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Overview of the ESI Algorithm CHAPTER 2 Chapter 1 Introduction Chapter 2: Overview Chapter 3: Decision Point A Chapter 4: Decision Point B Chapter 5: Decision Point C Chapter 6: Decision Point D Appendix A Appendix B A lgorithms are frequently used in emergency care.
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Emergency clinicians are familiar with algorithms to guide and prioritize care from courses such as Advanced Cardiovascular Life Support and Pediatric Advanced Life Support. These courses present a step-by-step approach to clinical decision-making that can be applied to practice.
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The ESI algorithm follows the same principles. This chapter presents an overview of how to assign a triage acuity level using the ESI algorithm and concludes with some common errors in application of the algorithm.
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Subsequent chapters elaborate on each decision point, explaining key concepts and population-specific information in more detail. Numerous examples are included in each chapter to clarify the specific points of ESI. Conceptual Overview The algorithm consists of four decision points.
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The decision points must be performed in order, but higher acuity patients will only require one or two decision points to assign an acuity level. Figure 2-1 is a simple conceptual overview depicting the decision steps as A, B, C, and D, with corresponding questions and resulting ESI acuity levels of 1 to 5 .
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The ESI is intended for use by nurses with both emergency nursing and triage experience. The first decision the triage nurse makes is regarding stability. If a patient does not meet high risk instability criteria (ESI level 1 or 2), the triage nurse then evaluates expected resource needs to help determine a triage leve...
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Acuity judgements are initially based on assessment of physiological or psychological stability and the need for immediate lifesaving intervention. Decision point A is the only one needed for ESI level-1 patients, who are defined as in need of immediate lifesaving intervention.
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Decision point B is used to determine whether the patient is likely to deteriorate and/or require more immediate care based on symptom presentation and patient risk factors. These patients are assigned an ESI level of 2.
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Both of these decisions may require a full set of vital signs and a focused assessment prior to reaching such a determination. Decision point C is used only after level 1 and 2 are excluded and patients are determined to be physiologically stable with low risk for deterioration.
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This step requires the anticipation of resources needed during a typical ED course for patients with similar presentations. Resources are listed in the full algorithm and further elaborated on in Chapter 5. ESI levels 3, 4, and 5 are based on how many resources the nurse anticipates will be used to reach a disposition ...
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Decision point D incorporates vital signs to identify more subtle high- risk presentations or an immediate need for lifesaving interventions and to reassess the acuity decision, potentially resulting in assignment of a higher acuity level as appropriate.
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To summarize, there are four conceptual decision points used in the ESI algorithm to determine an acuity level: Is this patient unstable and in nseed of immediate lifesaving intervention? Is this a high-risk situation? How many resources will this patient need? Do the patient’s vital signs warrant a reassessment of the...
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A B C D 1 2 5, 4, 3 Yes No No No Reassess acuity decision Yes 6 EMERGENCY SEVERITY INDEX – V5 Detailed Algorithm Figure 2-2 depicts the full algorithm with elaboration on the criteria for each decision point.
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(A similar representation is presented in Appendix B, “ESI Triage Algorithm, v5”.) The algorithm assumes the user has sufficient clinical knowledge to identify physiologic instability, determine risk of deterioration, and anticipate resource needs.
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This knowledge is based on emergency care experience and familiarity with the course typical of patient ED presentations. Comprehensive educational programs can be used to partially fill this gap for inexperienced clinicians but does not replace knowledge gained through clinical experience.
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Figure 2-2. ESI Triage Algorithm, Version 5 Requires immediate lifesaving intervention? High-risk situation? or Confused/lethargic/disoriented? or Severe pain/distress? How many different resources are needed? None One Many High-risk vital signs?
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< 1 mo 1–12 mo 1–3 y 3–5 y 5–12 y 12–18 y > 18 y > 190 > 180 > 140 > 120 > 120 > 100 > 100 > 60 > 55 > 40 > 35 > 30 > 20 > 20 SpO 2 < 92% Age HR RR A B C D 1 2 Yes No No No Reassess acuity decision Yes 5, 4, 3 A.
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Immediate life-saving intervention required: Airway or respiratory support, emergency medications, hemodynamic interventions such as fluid resuscitation or blood products Clinical presentations requiring lifesaving interventions include the following: intubated, unresponsive, pulselessness, apneic, severe respiratory d...
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Unresponsiveness is defined as a patient who either: Is nonverbal and not following commands (acutely) OR 2. Requires noxious stimulus (P or U on AVPU scale) B. High-risk situation: May become unstable, have high risk for deterioration, or exhibit newly altered mental status. Severe pain or distress is determined by pa...
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( For example, complete blood count, electrolytes, and coagulant studies equal one resource because they are all laboratory tests, while complete blood count plus chest radiograph equals two resources because one is a laboratory test and one is imaging ).
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ESI Resources Not ESI Resources • Labs (blood, urine) • Electrocardiogram, radiographs • Computed tomography, magnetic resonance imaging, ultrasound, angiography • Intravenous fluids (hydration) • Intravenous, intramuscular, or nebulized medications • Specialty consultation • Simple procedure = 1 (laceration repair, ur...
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High-risk vital signs: Reassess to determine whether the patient warrants a higher acuity level if a patient has one or more vital signs outside the normal parameters for the patient. Pediatric Fever Considerations 1-28 days of age:
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Assign at least ESI 2 if T > 38° C (100.4 ° F) 1-3 months: Consider assigning ESI 2 if T > 38 ° C (100.4 ° F) 3 months and older:
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Consider assigning ESI 2 or 3 if: T > 39°C (102.2°F) or < 36°C (96.8°F), or 2. Incomplete immunizations, OR 3. No obvious source of fever
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CHAPTER 2 –Overview of the ESI Algorithm 7 The Purpose of Acuity Levels ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs as determined by a trained triage nurse upon the patient’s presentation to the emergency department . The ESI tool was developed to categorize patients ...
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et al. (2016), all noted undertriage in minority populations of all ages. Vigil et al. (2015) reported that Black patients in the Veterans Administration system were assigned less urgent ESI scores than white patients, and this effect was more pronounced for Black male patients than Black female patients. A similar out...
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Patients who are described as “difficult” are perceived similarly (Mamede et al., 2017). It is critically important for the nurse to self-reflect, identify implicit and explicit bias, and use that knowledge to mitigate barriers to accurate assessment in triage. Experience does not always translate to expertise: more-ex...
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Summary The Emergency Severity Index is meant for use by nurses with both emergency nursing and triage experience. When a patient presents to the ED, the nurse follows decision points A through D to objectively assess them and assign an appropriate ESI acuity level. References Arslanian-Engoren, C. (2004). Do emergency...
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Undertriage in older emergency department patients — tilting against windmills? PLOS ONE , 9 (8), Article e106203. https://doi.org/10.1371/journal.pone.0106203 Helmke, N. (2021). Risk of cognitive bias associated with the treatment of urinary tract infection in patients with psychiatric disorders. Journal of the Academ...
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Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis. International Journal of Emergency Medicine , 11 (1), 3. https://doi.org/10.1186/s12245-017-0161-8 Levis-Elmelech, T., Schwartz, D., & Bitan, ...
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Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997–2006. Academic Emergency Medicine , 17 (8), 801–808. https://doi.org/10.1111/j.1553-2712.2010.00823.x Mamede, S., Van Gog, T., Schuit, S. C., Van den Berge, K., Van Daele, P. L., Bueving, H., Van der Zee, T., Van...
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The role of bias by emergency department providers in care for American Indian children. Medical Care , 54 (6), 562–569. https://doi.org/10.1097/MLR.0000000000000533 Schrader, C. D., & Lewis, L. M. (2013). Racial disparity in emergency department triage. The Journal of Emergency Medicine , 44 (2), 511–518. https://doi....
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Ethnic disparities in emergency severity index scores among U.S. Veteran’s Affairs emergency department patients. PLOS ONE , 10 (5), Article e0126792. https://doi.org/10.1371/journal.pone.0126792 Wolf, L. A., Delao, A. M., Perhats, C., Moon, M. D., & Zavotsky, K. E. (2018). Triaging the emergency department, not the pa...
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Racial differences in pediatric emergency department triage scores. The Journal of Emergency Medicine , 50 (5), 720–727. https://doi.org/10.1016/j.jemermed.2015.02.056
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Decision Point A: Lifesaving Intervention Required? CHAPTER 3 Chapter 1 Introduction Chapter 2: Overview Chapter 3: Decision Point A Chapter 4: Decision Point B Chapter 5: Decision Point C Chapter 6:
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Decision Point D Appendix A Appendix B A t decision point A of the ESI algorithm, the determination needs to be made whether the patient requires immediate lifesaving interventions (Figure 3-1). Signs of instability requiring immediate, lifesaving intervention include unresponsiveness, active seizure, occluded airway, ...
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A 1 Yes No Examples of ESI Level-1 Criteria Examples of ESI level-1 criteria include the following: • Ineffective airway clearance • Ineffective respiratory pattern • Impaired gas exchange • Ineffective tissue perfusion • Obtunded/unresponsive patient • SpO 2 < 90% that is not the patient’s norm, with other signs of re...
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In order to help explain the level-1 decision further, Table 3-1 provides a list of lifesaving interventions. Table 3-1. Examples of Lifesaving Interventions Intervention Type Lifesaving Interventions Airway/breathing Assisted ventilation Intubation Surgical airway Emergent non-invasive positive pressure ventilation El...
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For example, a CT scan for a stroke or use of the catheterization lab for hemodynamically stable patients are diagnostics but not interventions. 10 EMERGENCY SEVERITY INDEX – V5 THE PROBLEM OF GEOGRAPHY An ESI level-1 patient is not always brought to the emergency department by ambulance but may be dropped at the front...
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Rapid triage performed by nurses: Signs and symptoms associated with identifying critically ill patients in the emergency department. International Journal of Nursing Practice , 28 (1), Article e13001. https://doi.org/10.1111/ijn.13001
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Decision Point B: High-Risk Presentation? CHAPTER 4 Chapter 1 Introduction Chapter 2: Overview Chapter 3: Decision Point A Chapter 4: Decision Point B Chapter 5: Decision Point C Chapter 6:
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Decision Point D Appendix A Appendix B I f it is determined that the patient does not meet ESI level-1 criteria, the nurse moves to decision point B (Figure 4-1). At decision point B, the nurse assesses whether this patient is high-risk or likely to deteriorate.
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If the situation is high-risk or the patient is at elevated risk for physical or psychological deterioration, the patient is triaged as ESI level 2. Research findings suggest that nurse accuracy at decision point B is about 43% (Ivanov et al., 2021).
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Proper use of the ESI is especially useful for the older adult population. Studies demonstrate that individuals 65 years of age and older are at an increased risk of inaccurate triage acuity assignment, or under-triage, increasing their risk of adverse patient outcomes (Blomaard et al., 2020).
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It is crucial for the nurse to understand the criteria to prevent patients being under-triaged. Figure 4-1. Decision Point B: High-Risk Presentation High-risk situation? or Confused/lethargic/disoriented? or Severe pain/distress?
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B 2 No Yes The following questions are used to determine whether the patient meets the Level-2 high-risk criteria: • Is the situation high-risk? • Is the patient likely to deteriorate? • Does the patient have an acute change in mental status? • Is the patient in severe pain or distress (physiological or psychological)?...
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The patient who is high-risk can be identified through patient interview, assessment, and collection of confirmatory data. A high- risk patient is one whose condition could easily deteriorate or who presents with symptoms suggestive of a condition requiring time- sensitive treatment.
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This is a patient who has a potential threat to life, limb, sight, or organ. Vital sign assessment can be critically important to correctly identifying these high-risk patients. Specifically, abnormal respiratory rate and high pulse rate have been found to be independent predictors of adverse events or deterioration (C...
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Similarly, there is a large body of research showing that other indicators such as heart rate, blood pressure, respiratory rate, oxygen saturation, level of consciousness, temperature, age, and cardiac complaints are also associated with, or predictors of, deterioration in patients (Considine et al., 2012, Goldhill & M...
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Unrecognized or unmanaged abnormalities of these vital signs (i.e., Glasgow Coma Scale [GCS] score, blood pressure, heart rate, respiratory rate, and oxygen saturation) is significantly associated with higher mortality rates (Buist et al., 2004), highlighting the importance of monitoring a wide range of vital signs to ...
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NOTE Geriatric Considerations. Geriatric patients may not produce immune or compensatory responses due to age or medications used to manage chronic conditions (Martin et al., 2010; Melady & Perry, 2018).
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Consider vital signs in the context of medications before assigning an ESI level. (For more information see the ENA course “Geriatric Emergency Nursing Education (GENE) Level I 2.0”)
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12 EMERGENCY SEVERITY INDEX – V5 Examples of high-risk situations include the following: • Active chest pain, suspicious for acute coronary syndrome but does not require an immediate lifesaving intervention.
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• Signs of a stroke but does not meet level-1 criteria. • A possible ectopic pregnancy, hemodynamically stable. • A patient on chemotherapy, and therefore immunocompromised, with a fever. • Transplant recipient presenting with a fever or other indication of infection.
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• Actively suicidal or homicidal patient • A needle stick in a health care worker (time sensitive to postexposure prophylaxis treatment) • Sexual assault survivor • Increasing respiratory effort • Postpartum hemorrhage Is the Patient Experiencing New Onset Confusion, Lethargy, or Disorientation?
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At decision point B of the ESI algorithm, the presence of confusion, lethargy, or disorientation refers to a new onset or an altered mental status (AMS). In broad terms, AMS indicates a change in the level of consciousness and/or orientation from a patient’s baseline mental status.
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However, other clinical signs, such as confusion, somnolence, agitation, or belligerence, are commonly referred to as AMS (Smith & Masterson, 2023). Approximately 5–10% of ED visits are for AMS (Smith & Han, 2019), with up to 40% of ED visits in the geriatric population (Smith & Han, 2019).
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AMS is a high-risk complaint and may be caused by a variety of serious medical conditions including hypoxia, hypoglycemia, or hyponatremia, underperfusion due to occlusion or vascular collapse, increased intracranial pressure, or toxicological conditions.
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If the patient’s history is unknown, and the patient presents as confused, lethargic, or disoriented, the nurse should assume this condition is new and assign an ESI level 2.
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Is the Patient Experiencing Severe Pain or Distress? Pain is the most common presenting symptom, with up to 78% of ED visits involving pain (Cordell et al., 2002) and 11.75% involving abdominal pain specifically (Hooker et al., 2019).
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The patient should be assessed for the presence of severe pain or distress. All patients who have a pain rating of 7/10 or greater should be considered for meeting ESI level-2 criteria. This is an often-misinterpreted criterion of ESI. Because pain may or may not be proportional to actual tissue damage (Schiavenato & C...
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If the pain is a result of an orthopedic injury, for example, assuming no neurovascular compromise, the nurse can implement comfort measures at triage including ice, elevation, and analgesics (if standing orders are in place) to reduce the pain.
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The nurse should accept the patient’s pain rating is 10/10 and address the pain at triage. However, this patient can wait to be seen, and the resources needed to reach a disposition should be determined.
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Patients experiencing severe pain or distress as a result of a systemic disruption, for example, renal colic, cancer, or sickle cell crisis, should be triaged as ESI level 2, and placement should be facilitated as quickly as possible.
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Distress Psychological distress can be described as emotional suffering , a negative psychological reaction to threats to personal life goals and can affect up to 47% of ED patients who present for medical care (Faessler et al., 2016).
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In consideration of assigning an ESI level 2, the nurse must assess for severe distress, which can be physiological or psychological. Examples of patient behavior or experiences reflecting or resulting in severe psychological distress include the following:
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• Distraught after experiencing a sexual assault • Behavioral outbursts at triage • Combativeness • Survivor of sexual violence • Survivor of domestic violence • Acute grief reaction • Suicidal ideation, plan, or attempt • Prenatal loss The following sections provides a nonexhaustive list of examples of other presentin...
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Neurological Concerns Almost 3% of all ED visits are for headaches, with about 31% of those patients requiring neuroimaging (American College of Emergency Physician’s Clinical Policies Subcommittee (Writing Committee) on Acute Headache et al., 2019).
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Most concerning is the “thunderclap headache” (a severe, rapid-onset headache), which is often associated with subarachnoid hemorrhage (Edlow, 2018) and warrants immediate evaluation.
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Any headache accompanied by neck pain or nuchal rigidity falls into this category. Other presentations of concern that warrant an ESI 2 designation include headache plus fever, vomiting, lower back pain, altered mental status, and/or signs and symptoms of stroke, including gross deficits such as aphasia, apraxia, agnos...
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Patients presenting post-ictal are triaged as ESI level 2 (altered mental status). Patients with a known seizure history who are alert and oriented after having a seizure prior to ED presentation can be triaged according to their physiological presentation and expected resource needs.
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13 CHAPTER 4 – Decision Point B: High-Risk Presentation? NOTE Pediatric Considerations. Neurological concerns include the following: • Pediatric patients presenting as alert and appropriate after a febrile seizure can be triaged based on their physiological assessment and anticipated resource needs.
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• A subtle change in a pediatric patient’s mental status can be suggestive of a change in hemodynamics and should be immediately investigated as high risk. Ocular Concerns Ocular emergencies represent a small but significant number of cases presenting to the ED.
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They include pathologies that involve sudden threats to the visual system that left untreated can lead to permanent visual loss or severe threats to visual function (Khare et al., 2008). Bureau of Labor Statistics data shows that approximately 16,000 U.S.
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workers in private industry sustained work-related eye injuries in 2020, about a third of which were treated in EDs. The Alphabetic Triage score for Ophthalmology (ATSO) score (D’Oria et al., 2020) may be useful in stratifying risk; the elements of the score that predict urgency include the presence of altered vision; ...
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Other common ophthalmic concerns, especially in pediatric patients, can include red eyes, traumatic injury, eye pain with headache, and visual loss (Henríquez-Recine et al., 2020; Noval et al., 2020).
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The most frequent diagnoses in the pediatric population are conjunctivitis, corneal erosion, and allergic conjunctivitis (Henríquez-Recine et al., 2020; Noval et al., 2020); few of these merit an ESI level-2 designation.
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Ear, Nose, and Throat Concerns Airway emergencies may affect adults and children, upper (croup, epiglottitis, neck abscess, bleeding tonsil) and lower (foreign body aspiration, lower bleeding) airways, as well as natural and artificially created airways (e.g., tracheostomy) (Klein, 2019; Sokolovs & Tan, 2020).
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Patients who are unable to manage their own secretions and/or exhibit respiratory stridor are extremely high-risk patients and should be assigned an ESI level of 2. Airway emergencies are clinical diagnoses and care should be initiated rapidly. Several etiologies of epistaxis represent high-risk situations.
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Examples include brisk bleeding secondary to posterior nosebleed or when experienced by a patient with known thrombocytopenia, clotting dyscrasias, and use of warfarin or other anti-coagulants (Krulewitz & Fix, 2019; Hamlett et al., 2021).
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In these situations, patients are assigned an ESI level of 2. NOTE Pediatric Considerations. Esophageal button battery ingestion has a high risk of complication, especially in children less than 6 years of age and involving batteries greater than 20 mm in diameter (Mubarak et al., 2021).
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This presentation is extremely time sensitive. Respiratory Concerns The high-risk patient is one who is currently ventilating and oxygenating adequately but is in respiratory distress and has the potential to rapidly deteriorate.
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Signs of distress can include tachypnea, tachycardia, tripoding, speaking in short, 2-to-3-word sentences; audible stridor; wheezing; or congestion.
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Patients with mild to moderate distress should be further evaluated for respiratory rate and pulse oximetry to determine whether they should be categorized as ESI level 2. Patients in severe respiratory distress who require immediate lifesaving intervention, such as intubation, meet level-1 criteria.
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NOTE Pediatric Considerations. Grunting, belly breathing, and retractions suggest respiratory distress. In the pediatric patient, the arc of decline can be precipitous. Cardiovascular Cardiovascular complaints may include presentations such as chest pain, difficulty breathing, hypoperfusion, weakness, dizziness, and bl...
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Undertriage of these patients can result in poor patient outcomes (Tsai et al., 2016). Chest pain specifically accounts for 5–10% of US emergency department visits (Sakamoto et al., 2016), yet the presentation of acute coronary syndromes (ACS) is not always symptom specific, and it is sometimes difficult to determine t...
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Patients with cardiac events may present with fatigue, nausea, vomiting, and/or weakness, rather than the more “classic” chest pain. There are gender and sex differences in assessment and identification (Gao et al., 2019) that the triage nurse should be aware of, paying close attention to female patients.
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Patients with chest pain who are physiologically unstable and require immediate interventions such as intubation or hemodynamic support should be triaged as ESI level 1. An ECG within 10 minutes for patients with concerns of chest pain may also be helpful in determining acuity.
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If the ECG is abnormal, patients would be assigned level 2. NOTE A recent Covid-19 infection increases cardiac risk (Boukhris et al., 2020) regardless of age, sex, or menopausal status.
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14 EMERGENCY SEVERITY INDEX – V5 Abdominal and Gastrointestinal Concerns Abdominal pain is a common presentation to the ED (Kamin et al., 2003) and presents a triage challenge—causes of abdominal pain can be emergent or benign (Medford-Davis et al., 2016).
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A major cause of diagnostic errors involving abdominal pain is associated with inadequate history-taking, so a good history and assessment of current pain rating, location, onset, accompanying symptoms and current vital signs are important elements in determining the presence or absence of a high-risk situation.
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Abdominal pain can be caused by a vascular, genitourinary, infectious, or cardiac issue, rather than have a gastrointestinal etiology. The literature suggests that up to 31% of patients presenting with abdominal pain are undertriaged, with patients over the age of 80 undertriaged the most (52.1%) (Oh & Kim, 2021).
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The most frequently missed diagnoses include acute gallbladder pathology, urinary system infections, diverticulitis, small bowel obstruction, appendicitis, cancer, and ectopic pregnancy. Older patients are more likely to experience bowel obstructions, gastrointestinal bleeds, mesenteric ischemia, and other abdominal co...
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In addition, pregnancy-capable patients who present with abdominal pain may be having pregnancy complications or be in labor. Several important assessment questions can help the triage nurse determine whether or not the patient meets high-risk criteria.
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Such questions include the following: • Is the patient pregnant or postpartum? • Does the patient show signs of sepsis? • Does the patient show signs of hypoperfusion? • Was there blunt or penetrating trauma to the abdomen?
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• Is the patient’s pain refractory to analgesia, constant, and /or maximal on onset? Differentiation between ESI 2 and ESI 3 in the context of abdominal pain may depend on vital signs, patient age, and previous history.
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• Pediatric considerations: In younger children, pneumonia can present as abdominal pain. Button battery or earth magnet ingestion are time sensitive presentations, with high morbidity (Mubarak et al., 2021).
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• Geriatric considerations: Elderly patients with abdominal pain are likely to need hospitalization (Lee & Kim, 2019). • Obstetric/gynecological concerns: Abdominal pain with vaginal bleeding can suggest ectopic pregnancy or other emergent pregnancy complications.
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Obstetrical and Gynecological Concerns Pregnancy or postpartum status are important data elements that can influence understanding of patient risk; patients may or may not disclose this information. The maternal death rate in the United States is approximately 23.8 per 100,000 live births, (55.3 per 100,000 deaths in B...
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Assessing for current or recent COVID-19 infection is important to assessing risk. Critical determinants of acuity include blood pressure; bleeding; and abdominal, head, or chest pain. The pregnant or postpartum patient with a SBP of < 90 or > 150 should be designated an ESI 2 even in the absence of other symptoms (Hau...
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