EMERGENCYSEVERITY

INDEX

REVIEW

requires immediate life-saving intervention?

A

high risk situation?or

confused/lethargic/disoriented?or

severe pain/distress? B

How many different resources are needed?---------------------------------------------------------------------------------------

none one many C

Danger zone vitals? Age HR RR< 3 mo > 180 > 503m-3y > 150 > 403y- 8y > 140 > 30> 8 y > 100 > 20

SaO2<92%

D

ESI Triage Algorithm

5 4

2

3

1Yes

No

Consider

No

Yes

DECISION POINT A Does the patient require immediate life

saving intervention?Airway

Obstructed or partially obstructed Unable to protect their own airway

Breathing Apneic Intubated prehospital Severe respiratory distress SpO2 less than 90%

DECISION POINT A Cont.

Circulation Pulseless or concerned about rate, rhythm or

qualityDrugs

Hemodynamic interventions Immediate IV medications to correct

hemodynamic instability

DECISION POINT A Does this patient have an acute mental

status change that requires immediate life saving intervention?Hypoglycemia needs glucoseHeroin OD needs narcanSubarachnoid bleed needs airway

protection Is this patient a P or U on the AVPU scale

LEVEL 1 EXAMPLES Cardiac or respiratory arrest Overdose with a RR of 8 Severe respiratory distress Acute SOA with SpO2 < 90% Anaphylactic shock Critically injured trauma patient Chest pain, pale, diaphoretic Chest palpitations, HR 180+ Unresponsive with strong odor of

alcohol Severe stroke needs airway

protection

AGGRESSIVE LIFE SAVING INTERVENTIONSWILL THIS INTERVENTION SAVE THIS PERSONS LIFE?

Airway and breathing IntubationSurgical airwayCPAP, BiPAPBag valve mask

Defibrillation External pacing Chest needle decompression

HemodynamicsSignificant IV fluid resuscitationBlood administration IV medications

Vasopressors

Control of major bleeding

Immediate Life-saving Interventions

Life-saving Not life-saving

Airway breathing BVM ventilationIntubation Surgical airway Emergent CPAPEmergency BiPAP

Oxygen administrationNasal cannulaNon-rebreather

Electrical Therapy Defibrillation Emergent cardioversion External pacing

Cardiac Monitor

Procedures Chest needle decompressionPericardiocentesis Open thoracotomy Intraoseous access

Diagnostic testsECGLabs UltrasoundFAST (focused abdominal scan for trauma)

Hemodynamics Significant IV fluid resuscitation Blood administration Control of major bleeding

IV access Saline lock for medications

Medications Naloxone D50 Dopamine Atropine Adenocard

ASA IV nitroglycerin Antibiotics Heparin Pain medications Respiratory treatments with beta agonists

3 QUESTIONS USED TO DETERMINE WHETHER THE PATIENT MEETS LEVEL 2

Is this a high risk situation?

Is this patient confused, lethargic or disoriented?

Is this patient in severe pain or distress?

The triage nurse obtains pertinent subjective and objective information to quickly answer these questions

Decision Point B: Should the patient wait?

High risk situation?or

confused/lethargic/disoriented?or

severe pain/distress? B

2

Yes

DECISION POINT BIS THIS A HIGH RISK SITUATION?

Determination is based on a brief patient interview, gross observations, “sixth sense”

Do not require a full set of vital signs Unsafe for the patient to wait

Suggestive of a condition that could easily deteriorate

Symptoms of a condition that’s treatment is time sensitive

Potential for major life or organ threat

EXAMPLES OF “HIGH RISK” Episodes of chest pain, denies other

symptoms, known cardiac history R/O PE Newborn with a fever Rule out ectopic pregnancy Neutropenia with a fever Suicidal/homicidal

DECISION POINT BIS THE PATIENT CONFUSED, LETHARGIC OR DISORIENTED?

Is there an acute change in level of consciousness?

Is this situation where the brain is structurally or chemically compromised?

EXAMPLES New onset of confusion in an elderly

patient 30 y.o. with a known brain tumor whose

wife reports that he is confused Adolescent found confused and

disoriented

DECISION POINT BIS THE PATIENT IN SEVERE PAIN OR DISTRESS?

Is the patient currently in Pain?Pain intensity ratingChief complaintPMH, medicationsVS, physical assessment findings

Assign ESI level 2 if and only if:Self reported 7/10 or greaterAND

RN cannot intervene AND they require immediate intervention

Does this patient need your last bed?

ESI LEVEL 2 PAIN EXAMPLES ? Kidney stone

Severe flank pain, vomiting Burn victim

Burns to both arms Oncology patient Possible dislocated shoulder

Rates pain 10+, diaphoretic, tearful ? Compartment syndrome

IS THIS PATIENT IN DISTRESS?PHYSIOLOGICAL OR PSYCHOLOGICAL

Sexual assault victim Combative patient Homicidal/suicidal patient Bipolar patient who is manic Acute grief reaction Known alcohol use with head injury

DECISION POINT C

DECISION POINT CHOW MANY RESOURCES? Determined by the experienced ED RN

at triage Based on the standard of care Independent of type of hospital,

location, physician on duty, acuity of the department

WHAT IS A RESOURCE?Resources: Labs ECG X-ray CT, MRI IV fluids IV, IM meds & nebs Specialty Consult Simple procedure=1(lac repair, foley cath) Complex procedure=2(conscious sedation)

Not Resources: History and Physical Pelvic Point of care testing Saline or heplock PO medications Tetanus shot Prescription refills Phone call to PCP Simple wound care Crutches, gel splints, slings

ESI LEVEL 5 No Resources Examples

-Healthy 10y.o. with “poison ivy”-Healthy 52y.o. Who ran out of his

BP med recently-22y.o. involved in an MVC 2 days

ago, just wants to get checked-46y.o. with a cold

ESI LEVEL 4 Stable, can safely wait for hours to be

seen Care by mid-level providers in a fast

track or urgent care setting Requires a physical exam and one

resource

ESI LEVEL 4 Examples:

-Healthy 19y.o. with a sore throat and fever

-Healthy 29y.o. with a UTI, denies abdominal pain-Healthy 43y.o. with a stubbed toe-Healthy 12y.o. with a minor thumb laceration

ESI LEVEL 3 30-40% of patients seen in the ED Need 2 or more resources Require in-depth evaluation Long length of stay Before assigning a patient to ESI level 3

the nurse must consider the patients vital signs

DECISION POINT D

WHAT ARE THE PATIENTS VITAL SIGNS?

CONSIDER THE VITAL SIGNS:ARE THEY OUTSIDE OF THE ACCEPTABLE PARAMETERS FOR AGE?DO THEY FIT WITH ILLNESS, SUCH AS HR ELEVATED DUE TO FEVER?IF UNACCEPTABLE CONSIDER UP-TRIAGE TO ESI LEVEL 2

ESI LEVEL 3, 4 & 5 EXAMPLES ESI level 3

Fractured ankleAbdominal painMost migraines

ESI level 4Sprained ankleAbscess

ESI level 5Toothache

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