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<td height="30px"><span class="title"><a name="h1" id="h1"></a>Emergency Severity Index, Version 4: Implementation Handbook</span>
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<h2>Chapter 4. ESI Level 2</h2>
<p>This chapter expands on the introduction to the ESI
offered in <a href="esi3.htm">Chapter 3</a> and discusses in further detail
the decisionmaking process necessary to determine
which patients meet ESI level-2 criteria. Though the
ESI level-2 rating may be seen as subjective, it is
based on the experienced ED nurse's sound clinical
judgment. During the ESI triage educational
program, a considerable amount of time should be
devoted to explaining which types of patients
should be categorized ESI level 2. In this chapter, we
highlight common patient presentations that meet
ESI level-2 criteria.</p>
<p>After the triage nurse has determined that the
patient does not require immediate life-saving
intervention, he or she must then decide whether
the patient should wait. When making this decision,
the triage nurse should consider the following
question "Would I use my last open bed for this
patient?"</p> <p>The following three questions listed in
<a href="#Fig4-1">Figure 4-1</a> should be answered and are key
components of ESI level-2 criteria:</p>
<ol>
<li>Is this a high-risk situation?</li>
<li>Is the patient experiencing new onset confusion, lethargy, or disorientation?</li>
<li>Is the patient experiencing severe pain or distress?</li>
</ol>
<table border="0" cellpadding="8" cellspacing="1" width="40%" align="right"><tr>
<td><a id="Fig4-1" name="Fig4-1"></a>
<h4>Figure 4-1. Patient Assessment</h4>
<img src="esifig4-1.gif" width="355" height="151" alt="Detail from ESI Triage Algorithm. 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 a second arrow pointing downward." /> </td></tr>
</table>
<p>The remainder of this chapter discusses the decision
points of ESI level 2 in detail. Many examples are
provided that are based on the potential medical
diagnoses associated with patients' chief complaints
and presenting symptoms. An experienced triage
nurse will always assess the patient's chief
complaint, presenting signs and symptoms,
demographics, and medical history to attempt to
identify a high-risk situation. </p>
<a id="Tab4-1" name="Tab4-1"></a>
<p>While the purpose of
nurse triage is not to make a medical diagnosis,
these situations are based on the experienced triage
nurse's knowledge of possible medical diagnoses that
are associated with specific chief complaints. A good
source of information about the signs and
symptoms of various medical diagnoses is the
<em>Emergency Nursing Core Curriculum&copy;</em> or other
emergency nursing textbooks (<a href="#ENA01">Emergency Nurses Association [ENA], 2001</a>). The following
discussion provides some selected examples of high-risk
situations. This discussion is not intended to be
an exhaustive list. The examples are summarized in <a href="esitab4-1.htm">Table 4-1</a>.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>High-risk Situations</h3>
<p>The ability to recognize a high-risk situation is a
critical element of the triage decisionmaking
process, regardless of the particular triage system
used. ESI highlights the importance of recognizing
high-risk situations and uses the triage nurse's
expertise and experience to identify patients at high
risk.</p>
<p>Little has been written about how ED triage nurses
make decisions. Knowledge and experience are
necessary but not sufficient. The other factor that we
have found to be important is gut instinct or the
sixth sense. Novice triage nurses should be taught
rules of thumb which they can use until they have
the confidence and experience upon which to make
rapid, accurate decisions. Examples of these rules of
thumb include "all women of childbearing age are
pregnant until proven otherwise" or "all chest pain
is cardiac until proven otherwise."</p> <p>Novice triage
nurses are also taught symptom clustering such as
the cardiac cluster of chest pain with nausea,
shortness of breath, and diaphoresis. From prior
clinical situations ED nurses put together what have
been referred to as clinical portraits. The nurse puts
into long-term memory particular patient scenarios
in which they were involved in some way. For
example, the patient with fever, stiff neck, and a
meningococcal rash will always come to mind when
a patient with a similar complaint presents to triage.</p>
<p>The triage nurse needs to draw on all of his or her
knowledge and experience with each triage
encounter. High-risk situations should be easy for
the experienced triage nurse to identify.</p>
<p>Vital signs are often not helpful in the identification
of high-risk patients. The patient typically presents to the ED with a chief complaint, signs and
symptoms, or history suggestive of a problem or
condition that is serious and, unless dealt with
promptly, can deteriorate rapidly. Often patient age,
past medical history, and current medications
influence the perceived severity of the chief
complaint. For example, a frail elderly patient with
severe abdominal pain is at a much higher risk of
morbidity and mortality than a 20-year-old. The
elderly patient with abdominal pain should be
classified as ESI level 2, while the 20-year-old with
stable vital signs will usually be classified as ESI level
3.</p> <p>It is common for the triage nurse to identify a
high-risk situation which may then be confirmed by
finding abnormal vital signs. For example, a patient
who complains of a fever and productive cough may
be found to have a respiratory rate of 32 and an
oxygen saturation of 90 percent. The experienced
triage nurse uses knowledge and expertise to
recognize that this patient probably has pneumonia,
is at risk for desaturating and is therefore high risk.</p>
<p>Inexperienced ED nurses are not likely to have the knowledge and expertise to consistently identify
high-risk situations and make accurate triage
decisions. For this reason, the inexperienced triage
nurse is, in fact, a liability at triage, regardless of the
particular triage system used. They have not
incorporated symptom clustering, clinical portraits,
or "gut instinct" into their practice; such approaches
are key in identifying the high-risk patient situation.</p>
<p>The next section will provide specific examples of
high-risk situations.</p>
<h4>Abdominal and Gastrointestinal</h4>
<p>Abdominal pain is a frequent chief complaint in the
ED. What makes it high risk? A good history and
assessment of current pain rating, respiratory rate,
and heart rate are important elements to consider
and will help determine the presence of a high-risk
situation.</p> <p>Pain rating is only one of many factors to
consider. Tachycardia or respiratory distress that
accompanies severe abdominal pain can represent
shock and would place the patient at high risk. The
elderly patient with severe abdominal pain presents
another potentially risky situation. Often the elderly
experience bowel obstructions, gastrointestinal
bleeds, and other abdominal complications
associated with significantly higher morbidity and
mortality than younger patients.</p> <p>Signs and
symptoms of an acute abdomen are important to
assess for in all patients with abdominal pain: </p>
<ul>
<li>How long has the patient had the pain? </li>
<li>What made the patient come to the ED today? </li>
<li>Has the patient had severe nausea, vomiting, or diarrhea? </li>
<li>Is the patient dehydrated? </li>
</ul>
<p>Patients with severe "ripping"
abdominal pain radiating to the back should be
considered to potentially have an abdominal aortic
aneurysm. Patients describe the pain as severe,
constant, and sudden in onset and may have a
history of hypertension.</p>
<p>Patients with abdominal pain are often initially
considered ESI level 3 at the beginning of the triage
interview, and after the discovery of tachycardia or
other risk factors, the triage nurse may determine
that the patient is indeed high risk.</p>
<p>Vomiting blood or a chief complaint of blood per
rectum should be seriously considered and evaluated
in the context of vital signs. A 30-year-old with
bright red blood per rectum, normal vital signs, and
no other risk factors does not meet criteria for ESI
level 2. But the elderly patient who called an
ambulance because he started vomiting blood and
has a heart rate of 117 and a respiratory rate of 24 is
high risk and does meet ESI level-2 criteria.</p>
<h4>Cardiovascular</h4>
<p>Chest pain is also a very common chief complaint.
The presentation of acute coronary syndromes (ACS)
is not always specific, and it is sometimes difficult to
determine the risk of ACS at triage. Patients who
have an episode of chest or epigastric discomfort,
with or without accompanying symptoms, usually
will need an ECG performed rapidly to determine
the presence of ACS and need to be identified as
high risk-ESI level 2. It is important for the triage
nurse to incorporate into his or her knowledge of
women and presentational symptoms characteristic
of heart disease. The 54-year-old obese female who
presents to the ED with epigastric pain and fatigue is
at risk of ACS and should be assigned to ESI level 2-high risk.</p> <p>Patients with chest pain that are
physiologically unstable and require immediate
intervention such as intubation or hemodynamic
support should be triaged as ESI level 1. All chest
pain patients do not meet level-1 or 2 criteria. For
example, a 20-year-old healthy patient with chest
pain, cough, and fever of 101&deg; is at low risk for ACS
and does not meet ESI level-1 or 2 criteria. Each
patient must be assessed individually. Other high-risk
cardiovascular situations would include the
possibility of a hypertensive crisis, acute vascular
arterial occlusions, and patients who present with a
fever post valve replacement.</p>
<h4>Dental, Ear, Nose, and Throat</h4>
<p>Although less common, epiglottitis still exists and
represents a potential airway threat. Patients with a
peritonsilar abscess are another example of potential
airway compromise and both conditions represent a
high-risk situation. If a patient with either of these
complaints is in immediate danger of airway
compromise and requires immediate intervention,
level-1 criteria are met. </p><p>For patients with epistaxis,
the triage nurse should obtain a blood pressure,
although this is not in the ESI algorithm. Epistaxis
could be caused by a posterior nosebleed due to a
hypertensive crisis, nose picking by the patient on
Coumadin&reg;, or recent cocaine use. In any case, such
patients should be classified as ESI level 2, as they
represent a high-risk situation. </p>
<h4>Environmental</h4>
<p>Patients with inhalation injuries should be
considered high risk for potential airway
compromise. If the patient presents with significant
airway distress and requires immediate intervention,
they meet level-1 criteria.</p>
<h4>Facial</h4>
<p>Patients with trauma to the face should be evaluated
for possible facial fractures. When present, facial
fractures are often associated with other severe
trauma and may potentially lead to airway
compromise and should therefore be triaged as high
risk. Facial trauma with actual airway compromise
should be triaged as ESI level 1 to facilitate airway
management High-risk of airway compromise
should be triaged as ESI level 2.</p>
<h4>General Medical</h4>
<p>There are several other general medical complaints
that need to be considered for possible high-risk
situations. These medical complications include:</p>
<ul>
<li>Diabetic ketoacidosis.</li>
<li>Hyper- or hypoglycemia.</li>
<li>Sepsis.</li>
<li>Complaints of syncope or near syncope.</li>
<li>A variety of other electrolyte disturbances that may</li>
<li>need to be treated immediately.</li>
</ul>
<p> Hyperkalemia in
particular is a very high-risk situation that can lead
to serious cardiac dysrhythmias. Hyperkalemia
might be suspected in a renal dialysis patient
exhibiting weakness. Finally, oncology patients with
a fever who are undergoing chemotherapy are at risk
for sepsis and should be identified as high risk and
rapidly evaluated.</p>
<h4>Genitourinary</h4>
<p>Males with testicular torsion will complain of severe
pain, are easily recognized, and require rapid
evaluation and surgical intervention, in addition to
rapid pain control. Renal dialysis patients unable to
complete dialysis are another example of a high-risk
genitourinary emergency, since a variety of
electrolyte disturbances may be present. Females,
and more commonly males, can present to the
triage nurse with acute urinary retention. Males over
age 65 often present with benign prostatic
hypertrophy and the inability to urinate. Males and
females can present postoperatively with the
inability to void. These patients are in acute distress
and require emergency urinary catheterization.
These are examples of patients in severe distress who
should be categorized as ESI level 2.</p>
<h4>Mental Health</h4>
<p>Many patients that present with mental health
problems are at high risk if they are a danger either
to themselves, others, or the environment. Patients
who are suicidal, homicidal, psychotic, violent, or
present an elopement risk should be considered high
risk.</p><p> Intoxication without signs of trauma or
associated risk of aspiration does not represent a
high-risk criterion. The intoxicated patient needs to
be carefully assessed for signs of trauma or
behavioral issues related to alcohol use or past
medical history. Either could represent a high-risk
situation and the patient would be categorized ESI
level 2.</p>
<h4>Neurological</h4>
<p>Patients with severe headache associated with
mental status changes, high blood pressure, lethargy,
fevers, or a rash should be considered high risk. Any
patient with sudden onset of speech deficits or
motor weakness should also be assigned ESI level 2.
Patients with these symptoms may be experiencing
an acute stroke and immediate evaluation is critical.</p>
<p>Time from onset of symptoms is a critical factor in
determining treatment options, in particular
fibrinolytic or other therapies. A patient with no
past medical history of headaches that presents to
the emergency department with the sudden onset of
a headache should be identified as high risk for a
subarrachnoid bleed. The patient will often describe
exactly what they were doing when the headache
began, typically after lifting, having a bowel
movement, or after sexual intercourse.</p>
<h4>Obstetrical and Gynecological</h4>
<p>Females with abdominal pain or vaginal bleeding
should be carefully assessed and vital signs obtained
if there is no obvious life threat. Pregnancy history
and last menstrual period should always be
ascertained from all females of childbearing age.</p><p> The
triage nurse should assess for signs and symptoms of
the following conditions in late pregnancy: abruptio
placentae and placenta previa. In early pregnancy
the triage nurse should assess for signs and
symptoms of ectopic pregnancy and spontaneous
abortion. All pregnant patients 14 to 20 weeks and
over should be seen by a physician rapidly,
according to individual institutional policy.</p> <p>A
postpartum patient with a chief complaint of heavy
vaginal bleeding should also be seen by a physician
urgently. Any female patient, whether pregnant or postpartum, who presents with significant
hemodynamic instability and is in need of
immediate life-saving interventions should be
triaged as ESI level 1.</p>
<h4>Ocular</h4>
<p>Patients with trauma to the eye, sudden partial or
full loss of vision, or a chemical splash to the eye are
at high risk for permanent damage to the eye and
should be triaged at ESI level 2. Conditions
associated with some type of visual loss include:</p>
<ul>
<li>Central retinal artery occlusion.</li>
<li>Acute narrow-angle glaucoma.</li>
<li>Retinal detachment. </li>
</ul>
<p>Trauma to the
eye can result in a globe rupture and hyphema.
Chemical splashes to the eye, particularly alkali,
necessitate immediate flushing to prevent further
damage to the cornea. All of these conditions
require immediate evaluation and treatment to
prevent further complications or deterioration.
These patients meet ESI level-2 criteria. While
immediate irrigation is necessary, it is not
considered life-saving and thus these patients do not
meet ESI level-1 criteria.</p>
<h4>Orthopedic</h4>
<p>Patients with signs and symptoms of compartment
syndrome are at high risk for extremity loss and
should be assigned ESI level 2. Other patients with
high-risk orthopedic injuries include any extremity
injury with compromised neurovascular function,
partial or complete amputations, or trauma
mechanisms identified as having a high-risk such as
serious acceleration or deceleration.</p> <p>Patients with
possible fractures of the pelvis, femur, or hip and
other extremity dislocations should be carefully
evaluated and vital signs considered. These fractures
can be associated with significant blood loss. Again,
the need for immediate life-saving intervention in
hemodynamically unstable patients will meet ESI
level-1 criteria.</p>
<h4>Pediatrics</h4>
<p>It is not uncommon for the triage nurse to be
uncomfortable when making triage acuity decisions
about children, especially infants. It is important to
obtain an accurate history from the caregiver and
evaluate the activity level of the child. The child
who is inconsolable or withdrawn may be at high
risk of serious illness.</p><p> The following conditions are
examples of high-risk situations for children:</p>
<ul>
<li>Seizures.</li>
<li>Sepsis, severe dehydration.</li>
<li>Diabetic ketoacidosis.</li>
<li>Child abuse, burns.</li>
<li>Head trauma.</li>
<li>Vitamins/iron or other overdoses/ingestions.</li>
<li>Infant less than 28 days of age with a fever of 100.4&deg; F or 38&deg; C, or greater.</li>
</ul>
<h4>Transplant</h4>
<p>Patients who are status post-organ transplant are
usually ill and considered high risk. They can
present with organ rejection, sepsis, or other
complications. Patients who are on a transplant list
are also usually considered high risk.</p>
<h4>Respiratory</h4>
<p>There are many respiratory complaints that place
patients at high risk. Patients with mild-to-moderate
distress should be further evaluated for respiratory
rate and pulse oximetry to determine whether they
should be categorized ESI level 2. Patients in severe
respiratory distress that require immediate lifesaving
intervention such as intubation meet level-1
criteria.</p> <p>The high-risk patient is one who is currently
ventilating and oxygenating adequately but is in
respiratory distress and has the potential to rapidly
deteriorate. Potential etiologies of respiratory distress
may include asthma, pulmonary embolus, pleural
effusion, pneumothorax, foreign body aspiration,
toxic smoke inhalation, or shortness of breath
associated with chest pain.</p>
<h4>Toxicological</h4>
<p>Most patients who present with an overdose should
be rapidly evaluated and represent a high-risk
situation. It is often difficult to determine which
drugs were taken and the quantities actually
consumed. If the patient has taken an intentional
overdose, and admits to suicidal ideation, this meets
criteria for a high-risk situation. A patient who is
apneic on arrival or requires other immediate lifesaving
interventions should be categorized an ESI
level 1; all other admitted overdoses should be
considered ESI level 2.</p>
<h4>Trauma</h4>
<p>Frequently, patients who have been involved in a
traumatic event are at high risk for injury, although
no obvious injuries may be apparent. Any
mechanism of injury associated with a high risk of
injury should be categorized ESI level 2, unless they present with unstable vital signs and require
immediate intervention. These patients should be
triaged as ESI level 1. Serious injury results from the
transfer of mechanical or kinetic energy and is
caused by acceleration forces, deceleration forces, or
both. Motor vehicle and motorcycle crashes, victims
of falls, and gunshot and stab wounds are examples
of blunt and penetrating trauma, which should be
assessed carefully for potential for serious injury.</p><p> The
triage nurse should obtain the following details
regarding the injury:</p>
<ul>
<li>Age of the patient.</li>
<li>Pre-existing conditions of the patient and environment.</li>
<li>Distance the patient fell or jumped.</li>
<li>How fast the vehicle was moving.</li>
<li>History of loss of consciousness.</li>
<li>Location of penetrating injury.</li>
<li>Type of weapon. </li>
</ul>
<p>Again, the
nurse will draw from his or her knowledge of
biomechanics and mechanism of injury to assess the
patient and decide whether they meet ESI level-2
criteria. Gunshot wounds to the head, neck, chest,
or groin usually require trauma team evaluation and
immediate interventions and should be triaged as
ESI level 1.</p>
<h4>Wound Management</h4>
<p>What makes a wound high risk? Is there
uncontrolled bleeding? Is there arterial bleeding? Is
this a partial amputation? How was the wound
sustained and does the mechanism of injury leave
the patient at high risk for other traumatic
complications? Most wounds do not meet the
criteria for ESI level 2. A patient with a stab wound
to the subcutaneous tissue of the thigh with
controlled bleeding and good distal neurological
function can be classified as ESI level 4. Any
uncontrolled bleeding that requires immediate lifesaving
intervention to stabilize the patient meets
level-1 criteria.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>Confusion/Lethargy/Disorientation</h3>
<p>The second question to consider when determining
whether a patient meets level-2 criteria is "Does the
patient have new onset confusion, lethargy, or
disorientation?" Altered mental status is another
frequent chief complaint. Family members, friends,
or paramedics may accompany these patients to the
ED. At decision point B of the ESI algorithm, the
presence of confusion, lethargy, or disorientation
refers to new onset or an acute alteration in level of
consciousness (LOC). Chronic dementia and
confusion do not meet criteria for ESI level 2.</p>
<p>Confusion, lethargy, or disorientation may be caused
by a variety of serious medical conditions including
stroke, transient ischemic attack, and other
structural pathology to the brain, metabolic, and
electrolyte imbalances such as hypoglycemia or
hyponatremia and toxicological conditions.</p>
<p>This portion of the algorithm is usually very clear
and leaves very little open to interpretation. If the
patient's history is unknown and the patient
presents to triage confused, lethargic or disoriented,
the triage nurse should assume this condition is new
and select ESI level 2 as the triage category. Again, if
the patient has new onset confusion, lethargy or
disorientation and requires an immediate life-saving
intervention as previously described, the patient
then meets ESI level-1 criteria.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>Severe Pain/Distress</h3>
<p>The final question to address when determining
whether the patient meets level-2 criteria is "Does
the patient have severe pain or distress?" The patient
should be assessed for the presence of severe pain or
distress. All patients who have a pain rating of 7/10
or greater should be <em>considered</em> for meeting ESI level-2 criteria.</p>
<p><em>Considered</em> is a very important word. It is up to the
discretion of the triage nurse to determine whether
the clinical condition and pain rating in
combination warrant a rating of ESI level 2. For
example, a patient who had a heavy metal object
fall on his toe may rate the pain a 10/10. Indeed, the
patient may have a fracture and is experiencing
severe pain. The patient probably has done nothing
to try to relieve the pain prior to arrival in the ED.
The correct triage level for this patient would be ESI
level 4. Only one resource will be needed (an x-ray).
The triage nurse should implement comfort
measures at triage including ice, elevation, and
analgesics (if standing orders are in place) to reduce
the pain. The triage nurse should believe the
patient's pain is 10/10 and address the pain at triage.
However, this patient can wait to be seen and you
would certainly not use your last open bed for this
patient. </p><p>In summary, the triage nurse assesses not
only the pain intensity rating provided by the
patient, but also the chief complaint, past medical
history and physiologic appearance of the patient
when determining a triage category.</p> <p>Examples of
patients for whom the triage nurse could use severe
pain criteria to justify an ESI level-2 rating include:</p>
<ul>
<li>A patient with 10/10 flank pain who is writhing at triage. </li>
<li>An 80-year-old female with 7/10 generalized abdominal pain with severe nausea.</li>
<li>A 30-year-old patient in acute sickle cell pain crisis.</li>
<li>An oncology patient with severe pain.</li>
<li>Any full- or partial-thickness burn that will require immediate pain control.</li>
</ul>
<p>All ED patients are to be assessed for pain and asked
to rate their pain using a scale such as the visual
analog scale. Many triage nurses are uncomfortable
with documenting a patients pain rating and then
having them wait to be seen. It is important for the
triage nurse to understand that the patients self
reported pain rating is only one piece of the pain
assessment. For example, all ED triage nurses have
triaged patients who are laughing, talking on their
cell phone or eating chips but report their pain is
10+. Triage nurses should assign ESI level 2 if the
patient reports a pain rating of 7/10 or greater and
the triage nurse's subjective and objective assessment
confirms that the patient's pain requires
interventions that are beyond the scope of triage.
The triage nurse concludes that it would be
inappropriate for this patient to wait and they
would assign this patient to the last open bed.</p>
<p>Finally, in determining whether a patient meets ESI
level-2 criteria, the triage nurse must assess for severe
distress, which is defined as either physiological or
psychological. In addition to pain, patients
experiencing severe respiratory distress meet criteria
for ESI level 2 for physiological disturbances.</p>
<p>Examples of severe psychological distress include
patients who are:</p>
<ul>
<li>Distraught after experiencing a sexual assault.</li>
<li>Exhibiting behavioral outbursts at triage.</li>
<li>Combative.</li>
<li>Victims of domestic violence.</li>
<li>Experiencing an acute grief reaction.</li>
</ul>
<p>These are patients that the triage nurse usually
prefers to have placed in the treatment area
immediately so as to have the patient avoid the
waiting room.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>Summary</h3>
<p>We have reviewed the key components and
questions that need to be answered to determine
whether a patient meets ESI level-2 criteria. It is
critical that the triage nurse consider these questions
as he or she triages each patient. "Missing" a high-risk
situation may result in an extended waiting
period and potentially negative patient outcomes.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>Reference</h3>
<a id="ENA01" name="ENA01"></a>
<p>Emergency Nurses Association (2001). <em>Making the right
decision: A triage curriculum</em> (2nd ed.). Des Plaines, IL:
Author.</p><hr />
<a id="Appa" name="Appa"></a>
<p class="size2"><strong>Note:</strong> <a href="esiappa.htm#Ch4">Appendix A</a> of this handbook includes frequently
asked questions and post-test assessment questions for
Chapters 3 through 8. These sections can be incorporated
into the ESI training course.</p><hr />
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a><br />
<a href="esi5.htm">Proceed to Next Section</a></p>
<p>&nbsp;</p>
<div class="footnote">
<p> The information on this page is archived and provided for reference purposes only.</p></div>
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