Emergency Severity Index, 4 th ed : Introduction to the five-level Triage Scale

1. Emergency Severity Index, 4thed: Introduction to the five-level Triage Scale Christine Chao Northeastern University

2. Table of Contents • Triage Overview and Refocus • Current Triage Statistics • Emergency Severity Index (ESI) • ESI Triage Algorithm • A) Does this patient require immediate life-saving intervention? • APVU Scale • B) Is this a patient who shouldn't wait? • Level 2 Indications • C) How many resources will this patient need? • D) What are the patient's vital signs? • ESI Reliability and Validity • References

3. Triage: Overview and Refocus • Triage is used to systematically prioritize patients No standardization of triage acuity rating systems • Three-level triage systems resulted over triage or under-triage • In 2002, Joint Triage Five Level Task Force released the following statement: “Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid five-level triage scale such as the Emergency Severity Index (ESI).” • ESI takes into account patient’s physical, developmental, psychosocial needs, patient flow in the emergency care system, and health care access.

4. CURRENT Triage Statistics • In 2009, 57% of US hospitals have adopted the five-level Emergency Severity Index (ESI) system. • After implementation of five-level triage systems in Germany and Switzerland, the proportion of patients who leave the ED due to a long waiting time is lowered by 50%. • Of the 123.8 million visits to the U.S. emergency departments in 2008, only • 18% were seen in the first 15 minutes. • Several studies have demonstrated poor inter- and intraraterreliability of conventional three-level triage in the United States.

5. Emergency Severity Index Three-level triage resulted in • tendencies toward early discharge of patients • minimizing readmission rates • reducing the use of an overburdened health care system is changing the face and function of triage. Emergency Severity Index (ESI) was developed to increase accuracy. According the the ESI guidebook, “The ultimate goal of ESI implementation is to accurately capture patient acuity to optimize the safety of patients in the waiting room by ensuring that only patients stable to wait are selected to wait.”

6. ESI Triage Algorithm This algorithm is designed to help triage nurses differentiate the critically ill from a large population of patients. ESI uses several quality indicators to monitor a patient’s health: life-saving intervention, abnormal disposition/behavior, resources, and vital signs.

7. A) Does this patient require immediate life-saving intervention? • QUICK CHECKLIST • already intubated • apneic • pulseless • severe respiratory distress • SpO2 < 90 percent • acute mental status changes • unresponsive • To determine if a patient is classified as ESI level 1, the patient requires an immediate lifesaving intervention suchas resuscitation, immediate medication or another intervention such as a blood transfusion. The patient may need an intervention if there is any concern about the following: • ability to deliver adequate oxygen to the tissues • breathing, maintaining a patent airway • detectable pulse • abnormalities in pulse rate, rhythm, and quality • chest pain including patients who are pale, diaphoretic, in acute respiratory distress or present unstable blood

8. AVPU SCALE AVPU (alert, verbal, pain, unresponsive) scale: The goal is to identify the patient who has a recent and/or sudden change in level of conscience or are non-verbal or require noxious stimuli to obtain a response. • Patients scoring a P (pain) or U (unresponsive) on the AVPU scale meet level-1 criteria. Unresponsiveness is assessed in the context of acute changes in neurological status, not for the patient who has known developmental delays, documented dementia, or aphasia

9. B) Is this a patient who shouldn't wait? QUICK CHECKLIST for level-2 criteria: Is this a high-risk situation? Is the patient confused, lethargic or disoriented? Is the patient in severe pain or distress? • At decision point B, the nurse needs to decide whether this patient is a someone that should not wait to be seen. • If the patient should not wait, the patient is triaged as ESI level 2. • If the patient can wait, then the user moves to the next step in the algorithm. • At triage nurse will look at the three criteria detailed on the next slide. Patients who meet the ESI level 2 criteria should have their placement rapidly facilitated.

10. level 2 Indications

11. C) How many resources will this patient need? • Resources • Labs (blood, urine) • ECG, MRI, ultrasound • IV fluids for hydration • Specialty consultation • Simple and complex procedures • Not Resources • Physical exam • Saline • Prescription refills • Phone call to PCP • Simple wound care • Crutches, splints, slings • A patient is considered for ESI level 3, 4 or 5 is a triage nurse determines the patient is out of any immediate or oncoming threatby implementing the following information: • brief triage assessment • past medical history • medications • age • gender • to determine how many different resources will be needed for the ED provider to reach a solution.

12. D) What are the patient's vital signs? • In ESI, vital signs, while important, may not always be helpful in determining initial triage level. • Only absolutely required for patients classified as ESI level 3. If the danger zone vitals are reached, a triage nurse can consider up-triaging to the patient from a level 3 to a level 2. • In the cases of urgency such as ESI level 1 and 2, vital signs may not be needed unless there is enough time. • Vital signs are ideally only taken if needed to estimate urgency or if time permits

13. ESI Reliability and Validity • The Emergency Severity Index has shown high reliability and validity through the following studies: • Reliability and validity of a five-level triage instrument • Five level triage: A report from the ACEP/ENA Five Level Triage Task Force • Accuracy of the Emergency Severity Triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention. • Five-level triage system more effective than three-level in tertiary emergency department. • Validation of the Emergency Severity Index (ESI) in self-referred patients If implemented widely in the US, ESI can has the ability to become the standard triage acuity assessment in EDs. For further information, please refer to the Emergency Severity Index (ESI) Implementation Handbook, 2012 Edition online at http://www.ahrq.gov/professionals/systems/hospital/esi/esi1.html

14. References Aacharya, R., Denier, Y., & Gastmans, C. (2011, Oct 7) Emergency Department Triage: An Analysis. BMC Emergency Medicine, 11(16), 1-13. Christ, M., Grossman, F., Winter, D., Bingisser, R., & Platz, E. (2010, December 17). Modern Triage in the Emergency Department. DutschArztebl Intl, 107: 892-898. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021905/. Emergency Nurses Association and American College of Emergency Physicians. STANDARDIZED ED TRIAGE SCALE AND ACUITY CATEGORIZATION: JOINT ENA/ACEP STATEMENT. Emergency Nurse Association. Emergency Nurse Association, 2002. Web.  ESI Triage Algorithm, v. 4. Digital image. Welcome to the Emergency Severity Index (ESI). Emergency Nurse Association, 2004. Web. <http:// www.esitriage.org/algorithm.asp?LastClicked=algorithm>. Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. (2012, January 1). Emergency Severity Index (ESI): A Triage Tool for Emergency Department. Agency for Healthcare Research and Quality, 4. Retrieved from http://www.ahrq.gov/professionals/ systems/hospital/esi/esi1.html. Green, N., Durani, Y., Breecher, D., DePiero, A. (2012 Aug 28). Emergency Severity Index version 4: a valid and reliable pediatric emergency department triage. Pediactric Emergency Care, 28(8): 753-757. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22858740 Pitts, S., Pines, J., Handrigan, M., & Kellermann, A. (2012 Dec). National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity. Annals of Emergency Medicine, 60(6): 679-686. Retrieved from http://www.annemergmed.com/article/S0196-0644%2812%2900507-0/abstract. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. (2002 Mar 7) Reliability and validity of a new five-level triage instrument. AcadEmerg Med, 7:236;–42. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10730830

15. Notes Reflective Note: This presentation is intended for emergency medical professionals who are operating emergency departments with a two-, three- or four- level triage assessment. The Emergency Severity Index has proven to be more accurate and efficient in providing better patient care than other systems. The intention is to bring to attention the benefits of a more comprehensive system of classification. The language is geared towards a population with a strong medical background, reducing explanation of several medical terms. This PowerPoint is has a very simple design. Because the topic is more serious, I did not include any extra photos or comics as I intend to for project 4. Important points and key words for different slides are bolded or highlighted to make this an easy reference guide. I also included easy to read lists to show the breakdown of ESI. This also allows for easy comparison to other triage systems. Personal Note: I think this would make a great addition for my portfolio. I had a good time learning about triage and emergency departments as well as putting myself in the shoes of a medical professional. Project 3 demonstrates my ability to present information in a professional way.