Emergency Severity
th
Index, 4 ed:
Introduction to the
five-level Triage Scale
Christine Chao
Northeastern University
Table of Contents
• Triage Overview and Refocus
• Current Triage Statistics
• Emergency Severity Index (ESI)
• ESI Triage Algorithm
• A) Does this patient require immediate life-saving
intervention?
• APVU Scale
• B) Is this a patient who shouldn't wait?
• Level 2 Indications
• C) How many resources will this patient need?
• D) What are the patient's vital signs?
• ESI Reliability and Validity
• References
Triage: Overview and
Refocus
• Triage is used to systematically prioritize patients No standardization of triage
acuity rating systems
• Three-level triage systems resulted over triage or under-triage
• In 2002, Joint Triage Five Level Task Force released the following statement:
“Based on expert consensus of currently available evidence, ACEP and ENA
support the adoption of a reliable, valid five-level triage scale such as the
Emergency Severity Index (ESI).”
• ESI takes into account patient’s physical, developmental, psychosocial needs,
patient flow in the emergency care system, and health care access.
CURRENT Triage
Statistics
• In 2009, 57% of US hospitals have
adopted the five-level Emergency
Severity Index (ESI) system.
• After implementation of five-level
triage systems in Germany and
Switzerland, the proportion of patients
who leave the ED due to a long waiting
time is lowered by 50%.
• Of the 123.8 million visits to the U.S.
emergency departments in 2008, only
18% were seen in the first 15 minutes.
• Several studies have demonstrated poor inter- and intrarater reliability of conventional
three-level triage in the United States.
Emergency Severity
Index
Three-level triage resulted in
• tendencies toward early discharge of patients
• minimizing readmission rates
• reducing the use of an overburdened health care system is changing the face and
function of triage.
Emergency Severity Index (ESI) was developed to increase accuracy. According the
the ESI guidebook, “The ultimate goal of ESI implementation is to accurately
capture patient acuity to optimize the safety of patients in the waiting room by
ensuring that only patients stable to wait are selected to wait.”
ESI Triage Algorithm
This algorithm is designed to help triage
nurses differentiate the critically ill from
a large population of patients. ESI uses
several quality indicators to monitor a
patient’s health: life-saving
intervention, abnormal
disposition/behavior, resources, and
vital signs.
A) Does this patient require
immediate life-saving intervention?
QUICK CHECKLIST
• already intubated
• apneic
• pulseless
• severe respiratory
distress
• SpO2 < 90 percent
To determine if a patient is classified as ESI level 1, the patient • acute mental status
requires an immediate lifesaving intervention such as resuscitation,
changes
immediate medication or another intervention such as a blood • unresponsive
transfusion. The patient may need an intervention if there is any
concern about the following:
• ability to deliver adequate oxygen to the tissues
• breathing, maintaining a patent airway
• detectable pulse
• abnormalities in pulse rate, rhythm, and quality
• chest pain including patients who are pale, diaphoretic, in acute respiratory distress or present
unstable blood
AVPU SCALE
AVPU (alert, verbal, pain, unresponsive) scale: The goal is to identify the patient who has
a recent and/or sudden change in level of conscience or are non-verbal or require
noxious stimuli to obtain a response.
Alert
Alert, awake,
responds to voice,
oriented to
surroundings
Verbal
Pain
Responds to verbal
stimuli by opening
eyes, not fully
oriented
Does not respond
to voice but
responds to painful
or noxious stimuli
Unresponsive
Nonverbal and
does not respond
when painful
stimuli is applied
Patients scoring a P (pain) or U (unresponsive) on the AVPU scale meet level-1 criteria.
Unresponsiveness is assessed in the context of acute changes in neurological status, not for
the patient who has known developmental delays, documented dementia, or aphasia
B) Is this a patient
who shouldn't wait?
QUICK
CHECKLIST for
level-2 criteria:
1. Is this a high-risk
situation?
2. Is the patient
confused,
At decision point B, the nurse needs to decide whether this patient is
lethargic or
a someone that should not wait to be seen.
disoriented?
• If the patient should not wait, the patient is triaged as ESI level
3. Is the patient in
2.
severe pain or
• If the patient can wait, then the user moves to the next step in the
distress?
algorithm.
At triage nurse will look at the three criteria detailed on the next slide. Patients who meet
the ESI level 2 criteria should have their placement rapidly facilitated.
level 2 Indications
High Risk Situation
• Abnormal vital signs
• Abdominal pain/bleeding,
bloating
• Vomiting, bleeding, etc
• Chest pain (considered with
other health factors i.e. drug
use)
• Airway compromise or
inhalation injuries
• Third degree burns
• Electrolyte disturbances
• High or low glucose levels in
patients with diabetes
• Oncology patient
Confused,
lethargic,
disoriented
Pain or Distress
• Altered
• Assess pain using pain scale mental status
all patients who have a pain
– new upon
rating of 7/10 or greater should
injury
be considered for meeting ESI
• Chronic
level-2 criteria (but not
dementia and
automatically triaged)
chronic
• Assess for severe distress,
confusion
defined as either physiological
does not meet
or psychological
criteria; only
acute changes
are considered
C) How many resources
will this patient need?
A patient is considered for ESI level 3, 4 or 5 is a triage nurse
determines the patient is out of any immediate or oncoming
threat by implementing the following information:
• brief triage assessment
• past medical history
• medications
• age
• gender
to determine how many different resources will be needed for
the ED provider to reach a solution.
Resources
• Labs (blood, urine)
• ECG, MRI,
ultrasound
• IV fluids for hydration
• Specialty consultation
• Simple and complex
procedures
Not Resources
• Physical exam
• Saline
• Prescription refills
• Phone call to PCP
• Simple wound care
• Crutches, splints,
slings
D) What are the
patient's vital signs?
In ESI, vital signs, while important, may not always be
helpful in determining initial triage level.
• Only absolutely required for patients classified as
ESI level 3. If the danger zone vitals are reached, a
triage nurse can consider up-triaging to the patient
from a level 3 to a level 2.
• In the cases of urgency such as ESI level 1 and 2,
vital signs may not be needed unless there is
enough time.
• Vital signs are ideally only taken if needed to
estimate urgency or if time permits
ESI Reliability and
Validity
• The Emergency Severity Index has shown high reliability and validity through the
following studies:
•
Reliability and validity of a five-level triage instrument
•
Five level triage: A report from the ACEP/ENA Five Level Triage Task Force
•
Accuracy of the Emergency Severity Triage instrument for identifying elder emergency
department patients receiving an immediate life-saving intervention.
•
Five-level triage system more effective than three-level in tertiary emergency department.
•
Validation of the Emergency Severity Index (ESI) in self-referred patients
If implemented widely in the US, ESI can has the ability to become the standard triage
acuity assessment in EDs.
For further information, please refer to the Emergency Severity Index (ESI)
Implementation Handbook, 2012 Edition online at
http://www.ahrq.gov/professionals/systems/hospital/esi/esi1.html
References
Aacharya, R., Denier, Y., & Gastmans, C. (2011, Oct 7) Emergency Department Triage: An Analysis. BMC
Medicine,
11(16), 1-13.
Emergency
Christ, M., Grossman, F., Winter, D., Bingisser, R., & Platz, E. (2010, December 17). Modern Triage in the
Emergency
Department. Dutsch Arztebl Intl, 107: 892-898. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021905/.
Emergency Nurses Association and American College of Emergency Physicians. STANDARDIZED ED TRIAGE SCALE AND
ACUITY CATEGORIZATION: JOINT ENA/ACEP STATEMENT. Emergency Nurse Association. Emergency
Nurse
Association, 2002. Web.
ESI Triage Algorithm, v. 4. Digital image. Welcome to the Emergency Severity Index (ESI). Emergency Nurse Association, 2004. Web.
<http://
www.esitriage.org/algorithm.asp?LastClicked=algorithm>.
Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. (2012, January 1). Emergency Severity Index (ESI): A Triage Tool for Emergency
Department. Agency for Healthcare Research and Quality, 4. Retrieved from http://www.ahrq.gov/professionals/
systems/hospital/esi/esi1.html.
Green, N., Durani, Y., Breecher, D., DePiero, A. (2012 Aug 28). Emergency Severity Index version 4: a valid and reliable pediatric
emergency department triage. Pediactric Emergency Care, 28(8): 753-757. Retrieved from
http://www.ncbi.nlm.nih.gov/
pubmed/22858740
Pitts, S., Pines, J., Handrigan, M., & Kellermann, A. (2012 Dec). National Trends in Emergency Department Occupancy, 2001 to 2008:
Effect of Inpatient Admissions Versus Emergency Department Practice Intensity. Annals of Emergency Medicine, 60(6):
679-686. Retrieved from http://www.annemergmed.com/article/S0196-0644%2812%2900507-0/abstract.
Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. (2002 Mar 7) Reliability and validity of a new five-level triage instrument.
Acad Emerg Med, 7:236;–42. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10730830
Notes
Reflective Note: This presentation is intended for emergency medical professionals
who are operating emergency departments with a two-, three- or four- level triage
assessment. The Emergency Severity Index has proven to be more accurate and
efficient in providing better patient care than other systems. The intention is to bring
to attention the benefits of a more comprehensive system of classification. The
language is geared towards a population with a strong medical background, reducing
explanation of several medical terms. This PowerPoint is has a very simple design.
Because the topic is more serious, I did not include any extra photos or comics as I
intend to for project 4. Important points and key words for different slides are bolded
or highlighted to make this an easy reference guide. I also included easy to read lists
to show the breakdown of ESI. This also allows for easy comparison to other triage
systems.
Personal Note: I think this would make a great addition for my portfolio. I had a
good time learning about triage and emergency departments as well as putting myself
in the shoes of a medical professional. Project 3 demonstrates my ability to present
information in a professional way.