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Emergency Severity Index, Version 4: Implementation Handbook

Figure 3-1a. ESI Triage Algorithm

Flow chart demonstrating the algorithm. Box A is labeled 'requires immediate life-saving intervention?' with an arrow labeled 'Yes' pointing to a 1 in a circle and an arrow labeled 'No' pointing to Box B. Box B is labeled 'high risk situation? or confused/lethargic/disoriented? or severe pain/distress?' with an arrow labeled 'Yes' pointing to a 2 in a circle and an arrow labeled 'No' pointing to Box C. Box C is labeled 'how many different resources are needed?' with an arrow labeled 'none' pointing to a 5 in a circle, an arrow labeled 'one' pointing to a 4 in a circle, and an arrow labeled 'many' pointing to Box D. Box D is labeled 'danger zone vitals?' with the following vital sign formulae: HR/RR/SaO2<92%: <3 m/>180/>50; 3 m-3y/>160/>40; 3-8 y/>140/>30; >8y/>100/>20'. An arrow labeled 'Consider' points from Box D to a 2 in a circle and an arrow labeled 'No' points to a 3 in a circle. A. Immediate life-saving intervention required: airway, emergency medications, or other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO NOT count); and/or any of the following clinical conditions: intubated, apneic, pulseless, severe respiratory distress, SPO2<90, acute mental status changes, or unresponsive.

Unresponsiveness is defined as a patient that is either:
  1. Nonverbal and not following commands (acutely).
  2. Requires noxious stimulus (P or U on AVPU) scale.

B. High risk situation is a patient you would put in your last open bed.

Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale.

C. Resources: Count the number of different types of resources, not the individual tests or x-rays (examples: CBC, electrolytes and coags equals one resource; CBC plus chest x-ray equals two resources).

Resources Not Resources
  • Labs (blood, urine).
  • ECG, X-rays.
  • CT-MRI-ultrasound- angiography.
  • History & physical (including pelvic).
  • Point-of-care testing.
  • IV fluids (hydration).
  • Saline or heplock.
  • IV or IM or nebulized medications.
  • PO medications.
  • Tetanus immunization.
  • Prescription refills.
  • Specialty consultation.
  • Phone call to PCP.
  • IV or IM or nebulized medications.
  • Simple wound care (dressings, recheck).
  • Crutches, splints, slings.

D. Danger Zone Vital Signs. Consider uptriage to ESI 2 if any vital sign criterion is exceeded.

Pediatric Fever Considerations:
  1. 1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)
  2. 1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F)
  3. 3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), or incomplete immunizations, or no obvious source of fever.

©ESI Triage Research Team, 2004 (Refer to teaching materials for further clarification)

©ESI Triage Research Team, 2004. Reproduced with permission.

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