but no distress.
5. A 22-year-old female with 10/10 abdominal pain for two days. Denies nausea, vomiting, diarrhea, or urinary frequency. Her heart rate is 84 and she is eating ice cream.
6. A 70-year-old female with her right arm in a cast is brought to triage by her daughter. The daughter states her mother fell yesterday and fractured her arm. The patient is complaining of pain. Daughter states, "They put this cast on yesterday, but I think it's too tight." Daughter reports her mother has been very restless at home and thinks her mother is in pain. Patient has a history of Alzheimer's disease. The patient is confused, mumbling (per baseline); face flushed. She is unable to provide verbal description of her complaints. Her right upper extremity is in a short arm cast; digits appear tense, swollen and ecchymotic. Nail beds are pale; capillary refill delayed. Patient is not wearing a sling.
7. An 8-month-old presents with fever, cough, and vomiting. The baby has vomited twice this morning; no diarrhea. Mom states the baby is usually healthy but has "not been eating well lately." Doesn't own a thermometer, but knows the baby is "hot" and gave acetaminophen two hours PTA. The baby is wrapped in a blanket, eyes open, appears listless, skin hot and moist, sunken fontanel. Respirations are regular and not labored.
8. A 34-year-old male presents to triage with right lower quadrant pain, 5/10, all day. Pain is associated with loss of appetite, nausea and vomiting. PMH: None. The patient appears in moderate discomfort, skin warm and dry, guarding abdomen.
9. A 28-year-old male arrives with friends with a chief complaint of a scalp laceration. Patient states he was struck in the head with a baseball bat one hour prior to arrival. Friends state he "passed out for a couple of minutes." Patient complains of headache, neck pain, mild nausea, and emesis x 1. Patient looks pale, but is otherwise alert and oriented to person, place, and time. There is a 5-cm laceration to the scalp near his left ear with bleeding controlled.
10. A 28-year-old male presents with a chief complaint of tearing and irritation to the right eye. He is a construction worker and was drilling concrete. He states "I feel like there is something in my eye" and reports "irrigated the eye several times but it doesn't feel any better." Patient appears in no severe distress; however, he is continually rubbing his eye. Right eye appears red, irritated, with excessive tearing.
11. A 40-year-old male is brought in by his son. He is unable to ambulate due to foot pain. Patient states he fell approximately 10 feet off of a ladder and is complaining of foot and back pain. States he landed on both feet and had immediate pain. Denies LOC/neck pain. No other signs of trauma noted. The patient appears pale, slightly diaphoretic, and appears in mild distress. He rates his pain 6/10. Patient is sitting upright in a wheelchair.
12. A 12-year-old female is brought to triage by her mother who states her daughter has been weak and vomiting for three days. The child states she "feels thirsty all the time and her head hurts." Vomited once today. Denies fever, abdominal pain, or diarrhea. No significant PMH. The child is awake, lethargic, and slumped in the chair. Color is pale, skin warm and dry.
13. A 40-year-old male presents to triage with a gradual increase in shortness of breath over the past two days associated with chest pain. PMH: colon CA. He is in moderate respiratory distress, skin warm and dry.
14. A 60-year-old male presents with complaint of dark stools for one month with vague abdominal pain. PMH: None. Pulse is tachycardic at a rate of 140 and he has a blood pressure of 80 palpable. His skin is pale and diaphoretic.
15. A 25-year-old female presents to triage with a chief complaint of a moderate amount of dark red vaginal bleeding, with 9/10 pain. The patient states she is 7 months pregnant and this is her fourth pregnancy. PMH: Denies.
1. ESI level 2. This patient is high-risk, due to history of angina x 1 month. The patient complained of symptoms of AMI earlier in the morning. Smoking is a significant risk factor; however, the patient presentation is concerning enough to be considered high risk. These are symptoms significant for a potential cardiac ischemic event. AMI is frequently accompanied or preceded by waxing and waning symptoms. An immediate ECG is necessary.
2. ESI level 2. This patient is at high risk for epiglottitis. This is a life-threatening condition characterized by edema of the vocal cords. Onset is rapid, with a high temp (usually >101.3° F/38.5° C), lethargy, anorexia, sore throat. Patients do not have a harsh cough associated with croup, often assume the tripod position, and also have mouth drooling, an ominous sign, and may demonstrate an exhausted facial expression. Epiglottitis is more common in children, but may occur in adults; usually age 20 to 40. These patients are at high risk for airway obstruction and need rapid access of an airway (preferably in the operating room).
3. ESI level 2. This patient is presenting with signs of an acute stroke and requires immediate evaluation. If he meets criteria for thrombolytic therapy, he may still be in the time window of less than three hours, but every minute counts with this patient. He is a very high-priority ESI level-2 patient.
4. ESI level 2. High risk for central retinal artery occlusion caused by an embolus. This is one of the few true ocular emergencies and can occur in patients with risk factors of coronary artery disease, hypertension, or embolus. Without rapid intervention, irreversible loss of vision can occur in 60 to 90 minutes.
5. ESI level 3. Since she is able to eat ice cream, you would not give your last open bed for this patient. She will probably require at least two resources.
6. ESI level 2. High risk for compartment syndrome. Despite the patient being a poor historian, the triage nurse should be able to identify some of the signs of threatened compartment syndrome: Pain, pallor, pulselessness, paresthesia, and paralysis. The patient requires immediate life-saving intervention: Cutting of the cast and further evaluation for potential compartment syndrome.
7. ESI level 2. High risk for sepsis or severe dehydration. If the baby was alert and active with good eye contact, similar complaints, and a fever of 100.4° F (38.0° C) or greater, the ESI category would be 3. The temperature is not needed to make the assessment that the baby is high risk. The presence of lethargy and a sunken fontanel are indications of severe dehydration.
8. Initially ESI level 3. However, the patient could be upgraded to ESI level 2 if vital signs were abnormal, i.e., heart rate greater than 100. Signs of acute appendicitis include mild-to-severe RLQ pain with loss of appetite, nausea, vomiting, low-grade fever, muscle rigidity, and LLQ pressure that intensifies the RLQ pain. The presence of all these symptoms and tachycardia would indicate a high risk for a surgical emergency.
9. ESI level 2. High risk for epidural hematoma. This is a great example of the importance of understanding mechanism of injury. This man was struck with a baseball bat to the head with enough force to cause a witnessed LOC. Patients with epidural hematomas have a classic transient LOC before they rapidly deteriorate. Even though this patient looks good now and is alert and oriented at present, he must be immediately placed for further evaluation.
10. ESI level 2. High risk for severe alkaline burn. Concrete is an alkaline substance and continues to burn and penetrate the cornea causing severe burns. Alkaline burns are more severe than burns with acid substances and require irrigation with very large amounts of fluids.
11. ESI level 2. High risk for lumbar and calcaneus fractures. Again, mechanism of injury is very important to evaluate. Although he is not unresponsive or lethargic, he needs rapid evaluation and treatment.
12. ESI level 2. Lethargy and high risk for severe dehydration from probably diabetic ketoacidosis (DKA). It is not normal for a 12-year-old to be slumped over in a chair. Her history of being thirsty and lethargic suggest a strong suspicion for DKA. She needs rapid evaluation and rehydration.
13. ESI level 2. High risk for a variety of complications associated with cancer, i.e., pleural effusion, CHF, further malignancy, and pulmonary embolus. A history of cancer can help identify high-risk status.
14. ESI level 1. Patient is placed in ESI level 1 after consideration of heart rate, skin condition and blood pressure. Tachycardia and hypotension indicate blood loss. The patient needs immediate hemodynamic support.
15. ESI level 1. She is at high risk for abruptio placentae, and needs an immediate cesarean section to save the fetus. Abruption occurs when the placenta separates from its normal site of implantation. Primary causes include hypertension, trauma, illegal drug use, and short umbilical cord. Bleeding may be dark red or absent when hidden behind the placenta. Abruption is usually associated with pain of varying intensity.
Though crutch-walking instruction may consume a fair amount of the ED staff members' time, it is often provided to patients who have simple ankle sprains. These patients are typically classified as ESI level 4 (ankle x-ray = one resource). The patients are clearly less acute and less resource intensive than more complex patients like those with tibia/fibula fractures who are usually ESI level 3 (leg films, orthopedic consult, cast/splint, IV pain medications = two or more resources). A better way to reflect the ED staff's efforts for crutch-walking instruction is with a nursing resource intensity measure.
The application of simple, pre-formed splints (such as splints for ankle sprains) is not considered a resource. In contrast, the creation and application of splints by ED staff, such as thumb spica splints for thumb fractures, does constitute a resource. A helpful way to differentiate patients with extremity trauma is as follows: patients with likely fractures should be rated ESI 3 (two or more resources: x-ray, pain medications, creation and application of splints/casts), whereas patients more likely to have simple sprains can be rated as ESI level 4.
Generally speaking, insertion of a heparin lock doesn't consume a large amount of ED staff time. However, many patients who have heparin locks inserted also have at least two other resources (e.g., laboratory tests, intravenous medications) and are therefore classified as ESI level 3 anyway.
Yes, conscious sedation is considered a complex procedure (two resources) and is generally performed with patients who also have laboratory tests or x-rays, and other procedures such as fracture reduction or dilation and curettage.
All three are considered resources for the purposes of ESI triage ratings. The resources tend to be used for more acute patients, require significant ED staff time, and likely lead to longer length of stay for patients.
No. Stable asthmatics who only require a nebulized medications are assigned ESI level 4. However, some asthmatics are in severe respiratory distress and meet ESI level-2 criteria. Others are somewhere in between and will require intravenous steroids or an x-ray in addition to nebulized treatments and would be assigned ESI level 3. Finally, asthmatics who require only a prescription refill of their inhaler are assigned ESI level 5. They do not require any resources.
Read the following statements and provide the correct answer.
1. A magnetic resonance imaging (MRI) procedure
is considered a resource in the ESI triage system.
(T/F)
2. A psychiatry consult is considered a resource in
the ESI triage system.
(T/F)
3. Cardiac monitoring is considered a resource in
the ESI triage system.
(T/F)
4. How many ESI resources will this patient need?
A healthy 25-year-old construction worker
presents with back pain. The triage nurse
predicts he will need a lumbar spine x-ray, oral
pain medication administered in the ED, and a
prescription to take home.
(0, 1, 2 or more)
5. It is necessary to take vital signs in order to
determine the number of ESI resources an adult
ED patient will need.
(T/F)
6. The triage nurse must have enough experience
to be certain about the resources needed for
each patient in order to accurately assign an ESI
triage level.
(T/F)
7. A 30-year-old sexually active female patient
with vaginal bleeding and cramping, doesn't
use birth control, and is dizzy and pale. In
determining this patient's ESI triage level, does
it matter if the local ED does urine pregnancy
tests at the point of care versus sending a
specimen to the laboratory?
(Y/N)
How many
resources will this patient require?
(0, 1, 2 or
more)
8. How many ESI resources will this patient need?
A healthy 40-year-old man presents to triage at
2:00 a.m. with a complaint of a toothache for
two days, no fever, and no history of chronic
medical conditions.
(0, 1, 2 or more, irrelevant)
9. How many ESI resources will this patient need?
A 22-year-old female involved in a high-speed
rollover MVC and thrown from the vehicle,
presents intubated, no response to pain, and
hypotensive.
(0, 1, 2 or more, irrelevant)
10. How many ESI resources will this patient need?
A 60-year-old healthy male who everted his
ankle on the golf course presents with moderate
swelling and pain upon palpation of the lateral
malleolus.
(0, 1, 2 or more, irrelevant)
11. Is it considered an ESI resource if a psychiatric
patient requires a sitter or security staff member
present at the bedside?
(Y/N)
1. True. The MRI will make use of personnel outside the ED (MRI staff) and increase the patient's ED length of stay.
2. True. The consult involves personnel outside the ED (psychiatry team) and increases the patient's ED length of stay.
3. False. Monitoring is part of the routine care provided by ED staff. However, most patients who receive monitoring also need at least two other ED resources (electrocardiogram, blood tests, x-rays), and may therefore be classified as ESI level 3.
4. One ESI resource. The x-ray is considered a resource since it utilizes personnel outside the ED. The oral pain medication and take-home prescription are not considered resources since they are quick interventions performed by ED personnel.
5. False. While vital signs are helpful in up-triage of level-3 patients to level 2, they are not necessary for differentiating patients needing one, two, or more than two resources.
6. False. The ESI is based upon the experienced ED triage nurse's prediction, or estimation, of the number and type of resources each patient will need in the ED. The purpose of resource prediction isn't to order tests or make an accurate diagnosis, but to quickly sort patients into distinct categories using acuity and expected resources as a guide.
7. No, it doesn't matter. The patient will need at least two resources, and be classified as a level 3 whether the pregnancy test is done in the ED (not a resource) or in the laboratory (a resource). The predicted resources will include: Complete blood count, intravenous fluids, ultrasound, and possibly a gynecology consult and intravenous medications if it is determined that she is aborting a pregnancy and the cervical os is open.
8. No resources. This patient will likely have a brief exam (not a resource) and receive a prescription for pain medication (not a resource) by the provider, and therefore is an ESI level-5 patient.
9. Irrelevant. The patient is an ESI level 1 based on being intubated and unresponsive. The nurse does not need to make a determination of the number of resources in order to make the triage classification.
10. One resource. The patient will need an ankle x-ray (one resource), and may get an ace wrap or ankle splint (not a resource) and crutches (not a resource). Simple ankle sprains are generally classified as ESI level 4. However, if the patient was in severe pain that required pain medication by injection, or if he had a deformity that might need a cast, orthopedic consult and/or surgery, then he would need two or more resources and be classified as an ESI level 3.
11. Yes. A sitter or security staff member present at the bedside is considered a resource. However, such patients are high risk, since they are suspected to be a danger to themselves or others. So, in fact, these patients should be rated ESI-2 and it is not necessary to predict the number of resources they will require in the ED.
Vital signs are not necessary to rate patients as life threatening (ESI level 1) or high-risk (ESI level 2). Since ESI level 1 and 2 patients are critical, they require the medical team to respond quickly. Simultaneous actions can occur and vital signs can be collected as part of the initial assessment in the main acute area of the emergency department.
Vital signs are not necessary to rate patients as low or no resource (ESI level 4 or 5). Also, the pain, anxiety, and discomfort associated with an emergency department visit often alter a patient's vital signs. Vital signs may quickly return to normal once the initial assessment is addressed. However, a nurse may choose to assess vital signs if signs of deranged symptoms exist (e.g., changes in skin color, mentation, dizziness, sweating). If there is no physical sign indicating a need for vital signs, the patient can be taken in the main emergency department or express care room.
Vital signs can aid in differentiating patients needing multiple resources as either stable (ESI level 3) or potentially unstable or high-risk (ESI level 2). On occasion, ESI level-3 patients may actually have unstable vital signs while appearing stable. Vital signs for ESI level-3 patients provide a safety check. In general, ESI level-3 patients are more complicated and many are admitted to the hospital. Since these patients are not appropriate for the fast-track area, they are sometimes asked to wait for more definitive care. These patients present a unique challenge to the triaging process and caregivers find it necessary to rely on vital signs to confirm that an appropriate ESI level has been assigned.
Temperature is useful in differentiating pediatric patients that are low or no resource (ESI level 4 or 5) from those that will consume multiple resources. An abnormal temperature in the less than 3 month old may indicate bacteremia, and place the child in a high-risk category.
There is no definitive research on the utility of vital signs for emergency department triage. Many factors influence the accuracy of vital sign data. Vital signs are a somewhat operator-dependent component of a patient's assessment. In some cases, vital signs may be affected by many factors such as chronic drug therapy (e.g., beta-blockers). Vital signs may also be used to fulfill part of the public health obligation assumed by emergency departments. And, lastly, vital signs help segment young pediatric patients into various categories.
The Joint Commission on Accreditation of Healthcare Organizations does not specifically state a standard for vital signs. The organization does assert that physiologic parameters should be assessed as determined by patient condition.
In common usage, when the danger zone vital sign criteria are exceeded, up-triage is "considered" rather than automatic. The experienced triage nurse is called upon to use good clinical judgment in rating the patient's ESI level. The nurse incorporates information about the vital signs, history, medications, and clinical presentation of the patient in that decisionmaking process. Research is still needed to determine the predictive value of vital signs at triage, and to determine absolute cutoffs for up-triage.
Though it is not required to take vital signs in order to assign ESI 4 or 5 levels, many patients may have vitals assessed at triage if that is part of the particular ED's operational process. Per the ESI triage algorithm, the triage nurse does not have to take the vital signs into account in determining that the patient meets ESI level-5 (no resources) or ESI level-4 (one resource) criteria. However, in practice, the prudent nurse will use good clinical judgment and take the vital sign information into account in rating the ESI level. If the patient requests only a prescription refill and has no acute complaints, but has a heart rate of 104 after walking up the hill to the ED, the nurse might still rate the patient as an ESI level 5. But if the patient requests a prescription refill and has a heart rate of 148 and irregular, the nurse should rate the patient as ESI level 2. The triage nurse must also consider the following dilemma: an elevated blood pressure in an ESI level-4 or 5 patient. If the patient is asymptomatic related to the blood pressure, the triage level should not change. Most likely, an elevated BP in the asymptomatic patient will not be treated in the ED. However, it may be important to refer the patient to a primary care physician for BP followup and long term diagnosis and treatment.
Rate the ESI level for each of the following patients.
1. 3-week-old male
Vital signs:
Temperature: 100.8° F (38.2° C)
Heart rate: 160
Respiratory rate: 48
Oxygen saturation: 96%
Narrative:
Poor feeding
Less active than usual
Sleeping most of the day
2. 22-month-old, fever, pulling ears, immunizations
up to date, history of frequent ear infections
Vital signs:
Temperature: 102° F (39° C)
Heart rate: 128
Respiratory rate: 28
Oxygen saturation: 97%
Narrative:
Awoke screaming
Pulling at ears
Runny nose this week
Alert, tired, flushed, falling asleep now
Calm in mom's arms, cries with exam
3. 6-year-old with cough
Vital signs:
Temperature: 104.4° F (40.2° C)
Heart rate: 140
Respiratory rate: 30
Oxygen saturation: 91%
Narrative:
Cough with fever for two days
Chills
Short of breath with exertion
Green phlegm
Sleeping a lot
4. 94-year-old male, abdominal pain
Vital signs:
Temperature: 98.9° F (37.2° C)
Heart rate: 100
Blood pressure: 130/80
Oxygen saturation: 93%
Narrative:
Vomiting
Epigastric pain
Looks sick
5. 61-year-old female, referred with asthma
Vital signs:
Temperature: 99.1° F (37.3° C)
Heart rate: 112
Respiratory rate: 28
Blood pressure: 157/94
Oxygen saturation: 91%
Peak expiratory flow rate = 200
Narrative:
Asthma exacerbation with dry cough
Steroid dependent
Multiple hospitalizations
Never intubated
6. 9-year-old male, head trauma
Narrative:
Collided with another player at lacrosse game
Loss of consciousness for "about 5 minutes,"
witnessed by coach
Now awake with headache and nausea
1. ESI level 2. An infant less than 28 days with a temperature greater than 38.0° C (100.4° F) is considered high risk regardless of how good they look. With a child between 3 and 36 months with a fever greater than 39.0° C (102.2° F), the triage nurse should consider assigning ESI level 3, if there is no obvious source for a fever or the child has incomplete immunizations.
2. ESI level 5. A child under 36 months of age requires vital signs. This child has a history of frequent ear infections, is up to date on their immunizations and presents with signs of another ear infection. This child meets the criteria for ESI level 5 (exam, PO medication administration and discharge to home). Danger zone vitals not exceeded. If the child was underimmunized or there was no obvious source of infection the child would be assigned to ESI level 3.
3. ESI level 2. The clinical picture indicates high probability of tests that equal two or more resources (ESI level 3). Danger zone vital signs exceeded (SpO2 = 91%, Respiratory rate = 30), making the patient an ESI level 2.
4. ESI level 2. The clinical picture mandates ESI level 3 with expected utilization of x-ray, blood work, and specialist consultation resources. Danger zone vital signs not exceeded. If an experienced triage nurse reported this patient as looking in imminent danger of deterioration, the patient may be upgraded to an ESI level 2. A 94-year-old ill-appearing patient presenting with epigastric pain, vomiting, and probable dehydration should be considered a high-risk ESI level-2 patient. If this patient did not look toxic, an ESI level 3 might be an appropriate starting point in the decision algorithm.
5. ESI level 2. The clinical picture mandates ESI level 3 with expected utilization of x-ray, blood work, and specialist consultation resources. Respiratory rate and heart rate danger zone vital signs are exceeded, so patient is up-triaged to ESI level 2.
6. ESI level 2. This patient is assigned an ESI level 2 due to the high-risk information provided in the scenario. Vital signs are not necessary, and patient should be immediately taken to treatment area for rapid assessment.
Although it is very helpful and will expand the number of indicators you can monitor, you do not have to have electronic data monitoring to perform ESI QI.
No. An expert nurse in triage should determine whether the acuity ratings are correct.
This is a decision to be made by the leadership team. Select only those indicators that have been identified as important to your ED and select only the number of indicators you have the resources to monitor.
Return to Chapter 8
Return to Contents
Proceed to Next Section