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37 While these interventions highlight the promising out- comes for incidentaloma management using providers from multiple areas of health care, no studies to date have examined if these interventions have reduced disparities in Fig. 2 e IAM workup. DST [ dexamethasone suppression test; HTN [ hypertension. Table 2 e AD... | 70 | 5 | 5 | 90c20d724e007af6758810d808a00632b96a0fb05e4e0554be66631ca93b3a9e |
Ordering provider ADI Advantaged ( < 50 percentile) Disadvantaged ( > 50 percentile) N% n % EM 74 54.8 48 45.3 PCP 24 17.8 7 6.6 Subspecialist 37 27.4 51 48.1 o’connor et al adrenal incidentaloma management 147 | 70 | 5 | 5 | ed16488249b30ed48d3df9910e0bbade93d5047b7fb3cd71b127b1b1443635c2 |
the workup of adrenal nodules. It is not hard to imagine positive resources directed to identify IAM patients may be unequally distributed and benefit well-resourced clinics. Thus, to further improve health outcomes and equity, in- terventions must consider the patient population and setting. | 60 | 6 | 6 | 922c67a1822c68c0f770b48601b1db522d7cd268b51633cd16446e33e20a8931 |
One relevant model to help achieve these goals is the Health Disparities Framework, developed by the National Institute on Minority Health and Health Disparities. 38 The adaptation of the socioecological model evaluates five domains (biological, behavioral, physical/built environment, sociocul- tural environment, and h... | 83 | 6 | 6 | 1477dddc437a046181532e14111af5c9f7a4ab2974cb30901deb58ca26d500bf |
Building upon this and the findings of our study, we encourage researchers and doctors to consider patient and neighborhood-level dispar- ities when implementing subsequent interventions. We found a major obstacle for patients in disadvantaged com- munities is following up with PCPs after the identification of an IAM. | 58 | 6 | 6 | 2db69ae42f1fb9ddbcd86928106d8c29a490c61e23e996b4b03cc990981e9712 |
Although we cannot determine the exact reason for each patient, one proposal could be the use of patient navi- gators who can help overcome environmental and neigh- borhood factors such as transportation, costs, and insurance coverage. | 46 | 6 | 6 | 3609df69ef9f190b85302eb4939b0d8d884dbb9db910a8a30e4fb83d2fbbbdd3 |
This strategy has demonstrated success in improving cancer management and treatment. 39 , 40 For instance, one randomized control trial found patient navi- gation led to significantly greater compliance with follow-up among minority women with abnormal mammograms. | 46 | 6 | 6 | 3ae624b88caac97be474c9dfb0c42e2d6152bf84bd98fc60b6d77b24b3a3b0df |
41 As a result, navigators remain a promising method through which to eliminate disparities in care for IAMs, although obvious barriers such as costs and workflow burden require more in-depth investigation. Overall, the low rates of IAM follow-up, particularly among patients from disadvantaged neighborhoods, suggest th... | 79 | 6 | 6 | e0d04f6f384a1bdbd0e3ea7caf9a7c2abd2f38edfe432cb0e8b4853ba81c104d |
Our study had a number of limitations. For one, retro- spective data and inherent inaccuracies in the electronic medical record may skew results. The data were only from a single institution and the population skewed more toward White and insured, making the results less generalizable. | 54 | 6 | 6 | d3f02d5533bb86e48563dbfee06da3b4c61dd2f90dfe6afed1887417af60e5e3 |
Including a greater percentage of non-White or Medicaid patients could allow for further elucidation of barriers to workup which specifically constrain these populations. In addition, due to the retrospective nature, we cannot deter- mine the direction of the relationship between neighbor- hood disadvantage and lower r... | 62 | 6 | 6 | c008bf90de17e0f37cd42dc9171ef722aa82f22d1dbcce31ece272c99a555cf3 |
We are also unable to determine any verbal or other communication provided to the patient regarding their identified nodule. Table 3 e Factors associated with workup. Variable OR (95% CI) Sex Male ref Female 2.26 (1.19-4.31) Age > 65 ref < 65 1.34 (0.54-3.32) CCI 0 ref 1 1.03 (0.43-2.48) 2+ 1.16 (0.49-2.73) Race/Ethnic... | 257 | 6 | 6 | 2527e9f5df09ce885ae8323598329a5afaa72e825fdcae7492cbc2a1d83ddd61 |
Table 4 e Common themes for lack of workup among disadvantaged patients Radiologist recommended no workup PCP did not acknowledge nodule Patient lost to follow-up Number of patients 11 13 6 Selected quote from Electronic Health Record “Benign 1.6 cm left adrenal adenoma. | 59 | 6 | 6 | 74624d5d0e7cdb17d311b4b6a587a2fb82be983c165a3ae32f1e4780ef494d64 |
No follow-up imaging is necessary” “Partially imaged, indeterminant 4.6 cm right adrenal mass, likely adenoma or adrenal myelolipoma, both benign. | 44 | 6 | 6 | 148443087747107abc145b2d1a1f73b5c1c831a90c7a1298be40de680095076a |
Consider nonurgent adrenal protocol CT or MR for further characterization.” “Incidental indeterminate 1.4 cm adrenal nodule. Consider follow-up in 12 mo if no history of malignancy versus nonurgent evaluation with adrenal protocol CT or MRI.” “Discussed the need to complete testing for evidence of hypercortisolism or p... | 102 | 6 | 6 | 5de7efddedc2d1f9f8a53dbda4e9e1ddd830a1467010754a72d635c53eab364f |
148 journalofsurgicalresearch july 2025 (311) 143 e 150 | 17 | 6 | 6 | f268f8628097f5cc57ec181b8c29963c5dc7e2cb077a88ac61f03e4f4116104c |
Conclusions Overall, the rates of complete or partial guideline-based biochemical workup of adrenal incidentalomas in our study population were low at 11% and 18%, respectively. Patient neighborhood disadvantage and studies ordered by EM pro- viders were associated with lower rates of biochemical workup. Further invest... | 447 | 7 | 7 | 1e2d6ad6ee140d0e8c05c2fe8ddf178a55d7cd4f9418941c0de8172057aa403d |
1982;92:866 e 874 . 4. Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European society of endocrinology clinical practice guideline in collaboration with the European network for the study of adrenal tumors. Eur J Endocrinol . 2016;175:G1 e G34 . 5. Song JH, Chaudhry FS, Mayo-Smith WW. The ... | 449 | 7 | 7 | 4104fb5d4ede530eb61625808fd9c2edf464f5b9fbd5a762330751fb7db2aea5 |
adrenal incidentalomas that are either non-secreting or associated with intermediate phenotype or subclinical Cushing’s syndrome: a 15-year retrospective study. Lancet Diabetes Endocrinol . 2014;2:396 e 405 . 12. Feeney T, Madiedo A, Knapp PE, Gupta A, McAneny D, Drake FT. Incidental adrenal masses: adherence to guidel... | 450 | 7 | 7 | a3d7ccfb2b3ba79217917a98ec6050540a7b483852aaa17997cf866000b6e317 |
incidentaloma follow-up is influenced by patient, radiologic, and medical provider factors: a review of 804 cases. Surgery . 2018;164:1360 e 1365 . 21. Morelli V, Reimondo G, Giordano R, et al. Long-term follow-up in adrenal incidentalomas: an Italian multicenter study. J Clin Endocrinol Metab . 2014;99:827 e 834 . 22.... | 153 | 7 | 7 | e72e35c5ccdfdead343693a234bbca8d2b97815d88602b5f1930e5e05758b35a |
Kirby JB, Kaneda T. Neighborhood socioeconomic disadvantage and access to health care. J Health Soc Behav . 2005;46:15 e 31 . Schut RA, Mortani Barbosa EJ. Racial/ethnic disparities in follow-up adherence for incidental pulmonary nodules: an application of a cascade-of-care Framework. J Am Coll Radiol . 2020;17:1410 e ... | 86 | 8 | 8 | f9525ee843fcc385d11bce314e23bb1e491f27225b8f8ffcceda6aba89efced2 |
Abrahamowicz AA, Ebinger J, Whelton SP, Commodore- Mensah Y, Yang E. | 23 | 8 | 8 | 63b533b006a9edaab15b938638cbf1691a3375bc386d05f5e439b4de5732f3af |
Racial and ethnic disparities in hypertension: barriers and opportunities to improve blood pressure control. Curr Cardiol Rep . 2023;25:17 e 27 . Hassan S, Gujral UP, Quarells RC, et al. Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward. Lancet Diabetes Endocrin... | 449 | 8 | 8 | 3c05cfbe4a4a644e7211f3c6da70762c7a11ff4713caf87f49d04f031f8b992b |
Watari J, Vekaria S, Lin Y, et al. Radiology report language positively influences adrenal incidentaloma guideline adherence. Am J Surg . 2022;223:231 e 236 . | 41 | 8 | 8 | 7c008bf656da3f0ce847fa4d634b585fbed16d17dac52a5441d8bc47d4c72800 |
Woods AP, Feeney T, Gupta A, Knapp PE, McAneny D, Drake FT. Prospective study of a system-wide adrenal incidentaloma quality improvement initiative. J Am Coll Surg . 2024;238:961 e 970 . Barrett TW, Garland NM, Freeman CL, et al. Catching those who fall through the cracks: integrating a follow-up process for emergency ... | 105 | 8 | 8 | 260ce5d27ea862c2b4283bd499db90527cefeb1b043158ef42b33bcd12116605 |
Alvidrez J, Castille D, Laude-Sharp M, Rosario A, Tabor D. The national Institute on minority health and health disparities research Framework. Am J Public Health . 2019;109:S16 e S20 . Freund KM, Battaglia TA, Calhoun E, et al. Impact of patient navigation on timely cancer care: the patient navigation research program... | 204 | 8 | 8 | f135acba110eda106ef5277fbdfc7e6d44678b7db405b111467e60dc37d00a26 |
September 2023 ◆ Volume 108, Number 3 www.aafp.org/afp American Family Physician 275 ORAL SALT LOADING TEST For the oral salt loading test, a high-salt diet supplemented with sodium chloride tablets is consumed for three days with a goal sodium intake of 6 g per day. High salt intake should cause physiologic suppressio... | 450 | 3 | 3 | 1be443893ec2274d4c7747022b364c7fb565c683b2e249cb05ec9e2fe4c5dd44 |
adenomas can be reliably distinguished from malignant masses. 20 CT has lim - ited sensitivity for the detection of sub-centimeter nodules. Additionally, CT is unable to distinguish nonfunctioning adenomas from functioning adenomas. A systematic review showed an almost 40% rate of discordance between CT and adrenal vei... | 389 | 3 | 3 | ecae8350f8b196ea37b6df11b07d157f3c0a8445ae9a71345cc702722aabb733 |
276 American Family Physician www.aafp.org/afp Volume 108, Number 3 ◆ September 2023 significant higher rate of complete biochemical success when adrenalectomy was guided by adrenal vein sampling com - pared with adrenalectomy guided by CT alone (odds ratio = 2.78; 95% CI, 1.88 to 4.12). | 76 | 4 | 4 | 347dbb1840718490ef3d70bec45fc56888a1039700af3d70e4f697f5592d8ef9 |
18 Adrenal vein sampling is a nuanced procedure. Blood samples are taken from a peripheral vein and the right and left adrenal veins and tested for aldosterone and cortisol lev - els. 22 Success rates for adequate sampling range from 30.5% 23 to 99.2%. | 57 | 4 | 4 | f1c779379f984475984dd4694989ac594a6a9189af58ca1d15a7b28d7caab4a0 |
24 Operator experience at a center that performs at least 12 procedures per year has been shown to be associated with higher sampling adequacy. 25,26 An experienced and dedicated laboratory is necessary for a successful adrenal vein sampling program, 27 and the results should be interpreted based on expert consensus gu... | 58 | 4 | 4 | beba1cd76cc46bda5662f46d3d1d8f587bd08382096fa17d32cf3007c620892e |
28,29 Treatment UNILATERAL ALDOSTERONE PRODUCTION Adrenalectomy is recommended in cases of uni - lateral aldosterone production. Although hyper - tension is cured in only approximately one-third of cases, biochemical cure is achieved in 94% of cases. | 57 | 4 | 4 | 223ada36a173b2c8656a3e2d3aa0a9d73499a4387251d32acf9fbaa46cef8ac0 |
30 Compared with medical management, adrenalectomy reduces the rate of composite adverse cardiovascular outcomes by one-half 31 and is associated with superior quality of life. 32 BILATERAL ALDOSTERONE PRODUCTION When aldosterone production is bilateral, medi - cal therapy is necessary. | 58 | 4 | 4 | f43e1e1d72b9abc450d464448572c0f027849ccf01ba787b8b9511e889f7d7a7 |
Mineralocorticoid recep - tor antagonists are the cornerstone of therapy for patients with primary aldosteronism. They are often used concurrently with other antihyper - tensives. Dietary sodium restriction of less than 1,500 mg per day is recommended. | 54 | 4 | 4 | 2e33e5ea301a3d7e78f2e84eeb89a46839aee461ffa52a0ae033263d998650f1 |
33 Spironolactone is a nonselective mineralocorti - coid receptor antagonist and is the initial medica - tion of choice. Typical starting dosages are 12.5 to 25 mg per day and are increased, as needed, to a maximum dosage of 400 mg per day. | 61 | 4 | 4 | 94d064b375926110cfa95049a0efbbddc09d4343b9dc4aee6daedf8c2bc6a2bb |
10 Its dose - dependent antiandrogenic properties can lead to adverse effects, such as gynecomastia (more than 10%), erectile dysfunction, decreased libido, and irregular menses (1% to 10%). | 46 | 4 | 4 | b44f649a226f191e3a8a3ad68ebd04cd5fafa60d939d43dd304d74eadf1e901a |
34 If these adverse effects occur, eplerenone, a more selective but less potent and more expensive mineralocorticoid receptor blocker, may be used. 13,34 Recent observational studies have shown that titrating mineralocorticoid receptor antagonists based on plasma renin concentrations may lead to better outcomes. | 63 | 4 | 4 | 5d97d6819cd9ddc69f83581c0ca6a6a03dc5c04c43c3a6c8fd0b2748416b6efa |
35,36 Therefore, future guidelines may include interval measurements of renin as part of the mineralocorticoid receptor antagonist dosing strategy. 36 Data Sources: A PubMed search of clinical trials, meta-analyses, randomized controlled trials, and systematic reviews from 2000 to 2022 was completed using the key terms... | 84 | 4 | 4 | 3dfaa0c17cf448821b4564c696d07ad6ad507b5aa6ee50967d18d0a64d083c9b |
We also searched the Cochrane database, Agency for Healthcare Research and Quality (AHRQ), and Essential Evidence Plus using the same terms, but with limited results. If studies used race and/ or gender as a patient category but did not define how these TABLE 3 Medications to Hold Before Primary Aldosteronism Te s t in... | 154 | 4 | 4 | f6e7f6246c1f0fef0229810759083d084af125fbaa1aa1b8755322a0b406afc0 |
Because of interference with the renin -angiotensin-aldosterone system, certain antihypertensive medications may alter renin and angiotensin levels. *—Based on the 2016 Endocrine Society Guidelines. | 45 | 4 | 4 | 0b64056d505839be2028280aa720ba2dd85cda50a6a266513c5fb9b0d76aaeea |
† —Low-dose mineralocorticoid receptor antagonists may not need to be held before aldosterone-renin ratio testing, especially if renin levels are not suppressed. Information from reference 13. | 42 | 4 | 4 | 9959f9eb299f3a001c415e590dbfaf46e3e4746849b7bcf79c6e5f74dfc6b75c |
TABLE 2 Clinical Criteria for Patients Who Require Case Detection Testing for Primary Aldosteronism Controlled hypertension (any one of the following) Adrenal nodule Atrial fibrillation* Family history of early stroke (i.e., younger than 40 years) First-degree relative with primary aldosteronism Hypokalemia Obstructive... | 83 | 4 | 4 | 8ceeafc5ddf24294c74c71623822c48c66f0fc937da5f7c3d7a7de568c7b0f7b |
Criteria are based on the 2016 Endocrine Society Guidelines. *—The Endocrine Society does not distinctly list atrial fibrillation as criteria, but it acknowledges that some centers recommend testing given its association with primary aldosteronism. | 49 | 4 | 4 | acfe3ee680d2f2c502a10ae24f381503982eb9e809096defc5f944d30293c8e6 |
† —Resistant hypertension is hypertension that persists despite the concurrent use of three different classes of antihypertensive medications or the use of four antihypertensive medications to achieve adequate blood pressure control. | 40 | 4 | 4 | 2777a5e9acbe0cd35674c77edfb9239b1696b6c0cd96c55ab6563b6ba7583c97 |
Information from reference 13. September 2023 ◆ Volume 108, Number 3 www.aafp.org/afp American Family Physician 277 PRIMARY ALDOSTERONISM categories were assigned, they were excluded. Studies may not represent all populations. Physicians may need to exercise caution in applying such guidelines to populations not includ... | 231 | 4 | 5 | 72412e65735b94cb9b68e4b01765c8179279f3f44470916941db520417ad1d28 |
Reprints are not available from the authors. References 1. Conn JW, Louis LH. Primary aldosteronism, a new clinical entity. Ann Intern Med . 1956; 44(1): 1-15. 2. Monticone S, Burrello J, et al. Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol . 201... | 450 | 5 | 5 | 76ea031d5a5f96cae2c34d03f7571b31377a1ad71144510568b81188f578c537 |
2019; 285(2): 126-148. 11. Monticone S, D’Ascenzo F, et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hyperten - sion: a systematic review and meta-analysis. Lancet Diabetes Endocri - nol . 2018; 6(1): 41-50. 12. Monticone S, Sconfienza E, et al. Renal damage in prim... | 447 | 5 | 5 | f68198ceb7d689c297a3195d7435a7a10ea76c6aaa3f6a3b55878f817bb7603d |
steronism: a systematic review and meta-analysis. J Clin Hypertens (Greenwich) . 2022; 24(2): 106-115. 19. Lim V, Guo Q, et al. Accuracy of adrenal imaging and adrenal venous sam - pling in predicting surgical cure of primary aldosteronism. J Clin Endocrinol Metab . 2014; 99(8): 2712-2719. 20. Peña CS, Boland GW, et al... | 450 | 5 | 5 | 4a7e0efb68233a2f9cc3d9c675777329f05caf4a44e59ecca9153cd061f2da89 |
procedures. Diagn Interv Radiol . 2018; 24(2): 89-93. 27. Kline G, Holmes DT. Adrenal venous sampling for primary aldosteronism: laboratory medicine best practice. J Clin Pathol . 2017; 70(11): 911-916. 28. Kline GA, Harvey A, et al. Adrenal vein sampling may not be a gold-stan - dard diagnostic test in primary aldoste... | 450 | 5 | 5 | 1d40e3bb985f5ec9c89db05d54a0cab0db0635bd8efa3a2e3bd3f105babea788 |
F, et al. Safety profile of mineralocorticoid receptor antagonists: spironolactone and eplerenone. Int J Cardiol . 2015; 200: 25-29. 35. Köhler A, Sarkis AL, et al. Renin, a marker for left ventricular hypertrophy, in primary aldosteronism: a cohort study. Eur J Endocrinol . 2021; 185(5): 663-672. 36. Hundemer GL, Curh... | 151 | 5 | 5 | 5af38d2eda7a3feef6ab2e58b00b4fbde5044bd6bf01ed50301dd2f9fff913ab |
iii CONTENTS CONTENTS Preface v Acknowledgments vi CHAPTER 1 – Introduction to the Emergency Severity Index 1 CHAPTER 2 – Overview of the ESI Algorithm 5 CHAPTER 3 – Decision Point A: | 44 | 3 | 3 | a422850b2ac1858a942c935867bf7e9a899fe31b76add0851bda2cd18fb4bc91 |
Lifesaving Intervention Required? 9 CHAPTER 4 – Decision Point B : High-Risk Presentation? 11 CHAPTER 5 – Decision Point C : How Many Resources? 19 CHAPTER 6 – Decision Point D : High-Risk Vital Signs? | 52 | 3 | 3 | bc7e7e281267e48bfa8d6d2c1f26e6155bfad955ec72eccd051cb8e5f78435ab |
23 APPENDIX A – Frequently Asked Questions 27 APPENDIX B – ESI Triage Algorithm, v5 29 iv EMERGENCY SEVERITY INDEX V5 Dedication To those who pioneered and developed the Emergency Severity Index: | 53 | 3 | 4 | d2b65b7271644d72de290e8f1eafcbe3cdf8dda29f49431e4f46215aac695294 |
Richard Wurez, David Eitel, Nicki Gilboy, Paula Tanabe, Debbie Travers, Alexander Rosenau, and a host of others. v PREFACE PREFACE The Emergency Severity Index ® (ESI ® ) is a tool for use in emergency department (ED) triage. | 63 | 4 | 5 | 6c7b56946484faa180121c2d3eb59018039f98290b9e9f2e73069920798465c3 |
The ESI algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by acuity with consideration of resource needs for stable, low-risk patients. | 63 | 5 | 5 | 665c0fdd3b8a05eecd2e4593ac7bb4bd7d8749ded0a216853559af1bd5a232d5 |
Emergency physicians Richard Wurez and David Eitel developed the original ESI concept in 1998 and brought together other emergency professionals interested in triage with further refinement of the algorithm. The ESI Triage Group included emergency nursing and medical clinicians, managers, educators, and researchers. | 56 | 5 | 5 | 65d19931ac3d785c011a57ded0c6e2830a4ad7e79e362a5936070d730647e78e |
The ESI was initially implemented in two university teaching hospitals in 1999 and then refined and implemented in five additional hospitals in 2000. The tool was further refined based on feedback from the seven sites. Research over the last 20 years has established the reliability, validity, and ease of use of the ESI... | 60 | 5 | 5 | 3c2ab325b5a68ffc1260c371773136201bc2782ad8dfaf5a0f85fc7a2fe95bc4 |
One of the ESI Triage Group’s primary goals was to publish a handbook to assist emergency nurses and physicians with implementation of the ESI. The group agreed that this was crucial to preserving the reliability and validity of the tool. | 49 | 5 | 5 | 8ad62e92576f51eb28d4222a52ebcb107354a5bb8d7a4553554e231bbd8e34d9 |
The group completed the first edition of The Emergency Severity Index (ESI) Implementation Handbook in 2002 (published by the Emergency Nurses Association [ENA]). The group then formed the ESI Triage Research Team, LLC and worked with the Agency for Healthcare Research and Quality, which published the second edition in... | 63 | 5 | 5 | da662cd9abc7745390c8548fa694cdfb126583fd469a67d3331c334c9dfdbdbe |
The 2012 edition was significantly updated, including presentation of ESI Version 4, and there was the addition of a pediatric chapter. The fourth edition of the handbook was created in 2020 by the new owner of the ESI as of 2019, ENA. | 51 | 5 | 5 | 463471e132a4646b91bc38501e06854e754a08e3ef6ed21f8b58f9ed3b915ec9 |
The current handbook has been reorganized and simplified to better explain each decision point within the algorithm. While the algorithm is fundamentally unchanged, elimination of two questions used in decision point B will help users more accurately identify ESI level-2 patients. | 49 | 5 | 5 | 4a62ca0c08fb61bb717556ed7dd6b1fac07d594d0d69e0edb0470a2d4f998fdf |
With ED crowding, triage nurses have tended to misapply the algorithm by assigning an acuity based on the ED’s current capacity and bed availability rather than the patient’s physiologic status. | 43 | 5 | 5 | e5fb6100ff2e7ca7ec6943cb965de3a7cabd271d3bd0893b1a0b9ef2dd25e744 |
Given the current situation, there are ESI 2 patients who will have to wait and will not get an ED bed immediately. These patients should not wait , and removing this language supports the triage nurse in assessing the patient’s true acuity, instead of considering ED bed and staff capacity in that decision. | 63 | 5 | 5 | 0448977872998b034090c3f556920544e4759a8f7f356a5472e412c415f90aa9 |
The basic techniques of inspection, auscultation, and palpation are reinforced as the quickest way to assess physiologic stability. Patient appearance, work of breathing, quality of pulses, and skin color/temperature/ moisture may be all that is needed to identify a patient in need of immediate lifesaving intervention. | 63 | 5 | 5 | f3b302b95f27fc6f8a59ab56ad7926f635fcec2dbc2d0b8be2ec5ed15d205d79 |
Care should not be delayed by obtaining a full set of vital signs from the patient whose decompensation is readily apparent. However, greater emphasis has been placed on recognition of abnormal vital signs for patients initially assigned less urgent acuity levels as a means to identify underlying pathophysiology and in... | 61 | 5 | 5 | 7d6c066e82f751b085aa6a1ff2fe0a1a66746080e2e8fc8584f6d6ad2a781c37 |
Content has also been incorporated based on evolving evidence of how racism and other forms of bias and stigma lead to inaccurate triage decisions. Some of the practice and competency cases in the fourth edition of the handbook reinforced bias that leads to poor decision-making and did not reflect best practice decisio... | 72 | 5 | 5 | 6a17257f77200b39f5d2d845b2b8402bf29063fc4affe66cd902528be90fdaa8 |
This handbook is intended only as a guide to using the ESI system for categorizing patients at triage in ED settings. Nurses who implement an ESI educational program are expected to be experienced triage nurses and/or to have attended a separate, comprehensive triage educational program. | 58 | 5 | 5 | 6f6a89cfe4183716236a1c8b4f92de6a89d6e3550057c078c7cf3b7ab59df4ec |
This handbook does not provide a comprehensive triage educational program. This handbook is best used in conjunction with a comprehensive triage educational program in addition to education on institution-specific triage policies and protocols. | 42 | 5 | 5 | 5fc21f9ffe432ac95d2cad0539c3126fbc6a5ae759ba8b1ed100bdf93dbc5a73 |
vi EMERGENCY SEVERITY INDEX V5 ACKNOWLEDGEMENTS Contributors Lisa Wolf, PhD, RN, CEN, FAEN, FAAN Director, Emergency Nursing Research Emergency Nurses Association Schaumburg, Illinois Katrina Ceci, MSN, RN, TCRN, CPEN, NPD-BC, CEN Nursing Content Specialist Emergency Nurses Association Schaumburg, Illinois Danielle M... | 142 | 6 | 6 | c182d55b4c86cdd17d23bf3a80fe1ef672f27f9fdfb6f60e89e447c9628aef73 |
Wilmington, Delaware Reviewers Deb Jeffries, MSN, RN, CEN, CPEN, TCRN, FAEN Nursing Content Specialist Emergency Nurses Association Schaumburg, Illinois Rebecca McNair, RN Principal Consultant MetaVerge Consultancy, LLC Founder, Triage First, Inc. | 62 | 6 | 6 | 4f040bf9b6444df55e33ad5d9a077d7754b4676ed76aecf3b23d4601ce41bb58 |
Fairview, North Carolina Introduction to the Emergency Severity Index CHAPTER 1 Chapter 1 Introduction Chapter 2: Overview Chapter 3: Decision Point A Chapter 4: Decision Point B Chapter 5: Decision Point C Chapter 6: | 43 | 6 | 7 | ab0e1eb287e90202dee908c7004d83d1021f3d558e077c95d31a808cb0b1d819 |
Decision Point D Appendix A Appendix B I n 2018, there were more than 143 million visits to emergency departments (EDs) in the United States (U.S. Department of Health and Human Services, 2021). | 44 | 7 | 7 | 455fb5fdf38bddc02c3912a158a589ba1b12dc9b12918868c29da838db870fd5 |
Identification of patient acuity based on ED presentation is a crucial piece of effective and safe emergency department care. Accurate triage reduces patient morbidity and mortality. The purpose of triage is to rapidly sort patients presenting for emergency department care, prioritizing those who are in more immediate ... | 61 | 7 | 7 | 36819f27c3925cb826dfd93790e09ba2c1da0be6548e5ea427707e5529fd7c45 |
This chapter presents evidence for the utility of the Emergency Severity Index (ESI), a standardized 5-level triage tool. Standardization of Triage Acuity in the U.S. Crowding in emergency departments has been a serious problem for many years, often resulting in long wait times for patients. | 62 | 7 | 7 | b2b6c883dbf039f031be588b09c97cefa87c2346f70b8ba7a870fb7107844d2d |
The use of a standardized triage system with clear application and evaluative processes is key to safe patient care. Triage standardization also provides the capability to support clinical care through research activities, ED surveillance, and benchmarking capabilities (Barthell et al., 2004; Gilboy et al., 1999; Handl... | 68 | 7 | 7 | 84785676764ae096a7fc5f8059176f709aabbd398e71eaae00b855e36bb5d13c |
The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) recognized the need for triage standardization in 2003. A policy statement supporting standardization (2010), most recently updated in 2017, states, “Based on expert consensus of currently available evidence, ACEP and ENA sup... | 96 | 7 | 7 | 7832360d2d4952ca141de8f895bb8ae403ff5fef061b58c66f66e37a584282bb |
Following the initial adoption of this policy statement, the number of EDs using 3-level triage systems decreased, and the number of EDs using the ESI triage system increased significantly (McHugh et al., 2012). | 47 | 7 | 7 | 069f4106b3e19f574c2c64603cd6664787baf33dc6529b34a07d07d6c4b870af |
Currently, 94% of U.S. EDs use ESI (Worth et al., 2019). Other triage scales in use (e.g., the Australasian Triage Scale [ATS], the Canadian Triage and Acuity Scale [CTAS], and the Manchester Triage System [MTS]) utilize the triage decision to determine how long the patient can wait for care in the ED. | 84 | 7 | 7 | 8c6d5bea2a6c873c0228bb57e85a112e8e876df18ade3be43c16716d257f5bba |
Clear definitions of time to physician evaluation are an integral part of those algorithms. This represents a major difference between ESI, ATS, CTAS, and MTS. The ESI does not define expected time intervals to physician evaluation. | 47 | 7 | 7 | b78e1475ce9756ddd73468b4b91fd951e37d284c3f719fca7644d0a7bb8f5e8e |
Description of the Emergency Severity Index The ESI is a 5-level triage acuity scale developed by ED physicians Richard Wuerz and David Eitel in the U.S. (Gilboy et al., 1999; Wuerz et al., 2000). | 55 | 7 | 7 | 603ad07d22625bfa40da16e5d0f2631d272715867f4451fb3504ff5fbfa5e30d |
The ESI was developed around a new conceptual model of ED triage as a proxy measure of physiologic stability and risk for deterioration. For patients determined to be stable, prediction of resources necessary to move the patient to a final disposition (admission, discharge, or transfer) is used to further differentiate... | 64 | 7 | 7 | 2b19b8ca9f07ce191d5a717109ce5057e6d4438fa2296393ebf3947269e5c38c |
The ESI retains the traditional foundation of initially evaluating patient urgency and then seeks to maximize patient streaming: getting the right patient to the right resources at the right place and the right time. Research on the Emergency Severity Index The ESI has been studied and evaluated in the United States, a... | 151 | 7 | 7 | c2c46389a49552673fdcf32d9690fafdc783601558e3ee419b2d9a801ab443f3 |
While research data support the use of ESI, education is needed to ensure appropriate application and implementation of the index. Studies on the application of ESI demonstrate 59% accuracy in assigning acuity (Jordi et al., 2015; Mistry et al., 2018). | 54 | 7 | 7 | e09330dd5fcaa1c2f56b5eb282d3e6bb376a0386b63d2045c303f5baf8800429 |
Given the low accuracy rate, learning how to properly apply the algorithm is key to accurately assigning acuity levels. Benefits of Using the ESI ESI is the most used triage scale in the United States, and its adoption internationally is growing (Mistry et al., 2018, Hinson et al., 2019). | 63 | 7 | 7 | 593a096dc4999ee5a1c1da5612a94b939869887bd35b4e49d70162fa9872a5a7 |
ED clinicians, managers, and researchers at those sites have identified several benefits of ESI triage over conventional 3-level scales. One benefit of using a 5-level acuity scale is the rapid identification of patients who need immediate interventions and treatment. | 50 | 7 | 7 | 902760a2ceb4fb8980f262ed8bd5ff7a39bb08862babcdeada3bf643436094f2 |
The focus of 5-level acuity scales is on identification of unstable and high-risk patient situations and quick sorting of patients in the setting of constrained resources. 2 EMERGENCY SEVERITY INDEX V5 ESI triage is a summative clinical judgment that assists in the rapid sorting into five groups. | 65 | 7 | 8 | 27befc8632f9db34fca2077bf843d9a57b5ad6d1082b66ee1346e71b23020382 |
The five groups reflect clinically meaningful differences in physiological and psychological stability based on the assessment of vital signs and projected resource needs. Use of the ESI for this rapid sorting can lead to improved flow of patients through the ED, with highest acuity patients being identified and treate... | 55 | 8 | 8 | 81e9ee9a74839b23657c15dbbe59ead0ae17ae7e526cbfd990fb2eb053eb5bbd |
Assessing the department’s patient acuity burden based on ESI can inform staffing needs. While patient throughput and flow is outside the scope of ESI, some departments utilize it to safely assign patients to treatment areas outside the main department. | 49 | 8 | 8 | c552ec8fa263682a333ab1db3cc2a40c066e6d8c27596735c83a7ca4d93e1375 |
Nurses using the ESI have reported the tool facilitates communication of patient acuity more effectively than the former 3-level triage scales (Wuerz et al., 2001). For example, the triage nurse can tell the charge nurse, “I need a bed for a level-1 patient,” and through this common language, the charge nurse understan... | 96 | 8 | 8 | d3433fe7a65ba71aaf69bcc50ddfe4fdfd71325112851a482fcd8a148b8777e5 |
Understanding patient acuity in the ED waiting room may provide department and hospital stakeholders with the ability to make decisions regarding additional organizational resources to facilitate ED throughput. Summary ESI has been shown to be a uniquely effective triage tool. Evidence demonstrates its reliability and ... | 71 | 8 | 8 | df8ac948e3629840e5e4e3401552842d4532a4febfd371323ecfdcfd7e29ec31 |
ESI provides benefits such as rapid identification of patients needing immediate treatment, improved patient flow, information concerning staffing needs, and improved communication. 3 CHAPTER 1 – Introduction to the Emergency Severity Index References Aeimchanbanjong, K., & Pandee, U. (2017). Validation of different pe... | 121 | 8 | 9 | b70e80ef508ff28930dee983a3e54e7b7c7c1572389666aee497b757d906011e |
Triage scale standardization [Policy statement]. https://www.acep.org/globalassets/ new-pdfs/policy-statements/triage.scale.standardization.pdf Barthell, E. N., Coonan, K., Finnell, J., Pollock, D., & Cochrane, D. (2004). Disparate systems, disparate data: Integration, interfaces and standards in emergency medicine inf... | 145 | 9 | 9 | 25d35fda1b3d83ab964aafc300ac6685e7b89f689eb5e9770ee364f14951729a |
Triage of geriatric patients in the emergency department: Validity and survival with the Emergency Severity Index. Annals of Emergency Medicine, 49 (2), 234–240. https://doi.org/10.1016/j.annemergmed.2006.04.011 Blomaard, L. C., Speksnijder, C., Lucke, J. A., Gelder, J., Anten, S., Schuit, S. C. E., Steyerberg, E. W., ... | 202 | 9 | 9 | d564eeac5458b0c0b15dc78e561360914d336aaed63fd2957410d1dcdb1a1685 |
ESI triage distribution in U.S. emergency departments. Advanced Emergency Nursing Journal, 44 (1), 46–53. https://doi.org/10.1097/TME.0000000000000390 Durani, Y., Brecher, D., Walmsley, D., Attia, M. W., & Loiselle, J. M. L. (2009). The Emergency Severity Index version 4: Reliability in pediatric patients. Pediatric Em... | 173 | 9 | 9 | 5f576bafe7f4e682e430e02652e4f98f5b461a28ba37afaa816b0087359d8390 |
Are pediatric triage systems reliable in the emergency department? Emergency Medicine International , Article ID 9825730. https://doi.org/10.1155/2020/9825730 Emergency Nurses Association. (2017). Triage scale standardization [Joint policy statement with ACEP]. https://enau.ena.org/Users/LearningActivity/LearningActivi... | 329 | 9 | 9 | c7e265c94f6173d3b35308ade6b1157d1420ee1caa65c8d07b3d60ab2ff6d611 |
Triage performance in emergency medicine: A systematic review. Annals of Emergency Medicine , 74 (1), 140–152. https://doi.org/10.1016/j.annemergmed.2018.09.022 Jordi, K., Grossmann, F., Gaddis, G. M., Cignacco, E., Denhaerynck, K., Schwendimann, R., & Nickel, C. H. (2015). Nurses’ accuracy and self- perceived ability ... | 194 | 9 | 9 | 6b1702f754b455378d24187147fa6a7421a7d4c2ad9ca11ea982d2adaf367056 |
More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States. Academic Emergency Medicine , 19 (1), 106–109. https://doi.org/10.1111/j.1553-2712.2011.01240.x Mistry, B., Balhara, K. S., Hinson, J. S., Anton, X., Othman, I. Y., E’nouz, M. A., Avila, N. A., Henry, ... | 241 | 9 | 9 | 1122a8bdd34e87f329f0e171843c027951402ddd6f1c1a865013bfb15b003c74 |
Accuracy of the Emergency Severity Triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention. Academic Emergency Medicine , 17 (3), 238–243. https://doi.org/10.1111/j.1553- 2712.2010.00670.x Takaoka, K., Ooya, K., Ono, M., & Kakeda, T. (2021). Utility of the e... | 179 | 9 | 9 | 4365d8e063efdc515d77e8040b58baa1ee4062f16fc5dec209ffd43cc19f20b3 |
Reliability and validity of the Emergency Severity Index for pediatric triage. Academic Emergency Medicine , 16 (9), 843–849. https://doi.org/10.1111/j.1553-2712.2009.00494.x U.S. Department of Health and Human Services. (2021, March 1). Trends in the utilization of emergency department services, 2009–2018 . [Report to... | 187 | 9 | 9 | 4caaee2bc652d4fe83ac16866bffc9430d8eff657505e808c82b7450c5919cbd |
Are emergency departments in the United States following recommendations by the Emergency Severity Index to promote quality triage and reliability? Journal of Emergency Nursing , 45 (6), 677–684. https://doi.org/10.1016/j.jen.2019.05.006 Wuerz, R., Milne, L. W., Eitel, D. R., Travers, D., & Gilboy, N. (2000). Reliabili... | 180 | 9 | 9 | 135e5d4332a6b6a9520e1999b0b4eff358d8a59c5edb62eec31f91995c74beba |
Implementation and refinement of the Emergency Severity Index. Academic Emergency Medicine , 8 (2), 170–176. https://doi.org/10.1111/j.1553-2712.2001.tb01283.x | 49 | 9 | 9 | 062c8cf371cc3e8fa78a307d65cf8995d2a420caa9e6ceef107a26fdc4fa3725 |
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