publicdata/ahrq-gov
1
0
Fork 0
Code Issues Pull requests Projects Releases Packages Wiki Activity Actions
ahrq-gov/archive.ahrq.gov/research/esi/esi5.htm
Scott Williams 58222b51ed Initial commit
2025-02-28 14:14:25 -05:00

439 lines
24 KiB
HTML
Raw Blame History

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN"
"http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<title>Emergency Severity Index Implementation Handbook: Chapter 5 </title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<!-- "metadata" -->
<meta name="Title" content="Emergency Severity Index" />
<meta name="description" content="This document describes the Emergency Severity Index (ESI) triage algorithm, Implementation Handbook, and DVDs." />
<meta name="keywords" content="Agency for Health Care Policy and Research, Agency for Healthcare Research and Quality, AHRQ, AHCPR, bioterrorism, community resources, disaster preparedness, emergency, hospital, mass casualty event, public health, surge capacity, urgent care" />
<meta name="datecreated" content="May 2005" />
<meta name="datereviewed" content="November 2007" />
<meta name="language" content="English" />
<!-- end metadata -->
<script type="text/javascript" src="/foresee/foresee-trigger.js"></script>
<script type="text/javascript">FSR.CPPS.set('prep','prep')</script>
<link href="/includes/ahrqstyle_new.css" rel="stylesheet" type="text/css" />
<link href="/includes/ahrqstyleprint_new.css" rel="stylesheet" type="text/css" media="print" />
<meta name="WT.cg_n" content="Preparedness" />
<meta name="gsa_filter" content="Preparedness" />
<script>
(function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){
(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),
m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)
})(window,document,'script','//www.google-analytics.com/analytics.js','ga');
ga('create', 'UA-75759936-1', 'auto');
ga(' set', 'anonymizeIp', true);
ga('send', 'pageview');
</script></head>
<noscript>
Your browser doesn't support JavaScript. Please upgrade to a modern browser or enable JavaScript in your existing browser.
</noscript><body topmargin="0" leftmargin="0">
<!-- Page Header v2.0 -->
<a name="top" id="top"></a>
<!--Begin Banner CodeS-->
<div id="ahrqbanner">
<div class="hhsportion">
<a href="#h1" class="skipnav">Skip Navigation</a>
<a href="http://www.hhs.gov/" title="U.S. Department of Health and Human Services">
<img src="/images/hhs_banner.gif" alt="U.S. Department of Health and Human Services" />
</a>
<a href="http://www.hhs.gov/" title="www.hhs.gov/" class="hhsright">
<img src="/images/hhs_link.gif" alt="www.hhs.gov/" />
</a>
</div>
<div class="ahrqportion">
<a href="https://www.ahrq.gov/" title="Agency for Healthcare Research Quality">
<img src="/images/ahrq_banner.gif" alt="Agency for Healthcare Research Quality" />
</a>
<form name="searchForm" method="get" action="https://search.ahrq.gov/search" id="banner_searchform">
<label for="search" style="z-index:-1;position:relative;margin-right:-65px; font-size:0px;">Search</label>
<input name="q" type="text" value=" Search AHRQ" size="11" onfocus="this.value='';" class="gotext" id="search" />
<input type="hidden" name="entqr" value="0" />
<input type="hidden" name="output" value="xml_no_dtd" />
<input type="hidden" name="proxystylesheet" value="AHRQ_GOV" />
<input type="hidden" name="client" value="AHRQ_GOV" />
<input type="hidden" name="site" value="default_collection" />
<input src="/images/topbn_gobutton.gif" class="gobtn" name="Submit" onclick="javascript:document.searchForm.submit();" type="image" alt="Go" /> </form>
<a href="/" class="ahrqright">www.ahrq.gov</a>
</div>
<div class="ahrqlinks"><a href="/">AHRQ Home</a> | <a href="https://info.ahrq.gov">Questions?</a> | <a href="/info/customer.htm">Contact Us</a> | <a href="/sitemap.htm">Site Map</a> | <a href="/whatsnew.htm">What's New</a> | <a href="/browse/">Browse</a> | <a href="/consumer/espanoix.htm">Informaci<EFBFBD>n en espa<70>ol</a> | <img src="/images/envelope1.jpg" alt="" /><a href="https://subscriptions.ahrq.gov/service/multi_subscribe.html?code=USAHRQ">E-mail Updates</a></div>
</div>
<div id="PrintBanner">
<img src="/images/PrintBanner.gif" alt="www.ahrq.gov/" width="100%" />
</div>
<a name="h1"></a>
<!-- End banner code -->
<!-- End of Page header -->
<!-- Content Body -->
<div id="mainContent">
<table summary="layout" width="100%" border="0" cellspacing="0" cellpadding="0" >
<tr valign="top">
<td width="70%">
<!-- Center Content section -->
<table width="100%" border="0" cellpadding="0" cellspacing="0" style="margin-left:10px; margin-right:10px;margin-top:5px" summary="This table gives the layout format of the bread crumb area and the center content area.">
<!--DWLayoutTable-->
<tr>
<td class="crumb_link"><div id="crumbContent">
<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Home</a> &gt; <a href="/qual/" class="crumb_link">Quality Assessment</a> &gt; <a href="/qual/measurix.htm" class="crumb_link">Measuring Healthcare Quality</a> &gt; <a href="." class="crumb_link">Emergency Severity Index, Version 4</a> &gt; Chapter 5</span></p>
</div>
</td>
</tr>
<tr>
<td height="30px"><span class="title"><a name="h1" id="h1"></a>Emergency Severity Index, Version 4: Implementation Handbook</span>
</td>
</tr>
<tr>
<td><div id="centerContent">
<h2>Chapter 5. Expected Resource Needs</h2>
<p>Traditionally, triage systems have been based solely
upon the acuity of the patient. Such systems require
the nurse to assign an acuity level by making a
judgment about how long the patient can wait to be
seen by a provider. The Emergency Severity Index
(ESI) triage system uses a novel approach to triage
level assignment by including not only judgments
about who should be seen first, but also for the less
acute patients, adding predictions of the resources
that are likely to be used to make a disposition for
the patient. </p><p>This chapter includes background
information on why resource predictions were
included in the ESI and a description of what
constitutes a resource. Also included are examples of
patients rated ESI level 3 to 5 and the resources that
each patient is predicted to need.</p>
<p>Historically, comprehensive triage has been the
dominant model for triage acuity assignment in U.S.
emergency departments (<a href="#ENA97">Emergency Nurses Association [ENA], 1997, p. 3-10</a>; <a href="#Gilboy">Gilboy, Travers &amp; Wuerz, 1999</a>). Triage systems have been based on
the nurse's assessment of vital signs, subjective and
objective information, past medical history, allergies,
and medications to determine triage acuity.</p>
<p>Resource prediction is an integral part of the ESI for
patients identified as ESI level 3, 4, or 5. It is
important to understand that resource allocation
does not have a role for patients of high acuity, e.g.
ESI level 1 or 2. Resource prediction distinguishes
the ESI from other triage systems that are based only
on acuity. </p><p>When Drs. Wuerz and Eitel created the
ESI triage system, they added resource utilization to
provide additional data and allow a better, more
accurate triage decision. They believed that an
experienced emergency department (ED) triage
nurse was able to predict the nature and number of
tests, therapeutic interventions, and consultations
that a patient would need during his/her ED stay.
This has been verified in recent studies of ESI
implementation and validation, which have shown
that triage nurses are able to predict ED patients'
resource needs (<a href="#Eitel03">Eitel, Travers, Rosenau, Gilboy &amp;
Wuerz, 2003</a>; <a href="#Tanabe04b">Tanabe, Gimbel, Yarnold &amp; Adams,
2004</a>). One study was conducted at seven EDs
representing varied regions of the country, urban
and rural areas, and academic and community
hospitals. Nurses using the ESI were able to predict
how many resources the ED patients required 70
percent of the time. That is, ESI classification by
experienced triage nurses reasonably predicts at
triage how many resources patients will require to
reach ED disposition, but, more importantly,
discriminates at presentation low versus high
resource intensity patients. This differentiation by
resource requirements allows for much more
effective streaming of patients at ED presentation
into alternative operational pathways within the ED,
that is, the parallel processing of patients. Research
has also established that ESI triage levels correlate
with important patient outcomes, including
admission and mortality rates (<a href="#Eitel03">Eitel, et al., 2003</a>).</p><a id="Fig5-1" name="Fig5-1"></a>
<p>Again, it is important to note that resource
prediction is only used for less acute patients. At
decision points A and B on the ESI algorithm (<a href="esifig5-1.htm">Figure 5-1</a>), the nurse decides which patients meet criteria for ESI levels 1 and 2 based only on patient acuity.
However, at decision point C, the nurse assigns ESI
levels 3 to 5 by assessing both acuity and predicted
resource needs. Thus, the triage nurse only considers
resources when the answers to decision points A and
B are "no."</p>
<p>To identify ED patients' resource needs, the triage
nurse must be generally familiar with emergency
department standards of care, and, specifically, what
constitutes prudent and customary emergency care.
An easy way to think about this concept is to ask
the question, "Given this patient's chief complaint,
what resources are the emergency providers likely to
utilize?"</p>
<p>The triage nurse uses information from the brief
subjective and objective triage assessment, as well as
past medical history, medications, age, and gender,
to determine how many different resources will be
needed for the ED provider to reach a disposition.
For example, a healthy teenage patient with a
simple leg laceration and no prior medical history
would need only one resource: Suturing. On the
other hand, an older adult with multiple chronic
medical problems and no history of dizziness who
presents with a head laceration from a fall will
clearly need multiple resources: suturing, plus
blood/urine tests, ECG, and x-rays or consultations
with specialists. Accurate use of ESI triage is
contingent on the nurses' ability to predict resources
and as such is best performed by an experienced
emergency nurse. In general, we believe that no
matter what triage system is used, an experienced
emergency nurse is needed to safely perform triage.</p><a id="Tab5-1" name="Tab5-1"></a>
<p>Guidelines for the categorization of resources in the
ESI triage system are shown in <a href="esitab5-1.htm">Table 5-1</a>. ESI levels 3, 4, and 5 are differentiated by
the nurse's determination of how many resources
are needed to make a patient disposition. On the
basis of the triage nurse's predictions, patients who
are expected to consume no resources are classified
as level 5, those who are likely to require one
resource are level 4, and those who are expected to
need two or more resources are designated as ESI
level 3. Patients who need two or more resources
have been shown to have higher rates of hospital
admission and mortality and longer lengths of stay
in the ED (<a href="#Eitel03">Eitel, et al., 2003</a>; <a href="#Tanabe04a">Tanabe, et al., 2004</a> Reliability and validity).</p>
<p>Though the list of resources in <a href="esitab5-1.htm">Table 5-1</a> is not
exhaustive, it provides general guidance on the
types of diagnostic tests, procedures, and therapeutic
treatments that constitute a resource in the ESI
system. Emergency nurses who use the ESI are
cautioned not to become overly concerned about
the definitions of individual resources.</p><p> It is
important to remember that ESI requires the triage
nurse to merely estimate resources that the patient
will need while in the ED. The most common
resources are listed in <a href="esitab5-1.htm">Table 5-1</a>; however a
comprehensive list of every possible ED resource is
neither practical nor necessary. In fact, all that is
really necessary for accurate ESI rating is to predict
whether the patient will need no resources, one, or
two or more resources. Once a triage nurse has
identified two probable resources, there is no need
to continue to estimate resources. The essence of the
ESI resource component is to separate more complex
(resource-intensive) patients from those with simpler
problems. The interventions considered as resources
for the purposes of ESI triage are those that indicate
a level of assessment or procedure beyond an exam
or brief interventions by ED staff and/or involve
personnel outside of the ED. Resources that require
significant ED staff time (such as intravenous
medication administration or chest tube insertion)
and those that require staff or resources outside the
ED (such as x-rays by the radiology staff or surgical
consults) increase the patient's ED length of stay and
indicate that the patient's complexity, and,
therefore, triage level is higher.</p>
<p>There are some common questions about what is
considered an ESI resource. First, there is often a
question about the number of blood or urine tests
and x-rays that constitute a resource. In the ESI
triage method, the triage nurse should count the
number of different types of resources needed to
determine the patient's disposition, not the number
of individual tests:</p>
<ul>
<li>A complete blood count (CBC) and electrolyte panel comprise one resource (lab test).</li>
<li>A CBC and chest x-ray are two resources (lab test, x-ray).</li>
<li>A CBC and a urinalysis are both lab tests and together count as only one resource.</li>
<li>A chest x-ray and plain skull films are one resource (x-ray).</li>
<li>A cervical-spine films and a computerized tomography (CT) scan of the head are two resources (x-ray and CT scan).</li>
</ul>
<p>Another resource frequently questioned is the
application of a splint, which does not count as a
resource. If a splint did count, patients with sprained
ankles would be triaged as ESI level 3 (x-ray and
splint application). While the application of a splint
can certainly be resource intensive, it is important to
remember the only purpose of resource prediction is
to sort patients into distinct groups and help get the
right patient to the right area of the ED. In many
EDs, ESI level-3 patients are not appropriate for a
fast track or urgent care area. Triage scores are not a
measure of total nursing workload intensity.</p>
<p>Another common question about ESI resources
relates to the fact that eye irrigation is also
considered a resource. Patients with a chemical
splash usually meet ESI level-2 criteria because of the
high-risk nature of the splash, so eye irrigation is not
a key factor in their ESI rating. However, if the eye
problem was due to dust particles in the eye, the
patient would not necessarily be high risk. In this
type of patient, the eye irrigation would count as a
resource and the patient would meet ESI level-4
criteria. The eye exam does not count as a resource
because it is considered part of the physical exam.</p>
<p>Other common questions about resources are
addressed in the Chapter 5 Frequently Asked
Questions section of <a href="esiappa.htm#Ch5">Appendix A</a>.</p>
<p>Another frequent question posed by clinicians is
related to the items listed as "not resources" in <a href="esitab5-1.htm">Table 5-1</a>. The purpose of the list is to assist triage nurses
with quick, accurate sorting of patients into five
clinically distinct levels (<a href="#Wuerz00">Wuerz, Milne, Eitel, Travers
&amp; Gilboy, 2000</a>). As such, items listed as not being
resources include physical exams, point-of-care tests,
and interventions that tend not to lead to increased
length of stay in the ED or indicate a higher level of
complexity. Since the standard of care is that all ED
patients undergo a basic history and physical exam,
an exam and even a pelvic exam does not constitute
a resource for ESI classification. The beauty of the
ESI is its simplicity; the true goal of the resource
determination is to differentiate the more
complicated patients needing two or more resources
(level 3 or above) from those with simpler problems
who are likely to need fewer than two resources
(level 4 or 5). Emergency nurses should not try to
complicate ESI by concentrating overly on resource
definitions. Usually, a patient requires either no
resources, one, or two or more resources.</p>
<p>Though resource consumption may vary by site,
provider, and even individual patient, triage nurses
are urged to make the ESI resource prediction by
thinking about the common approaches to the most
common presenting problems. Ideally, a patient
presenting to any emergency department should
consume the same general resources. For example, a
provider seeing an 82-year-old nursing home
resident who has an in-dwelling urinary catheter
and a chief complaint of fever and cough will most
likely order blood and urine tests and a chest x-ray.
The triage nurse can accurately predict that the
patient needs two or more resources and therefore
classify the patient as ESI level 3.</p>
<p>There may be minor variations in operations at
different EDs, but this will rarely affect the triage
rating. For example, some departments do
pregnancy tests in the ED (not a resource by ESI)
and others send them to the lab (a resource by ESI).
However, patients rarely have the pregnancy test as
their only resource, so most of those patients tend to
have two or more resources in addition to the
pregnancy test. One ED practice variation that may
result in different ESI levels for different sites is the
evaluation of patients with an isolated complaint of
sore throat. At some hospitals it is common practice
to obtain throat cultures (one resource, ESI level 4),
while at others it is not (no resources, ESI level 5).</p>
<p>Another example of different site practice variation
is the use of the Ottowa Ankle Rules. These are
validated rules used to determine the need for an x-ray
of the ankle for patients that present with ankle
injuries. Institutional adoption of these rules into practice varies. Institutions that use these rules at
triage may obtain fewer x-rays when compared with
institutions that do not routinely use these rules.</p>
<p>Temperature is an important assessment parameter
for determining the number of resources for very
young children. This subject will be covered in
<a href="esi6.htm">Chapter 6</a>.</p>
<p>From a clinical standpoint, ESI level 4 and 5 patients
can wait several hours to be seen by a provider.
However, from a customer service standpoint, these
patients are perhaps better served in a fast-track or
urgent care setting. Mid-level practitioners with the
appropriate skills mix and supervision could care for
level-4 and 5 patients. The ESI provides yet another
operational advantage, in that level-5 patients can
sometimes be "worked in" for a quick exam and
disposition by the provider, even if the department
is at capacity. Often triage policies clearly state ESI
level-4 or 5 patients can be triaged to an urgent care
or fast-track area.</p><a id="Tab5-2" name="Tab5-2"></a>
<p>In summary, the ESI provides an innovative
approach to ED triage with the inclusion of
predictions about the number of resources needed to
make a patient disposition. Consideration of
resources is included in the triage level assignment
for ESI level-3, 4, and 5 patients, while ESI level-1
and 2 decisions are based only on patient acuity.
Examples of ESI level-3, 4, and 5 patients are shown
in <a href="esitab5-2.htm">Table 5-2</a>. Practical experience has demonstrated
that resource estimation is very beneficial in helping
sort the large number of patients with non-acute
presentations.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>References</h3>
<a id="Eitel" name="Eitel"></a>
<p>Eitel DR, Brown C, Takayesu J. (in press). The
business management life support course-BMLS&reg;&#8212;for
emergency department care delivery teams. York, PA:
Author.</p>
<a id="Eitel03" name="Eitel03"></a>
<p>Eitel DR, Travers DA, Rosenau A, Gilboy N, Wuerz RC (2003). The emergency severity index version 2 is reliable and valid. <em>Academic Emergency
Medicine</em> 10(10):1079-80.</p>
<a id="ENA97" name="ENA97"></a>
<p>Emergency Nurses Association (1997). <em>Triage: Meeting the
challenge</em>. Park Ridge, IL: Author.</p>
<a id="Gilboy" name="Gilboy"></a>
<p>Gilboy N, Travers DA, Wuerz RC (1999). Reevaluating
triage in the new millennium: A
comprehensive look at the need for standardization
and quality. <em>Journal of Emergency Nursing</em> 25(6):468-73.</p>
<a id="Tanabe04b" name="Tanabe04b"></a>
<p>Tanabe P, Gimbel R, Yarnold PR, Adams J (2004). The emergency severity index (v. 3) five level triage system scores predict ED resource consumption.
<em>Journal of Emergency Nursing</em> 30:22-9.</p>
<a id="Tanabe04a" name="Tanabe04a"></a>
<p>Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams J (2004). Reliability and validity of scores on the Emergency Severity Index version 3. <em>Academic
Emergency Medicine</em> 11:59-65.</p>
<a id="Wuerz00" name="Wuerz00"></a>
<p>Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000). Reliability and validity of a new five-level
triage instrument. <em>Academic Emergency Medicine</em> 7(3):236-42.</p>
<hr />
<a id="Appa" name="Appa"></a>
<p class="size2"><strong>Note:</strong> <a href="esiappa.htm#Ch5">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="esi6.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>
<p>&nbsp;</p>
</div>
</td>
</tr>
</table>
<!-- End of Center Content section -->
</td>
</tr>
</table>
</div>
<!-- End of Content Body -->
<!-- Footer graphic 1.2-->
<table cellspacing="0" cellpadding="0" border="0" width="100%">
<tr>
<td width="125" background="/images/bottom_ahrq_bkg.jpg"><img src="/images/bottom_ahrq_1.jpg" width="125" alt="AHRQ" /></td>
<td width="100%" background="/images/bottom_ahrq_bkg.jpg" ><img src="/images/bottom_ahrq_bkg.jpg" width="10" height="34" alt="" /></td>
<td width="310" background="/images/bottom_ahrq_bkg.jpg"><img src="/images/bottom_ahrq_2.gif" alt="Advancing Excellence in Health Care" width="310" height="34" /></td>
</tr>
</table>
<!-- Footer links section -->
<div id="banner_Footer2"><p> <a href="https://www.ahrq.gov/">AHRQ Home</a> | <a href="https://info.ahrq.gov" class="footer_navlink">Questions?</a> | <a href="https://www.ahrq.gov/contact/index.html" class="footer_navlink">Contact AHRQ</a> | <a href="https://www.ahrq.gov/sitemap.html" class="footer_navlink">Site Map</a> | <a href="https://www.ahrq.gov/policy/electronic/accessibility/index.html" class="footer_navlink">Accessibility</a> | <a href="https://www.ahrq.gov/policy/electronic/privacy/index.html" class="footer_navlink">Privacy
Policy</a> | <a href="https://www.ahrq.gov/policy/foia/index.html" class="footer_navlink">Freedom of Information Act</a> | <a href="https://www.ahrq.gov/policy/electronic/disclaimers/index.html" class="footer_navlink">Disclaimers</a> | <a href="http://www.hhs.gov/open/recordsandreports/plainwritingact/index.html" class="footer_navlink">Plain Writing Act</a> <br />
<a href="http://www.hhs.gov" class="footer_navlink">U.S. Department of Health &amp; Human Services</a> | <a href="http://www.whitehouse.gov" class="footer_navlink">The White House</a> | <a href="http://www.usa.gov" class="footer_navlink">USA.gov: The U.S. Government's Official Web Portal</a></p>
</div>
<div id="banner_Footeraddress"><p>Agency for Healthcare Research and Quality <img src="/images/bottom_dot.gif" alt="" /> 5600 Fishers Lane Rockville, MD 20857 <img src="/images/bottom_dot.gif" alt="" /> Telephone: (301) 427-1364</p></div>
<!-- End of Footer links section -->
</body>
</html>
Reference in a new issue View git blame Copy permalink