Emergency Severity Index, 4th ed: Introduction to the

five-level Triage ScaleChristine 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?

To determine if a patient is classified as ESI level 1, the patient requires an immediate lifesaving intervention such as resuscitation, immediate medication or another intervention such as a blood transfusion. The patient may need an intervention if there is any concern about the following:

QUICK CHECKLIST• already intubated• apneic• pulseless• severe

respiratory distress

• SpO2 < 90 percent

• acute mental status changes

• unresponsive• 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 SCALEAVPU (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.

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

Alert Verbal Pain UnresponsiveAlert, awake, responds to voice, oriented to surroundings

Responds to verbal stimuli by opening eyes, not fully oriented

Does not respond to voice but responds to painful or noxious stimuli

Nonverbal and does not respond when painful stimuli is applied

B) Is this a patient who shouldn't wait?

At decision point B, the nurse needs to decide whether this patient is a someone that should not wait to be seen. • If the patient should not wait, the patient is triaged as

ESI level 2.• If the patient can wait, then the user moves to the

next step in the algorithm.

QUICK CHECKLIST for level-2 criteria:1. Is this a high-

risk situation?2. Is the patient

confused, lethargic or disoriented?

3. Is the patient in severe pain or distress?

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 IndicationsHigh Risk Situation

Confused, lethargic,

disorientedPain or Distress

• 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

• Altered mental status – new upon injury

• Chronic dementia and chronic confusion does not meet criteria; only acute changes are considered

• Assess pain using pain scale - all patients who have a pain rating of 7/10 or greater should be considered for meeting ESI level-2 criteria (but not automatically triaged)

• Assess for severe distress, defined as either physiological or psychological

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• genderto 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

C) How many resources will this patient need?

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

ReferencesAacharya, R., Denier, Y., & Gastmans, C. (2011, Oct 7) Emergency Department Triage: An Analysis. BMC

Emergency Medicine, 11(16), 1-13.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/22858740Pitts, 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

NotesReflective 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.