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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>Appendix A. Frequently Asked Questions and
Post-test Materials for Chapters 3-8</h2>
<h3>Chapter 3</h3>
<h4>Frequently Asked Questions</h4>
<ol>
<li><strong>Do I have to upgrade the adult patient's triage level if the heart rate is greater than 100?</strong>
<p>No, it is a factor to consider.</p>
</li>
<li><strong>Do I have to upgrade the patient's triage level if the pain rating is 7/10 or greater?</strong>
<p>No, again this is one factor to consider.</p>
</li>
<li><strong>If the patient is chronically confused, should the patient then automatically be categorized as ESI level 2?</strong>
<p>No, an ESI level 2 is assigned to patients with an acute change in level of consciousness.</p>
</li>
<li>
<strong>When do I need to measure vital signs?</strong>
<p>For any patient who meets ESI level-3 criteria. Vital signs are always obtained if the triage nurse determines they may be useful.</p>
</li>
</ol>
<h4>Post-test Questions and Answers</h4>
<h5>Questions</h5> <p>Assign an ESI level to each of these
patients.</p>
<table border="0" cellpadding="4" cellspacing="1" width="70%">
<tr valign="top">
<th scope="col" width="15%">Level </th>
<th scope="col" width="85%" align="left">Patient</th> </tr>
<tr valign="top">
<td>1. _________</td>
<td>A 62-year-old with CPR in progress.</td></tr>
<tr valign="top">
<td>2. _________</td>
<td>A 53-year-old with 30% BSA burn.</td>
</tr>
<tr valign="top">
<td>3. _________</td>
<td>A 22-year-old who needs a work note.</td></tr>
<tr valign="top">
<td>4. _________</td>
<td>A 12-year-old with an earache.</td>
</tr>
<tr valign="top">
<td>5. _________</td>
<td>A 45-year-old involved in MVC, ejected from vehicle, BP 100/60.</td></tr>
<tr valign="top">
<td>6. _________</td>
<td>An unresponsive 14-year-old. EMS tells you he and his friends &quot;had been doing shots.&quot;</td></tr>
</table>
<h5>Answers</h5>
<p class="size2">1. ESI level 1<br />
2. ESI level 2<br />
3. ESI level 5<br />
4. ESI level 5<br />
5. ESI level 2<br />
6. ESI level 1</p>
<p class="size2"><a href="esi3.htm#Appa">Return to Chapter 3</a></p>
<a id="Ch4" name="Ch4"></a>
<h3>Chapter 4</h3>
<h4>Frequently Asked Questions</h4>
<ol><li><strong>Do I have to assign the ESI triage category of 2
for the 25-year-old female patient who rates her
pain as 10/10 and is eating potato chips?</strong>
<p>No. With stable vital signs and no other factors
that would meet high-risk criteria, this patient
should be assigned ESI level 3. She will most
likely need labs, and either x-rays, an IV, or pain
medications, i.e., two or more resources. You
would not use your last open bed for her.</p>
</li>
<li><strong> Does an 80-year-old female who is chronically
confused need to be triaged as ESI level 2?</strong>
<p>No. The new onset of confusion, lethargy, or
disorientation meet criteria for ESI level 2.</p>
</li>
<li><strong>Shouldn't the patient with active chest pain be
rated an ESI level 1? After all, they should be the
highest priority.</strong>
<p>Not all patients with chest pain meet ESI level-1
criteria. If they are unresponsive, pulseless, apneic
or not breathing, or require immediate life saving
intervention, they meet level-1 criteria. A chest
pain patient that is pale, diaphoretic,
hypotensive, or bradycardic will require
immediate IV access to improve their
hemodynamic status is level 1. Stable patients
with active chest pain usually meet high-risk
criteria and should be categorized ESI level 2;
immediate placement should be facilitated.</p>
</li>
</ol>
<h4>Post-test Questions and Answers</h4>
<h5>Questions</h5> <p>Read each case and determine whether
the patient meets the criteria for ESI level 2. Justify
your decision.</p>
<p>1. A 40-year-old male presents to triage with vague,
midsternal chest discomfort, occurring
intermittently for one month. This morning, he
reports a similar episode, which has now
resolved. Currently complains of mild nausea,
but feels pretty good. Medical history: Smoker.
He is alert, with skin warm and dry, does not
appear to be in any distress.</p>
<p>2. A 22-year-old female on college break presents to
the triage desk complaining of sudden onset of
feeling very sick, severe sore throat, and feels &quot;feverish.&quot; She is dyspneic, drooling at triage,
and her skin is hot to touch.</p>
<p>3. A 68-year-old male brought in by his wife for
sudden onset of left arm weakness, slurred
speech, and difficulty walking. Symptoms began
2 hours prior to arrival. PMH: Atrial fibrillation.
Meds: Lanoxin. The patient is awake, oriented,
mildly short of breath. Speech is slurred; rightsided
facial droop is present. Left upper-extremity
weakness noted with 2/5 muscle strength.</p>
<p>4. A 60-year-old male complains of sudden loss of
vision in the left eye that morning. Patient
denies pain or discomfort. PMH: CAD, HTN. The
patient is slightly anxious but no distress.</p>
<p>5. A 22-year-old female with 10/10 abdominal pain
for two days. Denies nausea, vomiting, diarrhea,
or urinary frequency. Her heart rate is 84 and she
is eating ice cream.</p>
<p>6. A 70-year-old female with her right arm in a cast
is brought to triage by her daughter. The
daughter states her mother fell yesterday and
fractured her arm. The patient is complaining of
pain. Daughter states, &quot;They put this cast on
yesterday, but I think it's too tight.&quot; Daughter
reports her mother has been very restless at home
and thinks her mother is in pain. Patient has a
history of Alzheimer's disease. The patient is
confused, mumbling (per baseline); face flushed.
She is unable to provide verbal description of her
complaints. Her right upper extremity is in a
short arm cast; digits appear tense, swollen and
ecchymotic. Nail beds are pale; capillary refill
delayed. Patient is not wearing a sling.</p>
<p>7. An 8-month-old presents with fever, cough, and
vomiting. The baby has vomited twice this
morning; no diarrhea. Mom states the baby is
usually healthy but has &quot;not been eating well
lately.&quot; Doesn't own a thermometer, but knows
the baby is &quot;hot&quot; and gave acetaminophen two
hours PTA. The baby is wrapped in a blanket,
eyes open, appears listless, skin hot and moist,
sunken fontanel. Respirations are regular and not
labored.</p>
<p>8. A 34-year-old male presents to triage with right
lower quadrant pain, 5/10, all day. Pain is
associated with loss of appetite, nausea and
vomiting. PMH: None. The patient appears in
moderate discomfort, skin warm and dry,
guarding abdomen.</p>
<p>9. A 28-year-old male arrives with friends with a
chief complaint of a scalp laceration. Patient
states he was struck in the head with a baseball
bat one hour prior to arrival. Friends state he
&quot;passed out for a couple of minutes.&quot; Patient
complains of headache, neck pain, mild nausea,
and emesis x 1. Patient looks pale, but is
otherwise alert and oriented to person, place,
and time. There is a 5-cm laceration to the scalp
near his left ear with bleeding controlled.</p>
<p>10. A 28-year-old male presents with a chief
complaint of tearing and irritation to the right
eye. He is a construction worker and was
drilling concrete. He states &quot;I feel like there is
something in my eye&quot; and reports &quot;irrigated the
eye several times but it doesn't feel any better.&quot;
Patient appears in no severe distress; however,
he is continually rubbing his eye. Right eye
appears red, irritated, with excessive tearing.</p>
<p>11. A 40-year-old male is brought in by his son. He
is unable to ambulate due to foot pain. Patient
states he fell approximately 10 feet off of a
ladder and is complaining of foot and back
pain. States he landed on both feet and had
immediate pain. Denies LOC/neck pain. No
other signs of trauma noted. The patient
appears pale, slightly diaphoretic, and appears
in mild distress. He rates his pain 6/10. Patient
is sitting upright in a wheelchair.</p>
<p>12. A 12-year-old female is brought to triage by her
mother who states her daughter has been weak
and vomiting for three days. The child states
she &quot;feels thirsty all the time and her head
hurts.&quot; Vomited once today. Denies fever,
abdominal pain, or diarrhea. No significant
PMH. The child is awake, lethargic, and
slumped in the chair. Color is pale, skin warm
and dry.</p>
<p>13. A 40-year-old male presents to triage with a
gradual increase in shortness of breath over the
past two days associated with chest pain. PMH:
colon CA. He is in moderate respiratory distress,
skin warm and dry.</p>
<p>14. A 60-year-old male presents with complaint of
dark stools for one month with vague
abdominal pain. PMH: None. Pulse is
tachycardic at a rate of 140 and he has a blood
pressure of 80 palpable. His skin is pale and
diaphoretic.</p>
<p>15. A 25-year-old female presents to triage with a
chief complaint of a moderate amount of dark red vaginal bleeding, with 9/10 pain. The
patient states she is 7 months pregnant and this
is her fourth pregnancy. PMH: Denies.</p>
<h5>Answers</h5>
<p>1. <strong>ESI level 2.</strong> This patient is high-risk, due to
history of angina x 1 month. The patient
complained of symptoms of AMI earlier in the
morning. Smoking is a significant risk factor;
however, the patient presentation is concerning
enough to be considered high risk. These are
symptoms significant for a potential cardiac
ischemic event. AMI is frequently accompanied
or preceded by waxing and waning symptoms.
An immediate ECG is necessary.</p>
<p>2. <strong>ESI level 2.</strong> This patient is at high risk for
epiglottitis. This is a life-threatening condition
characterized by edema of the vocal cords. Onset
is rapid, with a high temp (usually &gt;101.3&deg;
F/38.5&deg; C), lethargy, anorexia, sore throat.
Patients do not have a harsh cough associated
with croup, often assume the tripod position,
and also have mouth drooling, an ominous sign,
and may demonstrate an exhausted facial
expression. Epiglottitis is more common in
children, but may occur in adults; usually age 20
to 40. These patients are at high risk for airway
obstruction and need rapid access of an airway
(preferably in the operating room).</p>
<p>3. <strong>ESI level 2.</strong> This patient is presenting with signs
of an acute stroke and requires immediate
evaluation. If he meets criteria for thrombolytic
therapy, he may still be in the time window of
less than three hours, but every minute counts
with this patient. He is a very high-priority ESI
level-2 patient.</p>
<p>4. <strong>ESI level 2.</strong> High risk for central retinal artery
occlusion caused by an embolus. This is one of
the few true ocular emergencies and can occur in
patients with risk factors of coronary artery
disease, hypertension, or embolus. Without rapid
intervention, irreversible loss of vision can occur
in 60 to 90 minutes.</p>
<p>5. <strong>ESI level 3.</strong> Since she is able to eat ice cream,
you would not give your last open bed for this
patient. She will probably require at least two
resources.</p>
<p>6. <strong>ESI level 2.</strong> High risk for compartment
syndrome. Despite the patient being a poor
historian, the triage nurse should be able to
identify some of the signs of threatened
compartment syndrome: Pain, pallor,
pulselessness, paresthesia, and paralysis. The
patient requires immediate life-saving
intervention: Cutting of the cast and further
evaluation for potential compartment syndrome.</p>
<p>7. <strong>ESI level 2.</strong> High risk for sepsis or severe
dehydration. If the baby was alert and active
with good eye contact, similar complaints, and
a fever of 100.4&deg; F (38.0&deg; C) or greater, the ESI
category would be 3. The temperature is not
needed to make the assessment that the baby is
high risk. The presence of lethargy and a
sunken fontanel are indications of severe
dehydration.</p>
<p>8. <strong>Initially ESI level 3.</strong> However, the patient
could be upgraded to ESI level 2 if vital signs
were abnormal, i.e., heart rate greater than 100.
Signs of acute appendicitis include mild-to-severe
RLQ pain with loss of appetite, nausea,
vomiting, low-grade fever, muscle rigidity, and
LLQ pressure that intensifies the RLQ pain. The
presence of all these symptoms and tachycardia
would indicate a high risk for a surgical
emergency.</p>
<p>9. <strong>ESI level 2.</strong> High risk for epidural hematoma.
This is a great example of the importance of
understanding mechanism of injury. This man
was struck with a baseball bat to the head with
enough force to cause a witnessed LOC.
Patients with epidural hematomas have a classic
transient LOC before they rapidly deteriorate.
Even though this patient looks good now and is
alert and oriented at present, he must be
immediately placed for further evaluation.</p>
<p>10. <strong>ESI level 2.</strong> High risk for severe alkaline burn.
Concrete is an alkaline substance and continues
to burn and penetrate the cornea causing severe
burns. Alkaline burns are more severe than
burns with acid substances and require
irrigation with very large amounts of fluids.</p>
<p>11. <strong>ESI level 2.</strong> High risk for lumbar and calcaneus
fractures. Again, mechanism of injury is very
important to evaluate. Although he is not
unresponsive or lethargic, he needs rapid
evaluation and treatment.</p>
<p>12. <strong>ESI level 2.</strong> Lethargy and high risk for severe
dehydration from probably diabetic
ketoacidosis (DKA). It is not normal for a 12-year-old to be slumped over in a chair. Her
history of being thirsty and lethargic suggest a
strong suspicion for DKA. She needs rapid
evaluation and rehydration. </p>
<p>13. <strong>ESI level 2.</strong> High risk for a variety of
complications associated with cancer, i.e.,
pleural effusion, CHF, further malignancy, and
pulmonary embolus. A history of cancer can
help identify high-risk status.</p>
<p>14. <strong>ESI level 1.</strong> Patient is placed in ESI level 1 after
consideration of heart rate, skin condition and
blood pressure. Tachycardia and hypotension
indicate blood loss. The patient needs
immediate hemodynamic support.</p>
<p>15.<strong> ESI level 1.</strong> She is at high risk for abruptio
placentae, and needs an immediate cesarean
section to save the fetus. Abruption occurs
when the placenta separates from its normal
site of implantation. Primary causes include
hypertension, trauma, illegal drug use, and
short umbilical cord. Bleeding may be dark red
or absent when hidden behind the placenta.
Abruption is usually associated with pain of
varying intensity.</p>
<p class="size2"><a href="esi4.htm#Appa">Return to Chapter 4</a></p>
<a id="Ch5" name="Ch5"></a>
<h3>Chapter 5</h3>
<h4>Frequently Asked Questions</h4>
<ol>
<li><strong>Why isn't crutch-walking instruction a resource?</strong>
<p>Though crutch-walking instruction may consume
a fair amount of the ED staff members' time, it is
often provided to patients who have simple ankle
sprains. These patients are typically classified as
ESI level 4 (ankle x-ray = one resource). The
patients are clearly less acute and less resource
intensive than more complex patients like those
with tibia/fibula fractures who are usually ESI
level 3 (leg films, orthopedic consult, cast/splint,
IV pain medications = two or more resources). A
better way to reflect the ED staff's efforts for
crutch-walking instruction is with a nursing
resource intensity measure.</p>
</li>
<li><strong>Why isn't a splint a resource?</strong>
<p>The application of simple, pre-formed splints
(such as splints for ankle sprains) is not
considered a resource. In contrast, the creation
and application of splints by ED staff, such as
thumb spica splints for thumb fractures, does
constitute a resource. A helpful way to
differentiate patients with extremity trauma is as
follows: patients with likely fractures should be
rated ESI 3 (two or more resources: x-ray, pain
medications, creation and application of
splints/casts), whereas patients more likely to
have simple sprains can be rated as ESI level 4.</p>
</li>
<li><strong>Why isn't a saline or heparin lock a resource?</strong>
<p>Generally speaking, insertion of a heparin lock
doesn't consume a large amount of ED staff time.
However, many patients who have heparin locks
inserted also have at least two other resources
(e.g., laboratory tests, intravenous medications)
and are therefore classified as ESI level 3 anyway.</p>
</li>
<li><strong>Are all conscious sedation patients ESI level 3 or
higher?</strong>
<p>Yes, conscious sedation is considered a complex
procedure (two resources) and is generally
performed with patients who also have
laboratory tests or x-rays, and other procedures
such as fracture reduction or dilation and
curettage.</p>
</li>
<li><strong>Which of the following are considered resources:
eye irrigation, nebulized medication
administration, and blood transfusions?</strong>
<p>All three are considered resources for the
purposes of ESI triage ratings. The resources tend
to be used for more acute patients, require
significant ED staff time, and likely lead to longer
length of stay for patients.</p>
</li>
<li><strong>Are all asthmatics ESI level 4 because they will
require a nebulized medication?</strong>
<p>No. Stable asthmatics who only require a
nebulized medications are assigned ESI level 4.
However, some asthmatics are in severe
respiratory distress and meet ESI level-2 criteria.
Others are somewhere in between and will
require intravenous steroids or an x-ray in
addition to nebulized treatments and would be
assigned ESI level 3. Finally, asthmatics who
require only a prescription refill of their inhaler
are assigned ESI level 5. They do not require any
resources.</p>
</li>
</ol>
<h4>Post-test Questions and Answers</h4>
<h5>Questions</h5> <p>Read the following statements and
provide the correct answer.</p>
<p>1. A magnetic resonance imaging (MRI) procedure
is considered a resource in the ESI triage system.<br />&nbsp;&nbsp;&nbsp;(T/F)</p>
<p>2. A psychiatry consult is considered a resource in
the ESI triage system.<br />&nbsp;&nbsp;&nbsp;(T/F)</p>
<p>3. Cardiac monitoring is considered a resource in
the ESI triage system.<br />&nbsp;&nbsp;&nbsp;(T/F)</p>
<p>4. How many ESI resources will this patient need?
A healthy 25-year-old construction worker
presents with back pain. The triage nurse
predicts he will need a lumbar spine x-ray, oral
pain medication administered in the ED, and a
prescription to take home.<br />&nbsp;&nbsp;&nbsp;(0, 1, 2 or more)</p>
<p>5. It is necessary to take vital signs in order to
determine the number of ESI resources an adult
ED patient will need.<br />&nbsp;&nbsp;&nbsp;(T/F)</p>
<p>6. The triage nurse must have enough experience
to be certain about the resources needed for
each patient in order to accurately assign an ESI
triage level.<br />&nbsp;&nbsp;&nbsp;(T/F)</p>
<p>7. A 30-year-old sexually active female patient
with vaginal bleeding and cramping, doesn't
use birth control, and is dizzy and pale. In
determining this patient's ESI triage level, does
it matter if the local ED does urine pregnancy
tests at the point of care versus sending a
specimen to the laboratory?<br />&nbsp;&nbsp;&nbsp;(Y/N)</p> <p>How many
resources will this patient require? <br />&nbsp;&nbsp;&nbsp;(0, 1, 2 or
more)</p>
<p>8. How many ESI resources will this patient need?
A healthy 40-year-old man presents to triage at
2:00 a.m. with a complaint of a toothache for
two days, no fever, and no history of chronic
medical conditions.<br />&nbsp;&nbsp;&nbsp;(0, 1, 2 or more, irrelevant)</p>
<p>9. How many ESI resources will this patient need?
A 22-year-old female involved in a high-speed
rollover MVC and thrown from the vehicle,
presents intubated, no response to pain, and
hypotensive.<br />&nbsp;&nbsp;&nbsp;(0, 1, 2 or more, irrelevant)</p>
<p>10. How many ESI resources will this patient need?
A 60-year-old healthy male who everted his
ankle on the golf course presents with moderate
swelling and pain upon palpation of the lateral
malleolus.<br />&nbsp;&nbsp;&nbsp;(0, 1, 2 or more, irrelevant)</p>
<p>11. Is it considered an ESI resource if a psychiatric
patient requires a sitter or security staff member
present at the bedside?<br />&nbsp;&nbsp;&nbsp;(Y/N)</p>
<h5>Answers</h5>
<p>1. <strong>True.</strong> The MRI will make use of personnel
outside the ED (MRI staff) and increase the
patient's ED length of stay.</p>
<p>2. <strong>True.</strong> The consult involves personnel outside
the ED (psychiatry team) and increases the
patient's ED length of stay.</p>
<p>3. <strong>False.</strong> Monitoring is part of the routine care
provided by ED staff. However, most patients
who receive monitoring also need at least two
other ED resources (electrocardiogram, blood
tests, x-rays), and may therefore be classified as
ESI level 3.</p>
<p>4. <strong>One ESI resource.</strong> The x-ray is considered a
resource since it utilizes personnel outside the
ED. The oral pain medication and take-home
prescription are not considered resources since
they are quick interventions performed by ED
personnel.</p>
<p>5. <strong>False.</strong> While vital signs are helpful in up-triage
of level-3 patients to level 2, they are not
necessary for differentiating patients needing
one, two, or more than two resources.</p>
<p>6. <strong>False.</strong> The ESI is based upon the experienced
ED triage nurse's prediction, or estimation, of
the number and type of resources each patient
will need in the ED. The purpose of resource
prediction isn't to order tests or make an
accurate diagnosis, but to quickly sort patients
into distinct categories using acuity and
expected resources as a guide.</p>
<p>7. <strong>No, it doesn't matter.</strong> The patient will need
at least two resources, and be classified as a
level 3 whether the pregnancy test is done in
the ED (not a resource) or in the laboratory (a
resource). The predicted resources will include:
Complete blood count, intravenous fluids,
ultrasound, and possibly a gynecology consult
and intravenous medications if it is determined
that she is aborting a pregnancy and the
cervical os is open.</p>
<p>8. <strong>No resources.</strong> This patient will likely have a
brief exam (not a resource) and receive a
prescription for pain medication (not a
resource) by the provider, and therefore is an
ESI level-5 patient.</p>
<p>9. <strong>Irrelevant.</strong> The patient is an ESI level 1 based
on being intubated and unresponsive. The
nurse does not need to make a determination
of the number of resources in order to make the
triage classification.</p>
<p>10. <strong>One resource.</strong> The patient will need an ankle
x-ray (one resource), and may get an ace wrap
or ankle splint (not a resource) and crutches
(not a resource). Simple ankle sprains are
generally classified as ESI level 4. However, if
the patient was in severe pain that required
pain medication by injection, or if he had a
deformity that might need a cast, orthopedic
consult and/or surgery, then he would need two or more resources and be classified as an ESI
level 3.</p>
<p>11. <strong>Yes.</strong> A sitter or security staff member present at
the bedside is considered a resource. However,
such patients are high risk, since they are
suspected to be a danger to themselves or
others. So, in fact, these patients should be
rated ESI-2 and it is not necessary to predict the
number of resources they will require in the ED.</p>
<p class="size2"><a href="esi5.htm#Appa">Return to Chapter 5</a></p>
<a id="Ch6" name="Ch6"></a>
<h3>Chapter 6</h3>
<h4>Frequently Asked Questions</h4>
<ol>
<li><strong>Why aren't vital signs required to triage ESI level-1 and 2 patients?</strong>
<p>Vital signs are not necessary to rate patients as
life threatening (ESI level 1) or high-risk (ESI level
2). Since ESI level 1 and 2 patients are critical,
they require the medical team to respond
quickly. Simultaneous actions can occur and vital
signs can be collected as part of the initial
assessment in the main acute area of the
emergency department.</p>
</li>
<li><strong>Why aren't vital signs required for ESI level-4 and
5 patients?</strong>
<p>Vital signs are not necessary to rate patients as
low or no resource (ESI level 4 or 5). Also, the
pain, anxiety, and discomfort associated with an
emergency department visit often alter a patient's
vital signs. Vital signs may quickly return to
normal once the initial assessment is addressed.
However, a nurse may choose to assess vital signs
if signs of deranged symptoms exist (e.g., changes
in skin color, mentation, dizziness, sweating). If
there is no physical sign indicating a need for
vital signs, the patient can be taken in the main
emergency department or express care room.</p>
</li>
<li><strong>Why are vital signs done on ESI level-3 patients?</strong>
<p>Vital signs can aid in differentiating patients
needing multiple resources as either stable (ESI
level 3) or potentially unstable or high-risk (ESI
level 2). On occasion, ESI level-3 patients may
actually have unstable vital signs while appearing
stable. Vital signs for ESI level-3 patients provide
a safety check. In general, ESI level-3 patients are
more complicated and many are admitted to the
hospital. Since these patients are not appropriate
for the fast-track area, they are sometimes asked
to wait for more definitive care. These patients
present a unique challenge to the triaging process
and caregivers find it necessary to rely on vital
signs to confirm that an appropriate ESI level has
been assigned.</p>
</li>
<li><strong>Why are temperatures always done for pediatric
patients less than 36 months?</strong>
<p>Temperature is useful in differentiating pediatric
patients that are low or no resource (ESI level 4 or
5) from those that will consume multiple
resources. An abnormal temperature in the less
than 3 month old may indicate bacteremia, and
place the child in a high-risk category.</p>
</li>
<li><strong> Why does the literature present conflicting
information on the value of vital signs during the
triage process?</strong>
<p>There is no definitive research on the utility of
vital signs for emergency department triage.
Many factors influence the accuracy of vital sign
data. Vital signs are a somewhat operator-dependent
component of a patient's assessment.
In some cases, vital signs may be affected by
many factors such as chronic drug therapy (e.g.,
beta-blockers). Vital signs may also be used to
fulfill part of the public health obligation
assumed by emergency departments. And, lastly,
vital signs help segment young pediatric patients
into various categories.</p>
</li>
<li><strong>Does JCAHO require vital signs to be done during
triage?</strong>
<p>The Joint Commission on Accreditation of
Healthcare Organizations does not specifically
state a standard for vital signs. The organization
does assert that physiologic parameters should be
assessed as determined by patient condition.</p>
</li>
<li><strong>Should vital sign criteria be strict in the danger
zone vital sign box?</strong>
<p>In common usage, when the danger zone vital
sign criteria are exceeded, up-triage is
&quot;considered&quot; rather than automatic. The
experienced triage nurse is called upon to use
good clinical judgment in rating the patient's ESI
level. The nurse incorporates information about
the vital signs, history, medications, and clinical
presentation of the patient in that decisionmaking
process. Research is still needed to
determine the predictive value of vital signs at
triage, and to determine absolute cutoffs for up-triage.</p>
</li>
<li><strong>What if ESI level-4 or 5 patients have danger
zone vital signs?</strong>
<p>Though it is not required to take vital signs in
order to assign ESI 4 or 5 levels, many patients
may have vitals assessed at triage if that is part of the particular ED's operational process. Per the
ESI triage algorithm, the triage nurse does not
have to take the vital signs into account in
determining that the patient meets ESI level-5
(no resources) or ESI level-4 (one resource)
criteria. However, in practice, the prudent nurse
will use good clinical judgment and take the vital
sign information into account in rating the ESI
level. If the patient requests only a prescription
refill and has no acute complaints, but has a
heart rate of 104 after walking up the hill to the
ED, the nurse might still rate the patient as an
ESI level 5. But if the patient requests a
prescription refill and has a heart rate of 148 and
irregular, the nurse should rate the patient as ESI
level 2. The triage nurse must also consider the
following dilemma: an elevated blood pressure in
an ESI level-4 or 5 patient. If the patient is
asymptomatic related to the blood pressure, the
triage level should not change. Most likely, an
elevated BP in the asymptomatic patient will not
be treated in the ED. However, it may be
important to refer the patient to a primary care
physician for BP followup and long term
diagnosis and treatment.</p>
</li>
</ol>
<h4>Post-test Questions and Answers</h4>
<h5>Questions</h5> <p>Rate the ESI level for each of the
following patients.</p>
<p>1. 3-week-old male<br /> <em>Vital signs</em>:<br />
Temperature: 100.8&deg; F (38.2&deg; C)<br />
Heart rate: 160<br />
Respiratory rate: 48<br />
Oxygen saturation: 96%<br />
<em>Narrative</em>:<br />
Poor feeding<br />
Less active than usual<br />
Sleeping most of the day</p>
<p>2. 22-month-old, fever, pulling ears, immunizations
up to date, history of frequent ear infections
<br /> <em>Vital signs</em>:<br />
Temperature: 102&deg; F (39&deg; C)<br />
Heart rate: 128<br />
Respiratory rate: 28<br />
Oxygen saturation: 97%<br />
<em>Narrative</em>:<br />
Awoke screaming<br />
Pulling at ears<br />
Runny nose this week<br />
Alert, tired, flushed, falling asleep now<br />
Calm in mom's arms, cries with exam</p>
<p>3. 6-year-old with cough
<br /> <em>Vital signs</em>:<br />
Temperature: 104.4&deg; F (40.2&deg; C)<br />
Heart rate: 140<br />
Respiratory rate: 30<br />
Oxygen saturation: 91%<br />
<em>Narrative</em>:<br />
Cough with fever for two days<br />
Chills<br />
Short of breath with exertion<br />
Green phlegm<br />
Sleeping a lot</p>
<p>4. 94-year-old male, abdominal pain
<br /> <em>Vital signs</em>:<br />
Temperature: 98.9&deg; F (37.2&deg; C)<br />
Heart rate: 100<br />
Blood pressure: 130/80<br />
Oxygen saturation: 93%<br />
<em>Narrative</em>:<br />
Vomiting<br />
Epigastric pain<br />
Looks sick</p>
<p>5. 61-year-old female, referred with asthma
<br /> <em>Vital signs</em>:<br />
Temperature: 99.1&deg; F (37.3&deg; C)<br />
Heart rate: 112<br />
Respiratory rate: 28<br />
Blood pressure: 157/94<br />
Oxygen saturation: 91%<br />
Peak expiratory flow rate = 200<br />
<em>Narrative</em>:<br />
Asthma exacerbation with dry cough<br />
Steroid dependent<br />
Multiple hospitalizations<br />
Never intubated </p>
<p>6. 9-year-old male, head trauma<br />
<em>Narrative</em>:<br />
Collided with another player at lacrosse game<br />
Loss of consciousness for &quot;about 5 minutes,&quot;
witnessed by coach<br />
Now awake with headache and nausea</p>
<h5>Answers</h5>
<p>1. <strong>ESI level 2.</strong> An infant less than 28 days with a
temperature greater than 38.0&deg; C (100.4&deg; F) is
considered high risk regardless of how good they
look. With a child between 3 and 36 months
with a fever greater than 39.0&deg; C (102.2&deg; F), the
triage nurse should consider assigning ESI level 3,
if there is no obvious source for a fever or the
child has incomplete immunizations.</p> <p>2. <strong>ESI level 5.</strong> A child under 36 months of age
requires vital signs. This child has a history of
frequent ear infections, is up to date on their
immunizations and presents with signs of
another ear infection. This child meets the
criteria for ESI level 5 (exam, PO medication
administration and discharge to home). Danger
zone vitals not exceeded. If the child was underimmunized
or there was no obvious source of
infection the child would be assigned to ESI level 3.</p>
<p>3. <strong>ESI level 2.</strong> The clinical picture indicates high
probability of tests that equal two or more
resources (ESI level 3). Danger zone vital signs
exceeded (SpO<sub>2</sub> = 91%, Respiratory rate = 30),
making the patient an ESI level 2.</p>
<p>4. <strong>ESI level 2.</strong> The clinical picture mandates ESI
level 3 with expected utilization of x-ray, blood
work, and specialist consultation resources.
Danger zone vital signs not exceeded. If an
experienced triage nurse reported this patient as
looking in imminent danger of deterioration, the
patient may be upgraded to an ESI level 2. A 94-year-old ill-appearing patient presenting with
epigastric pain, vomiting, and probable
dehydration should be considered a high-risk ESI
level-2 patient. If this patient did not look toxic,
an ESI level 3 might be an appropriate starting
point in the decision algorithm.</p>
<p>5. <strong>ESI level 2.</strong> The clinical picture mandates ESI
level 3 with expected utilization of x-ray, blood
work, and specialist consultation resources.
Respiratory rate and heart rate danger zone vital
signs are exceeded, so patient is up-triaged to ESI
level 2.</p>
<p>6. <strong>ESI level 2.</strong> This patient is assigned an ESI level
2 due to the high-risk information provided in
the scenario. Vital signs are not necessary, and
patient should be immediately taken to
treatment area for rapid assessment.</p>
<p class="size2"><a href="esi6.htm#Appa">Return to Chapter 6</a></p>
<a id="Ch7" name="Ch7"></a>
<h3>Chapter 7</h3>
<h4>Post-Test Questions and Answers</h4>
<h5>Questions</h5>
<ol>
<li> Identify the three phases of change described by Lewin.</li>
<li> The ESI algorithm is so simple; why do the nurses need two hours of education to learn to use it?</li>
<li> As the nurse manager of a low-volume emergency department do I still need an implementation team?</li>
</ol>
<h5>Answers</h5>
<ol>
<li> Unfreezing, movement, and refreezing.</li>
<li> Yes, the algorithm looks simple but staff needs to develop a clear understanding of each of the decision points. Application to realistic cases will reinforce learning.</li>
<li> The change process is never easy. An implementation team provides input from various members of the department. They can assist in developing and carrying out the implementation plan.</li>
</ol>
<p class="size2"><a href="esi7.htm#Appa">Return to Chapter 7</a></p>
<a id="Ch8" name="Ch8"></a>
<h3>Chapter 8</h3>
<h4>Frequently Asked Questions</h4>
<ol>
<li><strong>What if we don't have good electronic data
monitoring systems for QI efforts?</strong>
<p>Although it is very helpful and will expand the
number of indicators you can monitor, you do
not have to have electronic data monitoring to
perform ESI QI.</p>
</li>
<li><strong>Can staff nurses monitor each other for the
accuracy of the ESI triage acuity rating?</strong>
<p>No. An expert nurse in triage should determine
whether the acuity ratings are correct.</p>
</li>
<li><strong>How many indicators should we be monitoring?</strong>
<p>This is a decision to be made by the leadership
team. Select only those indicators that have been
identified as important to your ED and select
only the number of indicators you have the
resources to monitor.</p>
</li>
</ol>
<p class="size2"><a href="esi8.htm#Appa">Return to Chapter 8</a><br />
<a href="esi1.htm#Contents">Return to Contents</a><br />
<a href="esiappb.htm">Proceed to Next Section</a></p>
<p>&nbsp;</p>
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<p> The information on this page is archived and provided for reference purposes only.</p></div>
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