Emergency Severity Index v.4 Lectures

a school nurse is assessing an adolescent who presents with multiple burns
This is a topic that many people are looking for. https://granthamandira.org/ is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, https://granthamandira.org/ would like to introduce to you Emergency Severity Index v.4 Lectures. Following along are instructions in the video below:

The purpose of this segment of the DVD is to familiarize emergency physicians and emergency nurses with the rationale to support your decision to implement a five-level triage system in your department. We must begin with discussing the concept of triage in general. What is the real purpose of triage? The first, and always most important function of triage, is to identify which patients that need to be seen immediately, and separate them from those patients that can safely wait to be seen. In the current era of crowded and overcrowded EDs, triage becomes more important everyday. In order to accomplish this critically important task, triages nurses must be experienced emergency department nurses who have demonstrated competence in the triage role. Triage decisions must be correct. It is never safe to under-triage as this compromises patient safety. Over-triage is also a problem and results in taking away a bed from the next patient who will actually need it more. Triage acuity rating decisions must be right. Therefore, more and more attention is being paid to triage systems in the United States. So, realizing that the most important purpose of triage is to enhance patient safety in the waiting room by determining who can wait, we also begin to realize, triage data can be used for other purposes. For example, hospital administrators will now have a way of describing the acuity of your department, other than admission rates. Administrators can use triage data to describe not only the number of patients seen in the Emergency Department (ED), but also describe the acuity level of those patients, and changes in acuity over time and during different periods of the day in your department. This data can also be used in real time as well. Do you need extra help tonight? Should you be going on bypass? Triage data can help administrators make decisions to increase staffing levels and identify other departmental resource needs. Once integrated in your department, a good triage system will allow you to compare yourself to other departments or to yourself over a designated time period. So, you can see, a good triage system provides more data than just describing the volume that you see in your department. So next, we ask who else uses our triage data? Actually, many agencies use emergency department triage data. State and local health departments, as well as government policy makers, use our data to help identify trends in ED visits. Our triage data help shape the need for public policy changes. In the current era of bioterrorism threats, real-time data can be used to help identify possible bioterrorism events. For example, a sudden increase in young, healthy Level 3 patients with respiratory complaints, post exposure at a public event, could raise the suspicion of a possible bioterrorism event. Finally, the Centers for Disease Control are primarily responsible for monitoring trends in emergency department care. The CDC conducts the National Hospital Ambulatory Medical Care Survey, also called NHAMCS. This survey is conducted every year by the Department of Health and Human Services, by the CDC, the national center for health statistics. Emergency departments across the United States are sampled. Surveyors select a number of EDs and come out and abstract many different data points from your ED records. Data points include demographics, chief complaints, treatments, medications administered, as well as the triage acuity rating. Historically, the CDC has used a 4-level triage system to categorize ED visit acuity. This data is reported yearly to describe the “state” of EDs. In a report published by the CDC in 2002, the CDC reported an alarming 17% decrease in the number of patients with emergent complaints seen from 1997-2000. This surprised many emergency clinician leaders. None of us, you included, probably felt this decrease in acuity. The report was limited by the quality of data that was abstracted. The CDC uses a 4-level triage system, while most EDs used a 3-level triage system. The problem the CDC faces when attempting to describe emergency care is the lack of a standardized triage system in the United States. Unlike Australia, Canada, and the United Kingdom, currently in the US, EDs use whatever triage system they choose. Previously, 3-level triage systems have been the standard. Unfortunately, as we will discuss, 3-level systems do not use standardized criteria and have been shown to be unreliable and not valid. In other words, there are no standardized definitions for 3-level triage acuity rating systems. Consequently, data used from 3-level systems are meaningless and not helpful in describing a particular department’s acuity status. It is also not a safe triage system when triage nurses will routinely triage patients differently. So, the CDC is limited by our lack of the use of a standard triage system in the United States. So, it is up to us, individual EDs, to begin to use a valid and reliable triage system. And, both professional organizations, the American College of Emergency Physicians and the Emergency Nurses Association have recognized the need to standardize triage systems in the US. A joint task force between the 2 organizations was initiated in 2003 and remains active today. The committee was charged with reviewing the evidence for all 5-level systems and making a recommendation to both organizations. A comprehensive literature review on all 5-level systems was conducted and published in the Journal of Emergency Nursing in February 2005. The task force recommended the following policy that was approved by both organizations in 2003. “The American College of Emergency Physicians and the Emergency Nurses Association believe that the quality of patient care would benefit from implementing a standardized ED triage scale and acuity categorization process. Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid 5-level triage system”. Clearly, the need for EDs to adopt a 5-level triage system with established reliability and validity has been recognized. While the group stopped short of recommending a particular system, the published paper suggests either the Canadian Triage and Acuity System (CTAS) or the Emergency Severity Index (ESI) are acceptable scales. So, the need for 5-level is clear from a National perspective. We realize many of you may still be using a 3-level system. So, you must evaluate the following questions: Can you manage your waiting room with 3 triage levels? Can you easily describe the acuity of your patients in the waiting room AND in the treatment area with only 3 choices? When faced with 10, 20, or 30 patients waiting to be seen in the typically over-crowded, or crowded ED, can you differentiate using only 3 levels, “really sick”, “sick” and “not so sick”? Probably not. If you don’t have any waits in your department this seems a moot point. However, it’s not. It is critical be able to report acuity levels for every ED patient including those not “triaged” by the triage nurse. For example, the trauma patients, cardiac arrest and all patients arriving by ambulance who may bypass triage. If these patients do not receive an acuity score, they are not included in your case mix data and you therefore under-estimate your departmental acuity. Remember the CDC report. You want to be able to capture the true acuity of your total patient population. So, back to the original questions, can you tell your hospital administrator the real acuity in your department at any minute? And, why do we care so much now? Well, there is a crisis in the ED! We are all acutely aware of the overcrowding issue, but so is most of the public. This is now a dated cover of the US News and World Report. We all recognize we are overcrowded and this makes the triage decision so much more important. But, why are we overcrowded? I don’t need to tell you the answer to that question. Hospital closures, down-sizing, the nursing shortage and the aging population have contributed each in their own important way to our current over-crowded state. Finally, we are always the safety net for anyone who cannot obtain health care. The prediction is the number of individuals without health care is only expected to increase. We are always open and must always provide care. We must be prepared to accommodate large numbers of patients. The time to use a valid and reliable 5-level triage system is now. So, what systems are we using in the United States? This data is the DEEDS data, published in 2001 by the ENA, and reflects approximately 1/3 of all EDs in the US. As you can see, at that time, most EDs were still using 3-level systems, with a few using 4-level and even fewer using 5-level. We expect that number will continue to dramatically shift towards more and more hospitals using 5-level systems. Of importance is the CDC data from 2001 compared with 2002 data. This slide demonstrates the importance of reporting a triage score for every ED patient. As can be seen in the 2001 data in the blue bar, approximately 25% of visits did not have a triage acuity level assigned. When reviewing the 2002 data, that number dramatically decreased and you can clearly see that the patients with no triage acuity score reported actually reflect sicker patients. There was a larger increase in the number of level 1-3 patients when compared with the increase in the number of level 4 patients. Stated more clearly, the patients that did not receive an acuity score were sicker. So take credit for all of your patients. In general, the data demonstrates the continued large increase in the number of ED visits – 110 million visits. So, we must then ask, what are we overcrowded with? Is it “sick” or “not so sick” patients? The general public perception may be that we are seeing a lot of “not so sick” patients. While there may be institutional differences, in general, most emergency clinicians believe we are seeing sicker patients. But, can we prove it? Do you use a triage system that can generate data that administrators and policy makers can actually use? If you are using a 3-level system, the answer is definitely not. So, what makes a triage system useful and a “good” triage system? It must be reliable and valid and triage of any particular patient cannot depend either on who the triage nurse is that day, or on who the attending physician is that day. Without a reliable triage system, you cannot describe your case mix and you certainly cannot compare yourself to other EDs. So, let’s talk about two crucial concepts to choosing a triage system: reliability and validity. Reliabilty of a triage system means the consistency or agreement. In other words, do two nurses assign the same triage score to an individual patient? This is described as inter-rater reliability. Triage systems also measure intra-rater reliability. For this question we ask, will I assign the same triage score to the same patient next week? Inter-rater reliability can be measured with different statistics, but is frequently measured with the kappa statistic. A kappa of 0 indicates no agreement, and 1 indicates perfect agreement. Generally, a kappa score of 0.7 or greater indicates very good agreement. A triage system must also be valid. Validity is an accuracy term. For example, when we measure pain, we want to make sure we are measuring pain and not anxiety. Measuring validity of a triage system is a little more challenging and proxy measures of acuity have been used. Typically hospitalization, number of resources used and death have been used to measure validity of triage systems. A triage system would be deemed not valid if a high proportion of low acuity patients were admitted to the hospital as typically, patients with low acuity complaints are discharged home from the ED. Now that we understand these terms let’s look at what we know about 3-level systems. The late Dr. Wuerz examined these concepts by asking triage nurses to rate written patient scenarios using a 3-level system. In phase I, kappa scores = .347. In phase II, Dr. Wuerz measured intra-rater reliability and found even more concerning results, kappa scores were between .145 to .554, very poor. Even worse, only 24% of nurses rated all their cases the same during both phases. Does this mean the triage nurses were not good? NO! It means that they were using a very poor triage system. It is our job as emergency leaders to give triage nurses the best tools that we can to enable them to do their job well. How could they possibly have good inter-rater reliability when 3-level systems do not have definitions, guidelines,

or rules? We can do better. So, in closing, using a 3-level system, you cannot reliably describe what is going on in your waiting room right now. How can you make critical decisions like when to go on bypass? You don’t really know who is and who is not stable in your waiting room. You can’t describe your acuity on a day-to-day or hour-to-hour basis. And you certainly can’t predict staffing needs or urgent care hours, or anything else. So, it is time for 5-level triage. And, the CDC has also recognized this. As we mentioned before, the NHAMCS survey is performed annually by the CDC. Beginning in 2005, it will collect data using a 5- not 4-level system. So, you may wonder, what other 5-level systems are available? There are actually four systems in the literature. The Australasians have been using 5-level triage the longest and began in the mid-1990s. The Canadians modified the Australasian Triage System (ATS) and rapidly followed with the Canadian Triage Acuity System, CTAS, in the mid-1990s. Emergency clinicians in both countries are required to use the scale and report data to the national ministries of health. The triage ratings are a rich data source in these countries, and decisions are made with this information. In the United Kingdom, the Manchester Triage Scale is used. This is a chief complaint driven algorithm. The triage nurse must first choose one of 52 chief complaints and then evaluates specific key elements. There are very good web sites available for both the CTAS and ATS. The fourth triage system, the Emergency Severity Index or ESI, was developed by Dr. David Eitel and the late Richard Wuerz, both emergency physicians. Their research involved a team of emergency nurses and physicians in the development and refinement of the algorithm. With proper training, the algorithm is easy to use. It also has demonstrated very good reliability and validity. A training handbook was published in 2003. There are actually many publications that have reported the reliability and validity of ESI. Today, we will present the results of only a few studies. Original work by Dr. Wuerz investigated the inter- and intra-rater reliability of written scenarios. Weighted kappa scores ranged between 0.68-.87 among a group of nurses. We conducted our own evaluation of inter-rater reliability at Northwestern by retrospectively reviewing 402 actual patient triages at our facility that was not an original research site. We reported a weighted kappa of .89. As we mentioned, more data is available and most studies have been published in the journal, Academic Emergency Medicine. In addition to reported reliability, validity of the ESI has also been reported in the literature. This paper by Eitel et al reports hospitalization as a measure of validity. As you can see from the chart, there is not much variability in admission rates for each triage category, between the 7 different EDs shown. Almost 100% of level 1 patients are hospitalized, somewhere between 60 and 80% of level 2 patients are hospitalized, 30-50% of ESI Level 3 patients were hospitalized and almost 0 level 4 and 5 patients were hospitalized. While there is some variability, this work demonstrates good validity of the ESI triage system. An individual hospital could use their own data to help administration make real-time decisions. If an ED waiting room had 20 level 3 patients and 5 level 2 patients, it would be easy to predict that between 9 and 15 of the level 3 patients would eventually be admitted and between 3 and 5 of the level 2 patients would be admitted. Administrators can use this data to plan ahead and hopefully prevent a bed crunch crises much earlier and ideally implement actions to help diffuse the situation. Finally, this chart depicts the ability of EDs using the ESI system to benchmark or compare themselves to other EDs. Case mix is depicted on the y axis and triage level is on the x axis. It is clear from examining this graph, that the 17th street ED sees a very different case mix with a much lower acuity. And, indeed this is the case. The facility is more of an urgent care walk-in than a full service ED. So, in summary, we have emphasized how critically important the triage role is today in the era of overcrowding. The use of a poor triage system has major safety implications. In addition to the first basic purpose of triage, we have discussed how hospital administrators and public health agencies use our triage data whether we realize it or not. So, it is time to start using a reliable and valid triage system not only to improve patient safety, but to provide better data. The purpose of this segment is to teach you how to use the Emergency Severity Index. I will review the algorithm in detail and will incorporate case examples to clarify important points. At the end of this segment, you should be able to use ESI to classify any patient that presents to your emergency department. Following this segment, you will have the opportunity to apply what you have learned to patient scenarios. The Emergency Severity Index uses both acuity and expected resource consumption to determine triage priority. Acuity or severity of illness or injury is used to assess the ABCs: airway, breathing and circulation. The triage nurse evaluates the potential for life, limb or organ threat to determine how soon the patient needs to be seen. Acuity is always assessed initially. After determining there is no immediate life threat, expected resource consumption is evaluated. Based on the patient’s chief complaint and brief triage assessment, the triage nurse estimates the number of resources a patient is expected to consume in order for a disposition decision to be reached. In other words, what is it going to take to get this patient out of the emergency department – whether that is admitted, discharged, or transferred. I will talk more about resources later in this segment. ESI is a 5-level triage system; each of the levels is clearly defined and mutually exclusive. A patient can’t be a little bit of this and a little bit of that – they must be assigned to one level. There are no 3.5s. ESI allows for rapid sorting of patients upon presentation into one of these five levels. Triage using ESI differs from a complete assessment in respect to the amount of information that is obtained. For triage with ESI, only the information necessary to assign an ESI level is gathered. The triage nurse is gathering only enough subjective and objective information to assign a triage acuity rating. In this era of ED overcrowding, rapid sorting at triage is critical. A triage assessment should, on average, take between 2 and 5 minutes. As Paula stated earlier, triage data needs to be valid and reliable. One of the ways to ensure that this requirement is met is by having an experienced emergency department nurse at triage – a nurse who has attended an ESI educational program and whose competency has been validated. A triage nurse needs the knowledge and critical thinking skills to function effectively in this role and rapidly sort patients. An inexperienced triage nurse will make unsafe decisions with any triage system. To understand how ESI works, it is important to first look at the conceptual model of the algorithm. You will notice 4 decision points: A, B, C and D. To use the algorithm, the triage nurse always starts with decision point A – is this patient dying? If the answer is yes, the patient meets ESI Level 1 criteria If the answer is no, the nurse moves on to decision point B. But lets look closely at decision Point A – Is this patient dying? The criteria used to answer this question are: does this patient require immediate life saving interventions? If the answer is yes, the patient is assigned ESI level 1. What is meant by immediate life saving intervention? Does the patient have an obstructed or partially obstructed airway? Are they unable to protect their own airway? Are they apneic, or were they intubated prior to arriving at the hospital? Or, does the triage nurse feel they need to be immediately intubated or placed on noninvasive ventilatory support because they are they in severe respiratory distress? Or, is their oxygen saturation less than 90%? Is this a patient who is pulseless? Is the triage nurse concerned that the pulse rate, rhythm or quality is an immediate threat to life? Does this patient require immediate cardiac pacing, cardioversion, defibrillation or immediate intravenous access and large amounts of fluid or blood given? Is this a patient who requires immediate medications to reverse a threat to life or limb? Does this patient have an acute change in mental status that requires immediate life saving intervention? For example, are they hypoglycemic and require IV glucose, a heroin overdose who needs a reversal agent, a subarachnoid hemorrhage that cannot protect their own airway? For decision point A, the triage nurse is identifying the patient who on the AVPU scale meets the P or the U – a painful stimulus is required for response or they are unresponsive. Any patient assigned to ESI level 1 is physiologically unstable and requires immediate life saving interventions. These patients need immediate care by both an ED MD and one or more ED RNs – In some EDs this may be a formal team response like the code team or trauma team. The hospitalization rate for ESI Level 1 patients is very high – most will be admitted to intensive care units – a few will die in the ED and a few will be discharged or may leave against medical advice following treatment. Some examples of ESI level 1 patients: a cardiac or respiratory arrest, an overdose with a respiratory rate of 8, someone in severe respiratory distress with agonal or gasping respirations, acute shortness of breath with an oxygen saturation of less than 90%, anaphylactic shock, a critically injured trauma patient – for example, a gunshot wound to the abdomen with a palpable blood pressure of 88, chest pain, whos pale, diaphoretic with a BP 90/palp, patient with a chief complaint of dizziness, with a recent loss of consciousness, who presents with a HR of 40, patients with chest palpitations with a HR of 180, unresponsive with a strong odor of alcohol, severe stroke who needs airway protection. For each of these examples, the patient needs immediate, aggressive life saving interventions. The question is will this intervention save this person’s life? Interventions include: intubation, surgical airway, continuous positive airway pressure (CPAP) or BiPAP, ventilation with a bag valve mask device, defibrillation, cardiovarsion, external pacing, chest needle decompression, significant volume replacement with crystalloid or colloid, immediate administration of medications such as vasopressors, glucose, and the control of major arterial bleeding. There are many interventions that may be performed routinely in the emergency department for diagnostic and therapeutic purposes that are not life saving. These include: diagnostic tests such as EKG, lab studies, administration of supplemental oxygen, placing the patient on a cardiac monitor, obtaining IV access, and the administration of medications that are important but not immediately life saving – these may include ASA, nitroglycerine, pain medications, antibiotics, and heparin. These interventions are NOT considered life saving and do NOT meet Level 1 criteria. It is important to clearly understand the need for immediate life-saving interventions. If you do not, you will end up over-categorizing ESI Level 2 patients and the meaning of ESI Level 1 will be lost. When you communicate with your physician and nurse colleagues that you have a patient that meets ESI Level 1 criteria, everyone will know this is the sickest patient in the department and both the doctor and nurse should drop what they are doing. The patient requires immediate life-saving interventions that cannot be administered only by the nurse. This is not a patient that the nurse can put on the monitor, get a line, and ECG and then let the doctor know about the patient. To summarize, decision point A – is this patient dying? If the answer is yes, the patient meets ESI level 1 criteria. If the answer is no, the triage nurse moves on to Decision point B – is this a patient who shouldn’t wait? There are three questions the triage nurse needs to use to identify the patient who meets ESI Level 2 criteria: Is this a high-risk situation? Is this patient newly confused, lethargic or disoriented? Is this patient in severe pain/distress? Lets look at each of these questions in more detail. Is this

a high-risk situation? This is a situation where the triage nurse feels it would be unsafe for the patient to wait for more than a few minutes for a bed. The patient is presenting with symptoms of a condition that could easily deteriorate or with a condition that’s treatment is time sensitive or they have signs or symptoms of a condition that has the potential for major life or organ threat. Again, this is where the experienced triage nurse is so important. Using their knowledge of anatomy, physiology, pathophysiology, emergency medicine, and their clinical experience, the triage nurse uses their critical thinking skills to identify high risk situations. The determination of high-risk is based on a brief patient interview or on gross observations of the patient or the triage nurse’s 6th sense or intuition. Some examples of “high risk’ situations include: the patient with a cardiac history who presents complaining of chest pain who is physiologically stable, rule out pulmonary embolus in a patient with multiple risk factors, again physiologically stable, a newborn with a fever – we will discuss these criteria in detail later, rule out ectopic pregnancy, neutropenia with a fever, suicidal/homicidal, a needlestick in a healthcare worker. Moving on – lets talk about: is this patient confused/lethargic or disoriented? The triage nurse needs to identify the patient with an acute change in level of consciousness. Is this a situation where the brain is structurally or chemically compromised? The triage nurse has to determine that the patient is physiologically stable and does not require immediate life saving interventions. Examples of new onset confusion, lethargy or disorientation. Lets talk about those. New onset of confusion in an elderly patient – the family reports that this 86 year old female is usually awake, alert and oriented, she took a nap and now woke up confused. A 30 year old, with a known brain tumor, whose wife reports that today he is confused. Adolescent who was found confused and disoriented The third question with decision point B: is this patient in severe pain or distress? This is probably the most difficult concept for new users of ESI to fully understand. Many patients present to the emergency department complaining of pain and so it is important for triage nurses to assess a patient’s pain on presentation. Pain is a subjective phenomenon that has been defined as whatever the patient says it is. Triage nurses are required to assess and document a patient’s pain upon presentation to the ED. Patients should be asked to rate their pain using a research-based pain intensity rating, scale such as the visual analogue scale or the Wong Baker phases. The triage nurse asks the patient if they are currently in pain – if the answer is yes, they are asked to rate their pain on a scale of 0-10, with 0 being no pain and 10 being the worst pain you can imagine – how would you rate your pain? At the same time, the triage nurse is completing a brief triage assessment, asking about chief complaint, past medical history, medications and allergies, and obtaining a set of vital signs. If the patient rates their pain as 7 out of 10 or greater, the triage nurse can assign the patient to ESI level 2 – IF and ONLY if – the triage nurse can do nothing to relieve their pain at triage AND the patient is in need of immediate interventions to relieve their pain. The test has to be whether the triage nurse would give their last open bed to this patient! Not every patient who rates their pain as 7 out of 10 or greater will be assigned to ESI level 2 – for many patients the nurse can provide comfort measures to relieve their pain, such as immobilization, ice, elevation, and distraction. In some EDs, the triage nurse works under triage protocol that provide for the administration of PO pain medication to certain patients. If the patient rates their pain as 9 out of 10, but has had the pain for a few days, is laughing at triage or eating chips, the nurse in good conscience will not give the patient the last open bed. Remember, it is the patient in severe pain that cannot be addressed at triage who will be given your last open bed. Patients who would meet this criteria include: the patient with a suspected or known kidney stone who cannot sit still, who is nauseous and needs IV pain medication, the patient with a severe burn, the oncology patient whose pain regimen is no longer working and they present to the ED for pain management, the patient with a possible dislocated shoulder who is crying, diaphoretic and clearly in excruciating pain, the patient with a suspected compartment syndrome. Let’s move on and talk about distress – any patient who is experiencing significant physiological or psychological distress should be assigned ESI Level 2. Some examples of this include: a sexual assault victim, the combative patient, the homicidal or suicidal patient, the bipolar patient who is manic the acute grief reaction, the known alcoholic with signs of minor head trauma. Frequently, the triage nurse struggles with assigning ESI Level 2 to any of the patients we just mentioned. However, it is important not to get emotionally involved in this decision. All of the patients we just discussed are indeed high risk. All of these patients need rapid assessment and close attention, and if they leave the ED, the triage nurse will be accountable for her decision. This is a good example of how triage category and process may differ. For example, you may assign a psychiatric patient ESI Level 2, but they may not be placed in an open bed for a period of time. But, the triage nurse may have called for security standby, notified your psychiatric liaison, or even initiated lab protocols. The patient remains high risk independent of when they are assigned a bed. Take credit for the high acuity of these patients. Finally, we must also discuss severe physiologic distress. Often patients in respiratory distress are triaged as ESI Level 2. The patient may not require immediate life-saving intervention, but timely intervention of oxygen may be required. In general, while there are no time definitions for ESI, it is ideal for all ESI Level 2 patients to be placed in a treatment area and evaluated by the emergency nurse within 10 minutes of arrival. We have covered high risk situations, new onset confusion, lethargy and disorientation, and severe pain and/or distress. To review, the following patients meet ESI Level 2 criteria: the patient with a history of renal colic who presents with severe flank pain and is vomiting – there is nothing the triage nurse can do to relive this patients pain; they need to be seen and have intravenous pain medication administered, a patient with severe burns to both arms, a patient with a dislocated shoulder who rates the pain as 10+ and is diaphoretic and tearful, a psychiatric patient who presents to the emergency department screaming obscenities, is in severe distress and meets ESI level 2 criteria. ESI level 2 patients remain a high priority. The triage nurse and the emergency department staff should be working together to facilitate rapid placement of the patient into an open bed, which is not an easy situation in this era of Emergency Department overcrowding! Patients assigned to ESI level 2 were identified by an experienced triage nurse as someone who shouldn’t wait! With ESI version 3, about 25-35% of patients were identified as ESI level 2. 50-60% of these patients were hospitalized and many required intensive care or telemetry beds. So, weve now addressed decision point A and B – lets move on to decision point C: how many different resources will this patient consume? Research has demonstrated that experienced emergency department nurses are actually very good at predicting how many different types of resources a patient will consume. This is based on the standard of care for a given chief complaint or diagnosis. It is independent of the type of hospital, location of the hospital, physician on duty or acuity of the department. Of course, there may be some regional variations in physician ordering. For example, in some areas of the country routine x-raying of injured toes may not be done – instead the patient is treated based on the physical exam. Some institutions use the Ottawa Ankle Rules, others do not. Another example is rapid strep screens – in some areas the patient is treated based on the history and physical, in other areas a rapid strep screen will be done to confirm the diagnosis of strep throat. All of these practice variations are ok, and triage will accurately represent your individual departments’ acuity mix. Lets look at the ESI decision point C: how many different resources will a patient consume? No resources is assigned ESI level 5, one resource – ESI level 4, two or more resources – ESI level 3. This graph demonstrates the average number of resources that were actually consumed by patients for each of the 5 triage levels. The data demonstrate the average number of resources used decreased monotonically as a function of ESI level – ESI level 3 used more resources than ESI level 4, ESI level 4 used more than ESI level 5. The triage nurse needs to count the number of different resources a patient will consume – but what is and what is not a resource? If you look closely at the chart, we have identified these for you. You will also notice when looking at the algorithm, although you need to estimate required resources, you never have to count beyond 2! Lab is a resource – whether you do one blood test and a urine test or two blood tests, whether you do one blood test and a culture – it still counts as lab – one resource. ECG is a resource; x-ray – whether you do one xray or 10 xrays, it still counts as one resource. A CT scan, an MRI, an ultrasound, an angiogram – each of those count as a resource. When a patient comes to the ED, it is expected that they will have a history and physical exam – so these are not resources. Their history and physical exam should be appropriate for their chief complaint – so if they have an eye complaint – they will have a slit lamp exam – not a resource. If the patient is female and presents with low abdominal pain, she will have a pelvic exam – not a resource but part of the H&P for that chief complaint. Point of care testing does not count as a resource. Examples include finger stick glucose or pregnancy tests done in the ED. Inserting a saline or heparin lock does not count as a resource, but the administration of intravenous fluid does count. The administration of IM or IV medications does count as a resource. The administration of PO medications does not count, neither does giving a tetanus immunization or handing a patients prescription refill. Specialty consults count as a resource. The patient who needs to see psychiatry will consume one resource, whereas the patient who needs to be seen by surgery and social service will use 2 resources. Emergency physicians as part of their plan of care may contact the patient’s primary care physician by telephone – this does not count as a resource. Finally, lets look at procedures. Simple procedures such as inserting a urinary catheter or nasogastric tube count as one resource each. Conscious sedation counts as 2 resources. Simple dressings and crutch walking, slings and splints do not count as resources. The ESI research team is asked many questions about this – nurses comment that they take a lot of time and should be counted. Remember, we are talking about a triage acuity rating system not a work load measure. And think, what if crutch walking counted? All patients with a sprain would now be ESI Level 3. They would require an xray and crutch walking. By including everything we do, we lose the ability to discriminate among the large number of lower acuity patients. So, don’t worry about it. The definitions are there to provide standardization. You do not get to decide what is and is not a resource. You must follow the algorithm. By doing this, you help maintain the reliability and validity of the algorithm. As I previously mentioned, patients who require no resources are assigned ESI level 5. Let me give you some examples of this type of

patient: a healthy 10 year old with poison ivy, a healthy 52 year old who ran out of his blood pressure medicine yesterday, a 22 year old involved in a car accident 2 days ago and wants to be checked out, nothing hurts, a 46 year old with a cold. ESI level 4 patients are also stable and can safely wait for hours to be seen. This is an ideal group of patients for mid level providers to care for in a fast track or express care setting. ESI level 4 patients require a history and physical exam and consume one resource. Some examples of ESI level 4 patients: a healthy 19 year old with a sore throat and fever – one resource: a rapid strep screen, a healthy 29 year old with a UTI, denies vaginal discharge – one resource: lab – needs a urine, urine culture and a urine pregnancy test which together are one resource, a healthy 43 year old with a stubbed toe, “I think I broke it” – one resource: an xray. If your facility does not routinely xray these patients, then the patient would be an ESI level 5. A healthy 12 year old with a minor thumb laceration – needs suturing – an ESI level 4 Now, let’s move on to ESI level 3 – 30-40% of the patients seen in Emergency Departments. These patients require an in-depth evaluation, and because of this, have a long length of stay in the ED. These patients will require a minimum of 2 resources. You must then address Decision point D: what are the patient’s vital signs? The nurse needs to consider the vital signs when assigning triage acuity. Are they outside the accepted parameters for age? If they are outside of those parameters, the triage nurse can up-triage the patient to ESI level 2. Vital signs outside the accepted parameters do not automatically up-triage a patient – instead the nurse should consider the vital signs and make a decision. This is a really important point to stress. The triage nurse does NOT have to up-triage every adult patient with a heart rate of 100 or greater. Decision Point D also includes temperature for children less than 36 months. The ESI triage research team is following the American College of Emergency Physicians practice guidelines. The infant, 0-28 days, brought to the ED for a fever of 38.0 degrees C or 100.4 F – this baby should be assigned to at least ESI level 2, regardless of how good they look or what the chief complaint was. If the neonate’s condition on presentation suggests that they are in need of immediate life saving interventions, they should be assigned to ESI level 1. For the infant 1 to 3 months, the triage nurse should also consider assigning the baby to ESI level 2 if their temperature is 38.0 degrees C or 100.4 degrees F. For the 3 month to 36-month old child with a temperature above 39.0 C or 102.2 F, the triage nurse should consider assigning to ESI level 3, if in addition to fever, their immunization history is incomplete or they have no obvious source of a fever. For the 24 month old presenting to the ED with a fever of 103 F, and the mom reports the child sees a pediatrician regularly and woke up from a nap pulling on his ear, the child would be assigned ESI level 5. Lets review frequently asked questions: Do I have to upgrade a patient’s triage level if the pain rating is 7 out of 10 or greater? The answer is no, you don’t have to. Lets review some examples of patients who might be assigned ESI level 3, 4 or 5 due to pain. ESI level 3: fractured ankle, abdominal pain, most migraines, ESI level 4: sprained ankle, toe, abscess ESI level 5: a toothache. Do I have to upgrade the patient’s triage level if their heart rate is 104? For the adult with a heart rate of 104, the triage nurse should consider this as part of the assessment. The patient does not have to be up-triaged to ESI level 2. If the patient is always confused are they automatically assigned to ESI level 2? No – ESI level 2 is for those patients with a new onset confusion, lethargy or disorientation. Does ESI identify time to reassessment for each triage level? No, ESI does not do this and this is a key difference between ESI and other 5-level triage acuity rating systems. The ESI triage research group has purposefully not identified reassessment times, but has left that to individual emergency departments to incorporate into their triage policy. We urge you to use caution – in this era of ED overcrowding, it is very difficult for busy triage nurses to reassess patients at a set time when they are busy sorting patients on arrival to the ED. And one last FAQ: What do I do with ambulance patients? These patients should receive an ESI acuity score using the same criteria we just discussed. What if I assign someone ESI Level 2 and I can’t get them back right away? This is a great question. As the triage nurse, you are required to identify the triage level You are not accountable to place the patient. Some ESI Level 2 patients – psychiatric patients – may not be placed immediately according to your protocol, but their triage score is the same regardless of your policy. However, it is desirable that the rest of your level 2 patients be placed as quickly as possible. “As possible” is the key. You should never lower your triage category because you know the patient must wait. You must be able to accurately represent the acuity of each individual patient, as well as your department case mix. So, you’re already a user of ESI and want to know more about the changes from version 3 to version 4 of the algorithm. This segment of the DVD will provide a succinct description of the changes. First, you are probably wondering, “why the change?” Feedback from emergency departments using ESI version 3 provided the impetus for further research. Triage nurses struggled with what they perceived as two categories of ESI level 2 patients. Frequently, patients present to triage in acute respiratory distress, may be pale, diaphorectic, hypotensive, tachycardic or bradycardic, but still be awake, be breathing and have a pulse. Using version 3, these patients do not meet ESI level 1 criteria. They are critically ill, unstable and require immediate interventions. The other group of ESI level 2 patients are those patients that are indeed high risk, in severe pain or distress, or have new onset mental changes. Examples of these patients include: a chest pain patient with normal vital signs and no respiratory distress, patients with severe pain due to kidney stone or cancer, or perhaps and elderly patient that is weak and dizzy with a significant medical history, but physiologically stable at triage. The triage nurse is often faced with the dilemma of multiple level 2 patients and consequently, nurses have to reorganize their level 2 patients accordingly. While this is certainly the right thing to do, the research team discussed the situation at length. We began to feel strongly that the physiologically unstable level 2 patients do require immediate care and probably deserve a higher triage prioritization. In reviewing the conceptual algorithm, ESI level 1 criteria asks the question “Is the patient dying?” Clearly some of the patients we just described above may meet this definition if left to wait. The actual definition of ESI Level 1 criteria on the algorithm lists the following criteria: intubated, apneaic, pulseless or nonresponsive. We began to feel strongly that these criteria were too limiting. So, members of the research team went to work and designed a research project aimed at revising and expanding the ESI level 1 criteria. We conducted a research study at 5 different emergency departments that had been using ESI for several years. We enrolled over 500 level 2 patients and asked the triage nurse to identify which patients she thought were going to need immediate interventions. We also recorded vital signs, past medical history and chief complaint. Patients were later divided into 2 groups: those that actually received immediate intervention upon arrival and those that did not. Interventions were clearly defined. Actions such as starting an IV just to have one or obtaining an ECG did NOT count. An ECG is a diagnostic intervention and has never saved a life yet. The IV is nice access, but we don’t save a life with it unless we administer a medication, fluid boluses or blood. Interventions that did count were any intervention performed to secure an airway, breathing or circulation. Examples include the following: prepare for intubation, starting an IV to administer vasoactive or drugs to control a heart rate, cardioversion, and application of pacer pads. When we analyzed the data, we found that the triage nurses prediction of need for an immediate intervention was the most important factor that predicted whether or not patients actually RECEIVED immediate intervention. In other words, triage nurses did not have a problem identifying which level 2 patients were most sick. A few other factors also predicted immediate interventions, including severe respiratory distress, and SpO2 less than 90. We took these factors and re-worded them into a clinically meaningful way and integrated them into decision point A on the back of the algorithm. So how will this change practice? Actually, it should just make sense. Any patient that the triage nurse perceives will need immediate intervention, as defined on the back of the algorithm card, will now meet ESI level 1 criteria. The definitions on the back are again critical. In maintaining ESI as a reliable and valid system, you can’t choose the interventions, we did. We have listed examples of interventions that do not count. These definitions should be adhered to in order to avoid every level 2 patient becoming an ESI level 1 patient. We really anticipate this change will affect very few patients, but these patients should be easily identified. In our study, 20% of level 2 patients actually received immediate intervention, and using version 4 criteria would now become ESI level 1. So, moving forward, the triage nurse should now ask the following question to help guide the decision to assign ESI level 1: Do I need to bring a physician to the bedside now? If the answer is yes, the patient is probably an ESI level 1. Patients in physiological distress who require advanced airway management, NOT just O2, immediate cardioversion, potential pacing or the administration of vasopressors or other cardiac drugs are good examples. The administration of large volumes of fluid or blood are also another example. These patients require immediate resuscitation efforts. It is important to remember that most level 2 patients should remain ESI level 2, but they should still remain a high priority. For example, most patients with chest pain will remain an ESI level 2. A high risk trauma patient by mechanism, that walks in and is physiologically stable will remain ESI Level 2. They may be walked to your trauma room and assigned a different trauma category, but if stable, they would remain ESI level 2. So, how will this change help you? Again, the language will be beneficial to your team of nurses and physicians. When you walk back or call with an ESI level 1 patient, and communicate this, it should be clear to everyone on the team that a physician and multiple nurses will be needed at the bedside immediately. A stable patient with chest pain is easily managed by the emergency nurse for at least the first 10 minutes without a physician. The nurse can facilitate an ECG, obtain IV access, and administer oxygen without a physician present. However, if the patient was hypotensive, the nurse will need orders for medications and more specific direction. We believe that ESI version 4 will help facilitate care of the most critically ill patients in your department and also more accurately describe your acuity mix. This was the major change in the algorithm from version 3 to version 4 and details of the research project can be obtained in the literature. You may ask, “Was this the only change?” Actually, the research team took this opportunity to update one more portion of the algorithm – pediatric fever criteria. The pediatric fever criteria were strict and outdated. The team reviewed the literature and updated the criteria to reflect the American College of Emergency Physicians Pediatric fever

in the October 2003 issue of the Annals of Emergency Medicine. There is clear direction that any child less than 28 days with a fever of greater than 38.0 C or 100.4 F or higher should be considered high risk. There is debate in the literature over what to do with a child between 28 days and 3 months old. ESI version 4 suggests the triage nurse follow their institutional policy for these children and may triage these children as ESI level 2 or 3. For children 3 months to 3 years of age, the triage nurse should consider assigning ESI level 3 if they have a temperature of 39.0 C, 102.2 F, or their immunizations are incomplete or they have no obvious source of fever. In summary, we believe the pediatric fever criteria will help clinicians more safely assign triage scores to children with fever. So that’s it. Version 4 expands Level 1 criteria to include any patient that requires an immediate life saving intervention and these interventions are research-based and defined on the back of the algorithm. The second change updates the pediatric fever criteria to reflect current practice guidelines. Again, we stress, do not change the algorithm: conduct the research and publish. The ESI research team will continue to evaluate the research and will update the algorithm as needed. You now have a very good understanding of the nuts and bolts of the ESI triage system. It’s time to get serious about implementing it in your own setting. First off, you need to remember the beauty of ESI is that is it a research based triage system with established reliability and validity. Having said that, it is important not to “mess with it”. It is not perfect. However, research is ongoing. If there is something you don’t like about it, you should not change the algorithm. We encourage our peers to conduct further research and publish. The ESI Triage Research Group constantly reviews the literature and has made changes in the algorithm based on important research and clinical guidelines. Again, do not change the algorithm, conduct the research. Changes by individuals and hospitals will compromise the reliability and validity of the system. So, it’s time to implement and you’re in charge. We are going to discuss several key concepts to consider based our experiences and those of others who have been using ESI for a period of time. We will discuss timing of the change, commitment, involvement, planning, education, the go-live phase and on-going monitoring. First, you want to clearly identify and think about why you are making the change. Have their been sentinel events with bad outcomes? Or, are you just being pro-active? What do you expect by implementing ESI? The purpose should really only be to improve the safety of triage and generate accurate acuity data. ESI will not fix your length of stay or necessarily ease the burden of long waits at triage or improve your customer service. But it should ensure that the patients who are waiting are safe to wait. It will also accurately describe your acuity and may generate some very “bad” data. For example, it may demonstrate that your average wait to physician evaluation for ESI Level 2 patients is 30 minutes. This is clearly not a good thing and has patient safety implications. But, this data can be used to help make improvements in your department. Another advantage of implementing ESI, a standardized triage system, is the ability to use a common language to describe the acuity of patients in your waiting room. The day that you implement ESI, all physicians and nurses in your department will be speaking the same language regarding patient acuity. You will no longer need to describe individual patient presentations to describe your waiting room. Next, you need to consider, how much time do we need to get ready to implement ESI? We are frequently asked this question, and the answer is between 3 and 6 months, depending on the complexity of your department and size of your staff. Typically, institutions don’t leave enough time to plan for implementation and we know that poorly planned change is the number one reason for failure. Changing a triage system is a HUGE endeavor, don’t take it lightly. Many times, another change drives the desire to change the triage system. For example, an ED decides to implement a computer tracking system and they already have a go-live date. At the same time, they realize they should be moving to a 5-level system so they want to implement both on the same day. Bad idea. One change at a time. Go ahead and implement your tracking system with 5-level capability. Let everyone get used to that system, but continue to use 3 levels or whatever system youre currently used to. When things have settled down, when everyone is used to the tracking system, then begin the triage acuity rating system change. Once you begin using your tracking system AND you have implemented ESI, you will then be using all 5 levels of your tracking system. It is not possible to expect staff to learn a new tracking system and triage system at the same time. At least, not if you expect lasting change with either one. In addition, be mindful of other big changes that may be happening in your department. You should also think about key players and make sure they are available for training and for go-live. Vacations are very important, plan around them. The next thing to consider when implementing ESI is commitment. This will tie in to your reasons for making the change. Everyone needs to understand the reason for change. Commitment means commitment to training and education, and this means a commitment of financial resources. ESI cannot be implemented successfully without adequate training and this costs money. You should form an implementation task force consisting of emergency nurses, triage nurses, physicians, educators, clinical specialists and administrators. All members perspective are critically important. For example, physicians must be included as they are end users of the system. Triage and staff nurses are the front line users. Educators and administrators are critical as they will be accountable for planning training and organizing other aspects of implementation. All members must be actively involved in the planning process and must understand that the triage system provides a common language to describe real-time patient acuity. Each member of the task force represents their discipline and will provide unique perspectives. Nursing will need to identify strong triage nurses to use as triage preceptors. All triage nurses should have competency assessed with real patients in addition to paper cases in a classroom setting. The implementation team should plan to meet regularly. No one likes going to meetings. So, set goals, stick to them, have agendas, accomplish tasks at your meetings andmake them very productive. And fun is also a very good thing. One of your first tasks for your group is to pick the go-live date. Pick a realistic date and stick to it. Make it a big deal. Everyone should know about it. There should be very clear communication in advance. During the task force meetings, you will also need to plan your educational strategy, not only for classroom, but also for competency assessment of real patients. It is important for each triage nurse to be assessed by an expert or preceptor when triaging real patients. This will require some serious commitment and significant planning, but it can be done. Your educator or CNS can be a critical person in this phase of validation. Also, strong triage nurses can also be used to help assess staff competency. This live assessment is very important. Even though you will use paper cases to assess competency prior to implementation, patient scenarios are always more unclear. Triaging real patients is always a challenge and patients do not present with black and white scenarios, but always very grey. Educational planning in general is critical. The didactic component can be accomplished either by using video as a group setting, having clinicians view segments individually, or by enhancing the video with other cases. The intent of this video is to provide each triage nurse with an opportunity to understand the system at their own pace. This video will also allow maximum flexibility in how an organization decides to plan its’ educational component. If you use this video in a group setting, you can always stop the DVD and lead a group discussion. Group settings can also be used to discuss aspects of your triage policy. For example, standing orders at triage, how to handle patients brought by the police, etc. Finally, you must always consider how you would like to complete physician education. Most physicians will appreciate copies of the ESI research publications. At a minimum, it is suggested physicians review the section of the DVD that reviews the algorithm and provides definitions of each triage level. So, classroom training is now complete. It’s go-live time! And, there should be lots of support, 24/7 on the day-of and surrounding the go-live date. Don’t forget the nightand weekend shifts, they triage patients too!!! We strongly suggest a team member is available 24/7 and weekends to be physically in the department to answer questions and assess triage level accuracy. Ideally, a triage preceptor will work with each triage nurse for a minimum of 4 hours to validate competency in assigning the ESI triage acuity ratings. If this is not possible, you should plan for a super-user available on the unit to spot check triage scores and address problems. This is a large commitment, but a critically important step in ensuring proper use and reliability of the system in your institution. Don’t expect smooth sailing. With any change, there will be unexpected situations to deal with, no matter how you planned. So, provide a mechanism for everyone to contribute feedback, both positive and negative. You will not be successful if you stifle negative feedback. And, most importantly, provide lots of positive feedback to everyone. Discuss cases in which there is disagreement. Do not be negative or punative. Provide a tremendous amount of positive feedback. And finally, evaluation of your use of ESI is never finished. You should plan for how you are going to conduct on-going monitoring. There are many ways to accomplish this. You should, at a minimum, evaluate the accuracy of the triage ratings. This can be accomplished by chart audits. Ideally, all triage nurses can participate in the review at some point. Each chart should also be reviewed by a triage expert – your educator, CNS or designee. Feedback from these reviews should be provided to the staff. When reviewing charts, it is important to review only the triage note. It is very easy to look at the discharge diagnosis and predict a triage score. However, the triage nurse has limited information. So, when reviewing notes, only review triage information and make your decision regarding accuracy of the triage acuity score using that information. One successful example was, as a CNS, I reviewed 15 charts per week with staff nurses. Any “mis-triages” were typed up with a summary of why the triage score was inaccurate. We would accumulate 5 or 6 cases a month and distribute the summaries to each nurse. The nurses enjoyed reading them and we were able to correct any misunderstandings or knowledge deficits. They were used as a learning tool, not a punitive mechanism. Another useful strategy may be to establish a mechanism in which anyone can have a case reviewed because they thought the triage score was inaccurate. Most importantly; nurses and physicians should be encouraged to discuss their concern or rationale with each other. We all learn best by a collaborative approach. And one final note on something that should NEVER be audited as a measure of ESI. We are often asked if facilities should actually count the resources that were used to determine if the triage nurse was “right”. This should never be done. The triage nurse estimates resources for ESI Level 3, 4, and 5 patients on arrival only to help differentiate between the large numbers of patients that do not require immediate evaluation. Triage nurses actually do a very good job with this. But, patient stories change, new clinical information is provided, and the number of resources is not a good indicator to monitor. So, in summary, there is a lot of planning to be done, so get to it, and best of luck! You and your colleagues will be successful. And you will feel more comfortable that those patients in your waiting room are safe to wait!

AHRQ, Agency for Healthcare Research and Quality, patient safety, Emergency Severity Index, ESI, triage, protocol, algorithm, Tanabe, Gilboy, emergency depar…
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