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Approximately 60% of patients with new, delayed-onset postpartum preeclampsia have no antecedent diagnosis of a hypertensive disorder of pregnancy (Al-Safi et al, 2011).
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f5d8723dd480b1e158fdd7641848a078492269e033c9629a5091cec61a351fd2
Pregnant patients with chest pain and/or shortness of breath, abdominal pain, or headache (Sperling et al., 2015) should be triaged as ESI 2 and rapidly assessed by ED and/or OB providers.
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77f13ca59b58b116f0b26f57a824b0835a3115e5220f9ee67db8d8beb35c8ed5
Pregnant patients who present with heavy vaginal bleeding and abnormal vitals with suspicion of infection should be categorized at ESI level 2. (Heavy vaginal bleeding generally means soaking through a pad an hour, plum-sized clots, bright red bleeding that does not slow down, or bleeding that has increased after a dec...
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fa5400ceeec6aee03f7e6dd6f3a05d45ea6b07172e1ff4523ea33af539366d70
Any pregnancy-capable patient, whether pregnant or postpartum, who presents with significant hemodynamic instability and who needs immediate lifesaving interventions should be triaged as ESI level 1. Genitourinary Pain in the male or female genitourinary tract should be investigated with respect to history, onset, pain...
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fae61c91954862a6b92a5db563d94900dd7bc5fb0ff447836b47f36b52e29051
Testicular or scrotal pain should be immediately evaluated for testicular torsion (Laher et al., 2020), a time-sensitive clinical situation capable of producing permanent organ loss. Similarly, unilateral lower quadrant pain in patients with ovaries should be evaluated for ovarian torsion and ectopic pregnancy (Bridwel...
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06f2f6d7b2d496ebfd82f6eac3e66179f622e824f3a10bb21e60197beec5c61b
The patient with symptoms of a UTI who is elderly (Liang, 2017) or who also complains of back pain, chills, and rigors may have urosepsis and should also be assigned to ESI 2.
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a65132ad94c24810c9bf90acc7f63e0895016981793c865688fcdb6bb4883d36
Patients presenting with severe flank pain receive a level-2 designation (Gelber & Singh, 2021). 15 CHAPTER 4 – Decision Point B: High-Risk Presentation? Trauma Injury results from mechanical or kinetic energy transfer and is caused by acceleration forces, deceleration forces, or both.
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1a06683830def9bd8929619be6d0ff5c3679ecd4f1f286685458a528f36b1860
Victims of motor vehicle and motorcycle crashes, falls, and gunshot and stab wounds are examples of blunt and penetrating trauma, which should be assessed carefully for the potential for serious injury. Especially at nontrauma centers, it is critical to rapidly identify patients who may need higher levels of care (Wolf...
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602d71b62fb01ff9e73828d805505d4b907c0577e1642ffbbfc1ec58b820122d
In many emergency departments, trauma patients can arrive by private vehicle, so a careful assessment of both injuries and mechanism is warranted to correctly identify the high-risk patient. Mechanisms of injury that warrant an ESI 2 designation include falls of 20 feet (6 meters) or more, ejection from a vehicle, or r...
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c4fddcabc0165622a1ffd547396e74895a7a89e4d4bbd8fa167c8e9ac43065af
Injuries that warrant an ESI level of 2 may include penetrating trauma of the head, neck, chest, and abdomen without signs of hemodynamic instability. Specifically, advanced age is a known risk factor for poor outcomes among trauma patients, and the severity of injury in older adults often exceeds what would normally b...
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de5c06df0dbf46d136fdc72fc3b68d58d38bb68a7e61093f74a14fc177da045f
Occult hypoperfusion with normal vital signs is associated with age greater than 55, and so a careful assessment should be made in the older patient (Hatton et al., 2020). Patients with high-risk orthopedic injuries include those presenting with any extremity injury with compromised neurovascular function, symptoms of ...
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28970bcc99d80df35601f2d67401730af8bcacb05786918388317af59f1a9978
Patients with possible fractures of the pelvis, femur, or dislocations should be carefully evaluated and vital signs considered. These injuries can be associated with significant blood loss and neurovascular compromise. Ingestions Toxic ingestion is a high-risk presentation which needs to be rapidly evaluated. The drug...
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8625571402a093b5ed7e593a0ca2204c62bfbed2d5af84a9d07fa8b56f242b4e
Patients who present with alterations in mental status, difficulty breathing, changes in breathing pattern, or changes in heart rate and/or rhythm without an obvious cause should be evaluated as a possible toxic ingestion (Chandran & Krishna, 2019).
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9c61ee010800ea013378bd72870036524afabb367f95f537e64968d41c2c75f0
Transplant Transplant recipient patients have a high ED utilization rate even after transplant surgery (Lovasik et al., 2018; Unterman et al., 2009). Solid organ transplant recipients often present with fever and infectious processes and have a high hospitalization rate (McElroy et al., 2015; Unterman et al., 2009).
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a0ccb120e7b9157bec23886d08ca587da8922c2bca62959028d8d43686b20dd5
Patients presenting with a fever or other indication of infection or rejection should be designated ESI level 2 due to their immunocompromised status. Patients who are on a transplant list are also usually considered high-risk.
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Mental and Behavioral Health Emergency department visits for mental/behavioral health concerns in the U.S. comprise more than 12% of all visits (Moore et al., 2017). Patients who present with specific mental health concerns are at high risk if they are a danger either to themselves, others, or the environment.
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245ebc15661b0a1cf5db4ec061c9d23d25bae3a3a413caabd10e932d6edb55a1
A focused assessment of the patient’s potential for self- or other-directed harm is critical to establishing an ESI designation. Patients who are suicidal, homicidal, psychotic, or violent should be assigned an ESI level of 2 (Sands et al., 2014).
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Summary ESI level-2 patients remain a high priority, and placement and treatment should be initiated rapidly. ESI level-2 patients have the potential to be very ill and at high risk for decompensation.
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8812d796b0da080febb2b46b5b4e338fc2209b744c8670148b895d83e2e0b657
Usually, rather than move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level-2 patient.
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We have reviewed the key components and questions that need to be answered to determine whether a patient meets ESI level-2 criteria. It is critical that the triage nurse consider these questions as they triage each patient.
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Missing a high-risk situation may result in an extended waiting period, increasing the chance of morbidity and mortality. 16 EMERGENCY SEVERITY INDEX – V5 References Al-Safi, Z., Imudia, A. N., Filetti, L. C., Hobson, D. T., Bahado-Singh, R. O., & Awonuga, A. O. (2011). Delayed postpartum preeclampsia and eclampsia: De...
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6204014f8ed791bf8e1b6ef4d736fef6ed239b9d3d70773f88d76feedcf77349
(2009). When trauma walks into triage. Journal of Emergency Nursing , 35 (4), 389–391. https://doi.org/10.1016/j.jen.2009.03.006 Zweifler, R.
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(2017). Initial assessment and triage of the stroke patient. Progress in Cardiovascular Diseases , 59 (6), 527–533. https://doi.org/10.1016/j.pcad.2017.04.004
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Decision Point C: How Many Resources? CHAPTER 5 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 O nce an ESI 1 or 2 designation has been ruled out, the presumed stability of the patient enables the nurse to move to the next decision point (Figure 5-1).
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Patients who require two or more resources are assigned level 3, those who require one resource are assigned level 4, and those who require no resources are assigned level 5. The ESI triage acuity tool uses an approach that includes the nurse’s judgement about who should be seen first (ESI level 1 and 2) as well as res...
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Resource prediction requires the nurse to determine how many resources are likely to be used in order for the provider to reach a disposition decision, which could include discharge home, admission to an observation unit, transfer to another institution or others (Tanabe et al., 2004).
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To determine resource needs the nurse must have familiarity with general ED standards of care. This decision point may also require the nurse to draw from past experiences in caring for similar patients. Resource determination is independent of type of hospital (teaching versus nonteaching) and location of the hospital...
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A patient presenting for care should require the same general resources in one ED as in any other ED. Figure 5-1 Resource Prediction How many different resources are needed? None One Many C 4 5 3 Common Questions There are some common questions about what is considered an ESI resource.
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One question often asked concerns the number of blood or urine tests and radiographs that constitute a resource. In the ESI triage method, the ED nurse should count the number of different types of resources needed to determine the patient’s disposition, not the number of individual tests.
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Illustrative examples follow: • A complete blood count and electrolyte panel comprise one resource (lab test). • A complete blood count and chest radiograph are two resources (lab test, radiograph). • A complete blood count and a urinalysis are both lab tests and together count as only one resource.
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• A chest radiograph and abdominal radiograph are one resource (radiograph). • Cervical-spine films and a computed tomography scan of the head are two resources (radiograph and computed tomography scan).
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Table 5-1 provides further examples of what constitutes a resource and what does not. In order to understand what counts as a resource, it is important to realize that resources are defined by presentational acuity.
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The purpose of resource prediction in ESI is to sort patients into distinct groups and help get the right patient to the right area of the ED. Summary ESI is an approach to ED triage that includes prediction of the number of resources needed to make a patient disposition.
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Consideration of resources is included in the triage level assignment for ESI levels 3, 4, and 5, while ESI level 1 and 2 decisions are based only on patient acuity. Examples of ESI level 3, 4, and 5 patients are presented in Table 5-2.
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Practical experience has demonstrated that resource estimation is very beneficial in helping sort the large number of patients with non-acute presentations. 20 EMERGENCY SEVERITY INDEX – V5 Table 5-1 Predicted ESI Resources Resources Not Resources Labs (blood, urine) Electrocardiogram, radiographs Computed tomography, ...
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Vital signs WNL. Needs an exam and prescription None 5 A 42-year-old patient who lost their rescue inhaler and needs a new prescription, Patient is asymptomatic and vital signs WNL.
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Needs an exam and prescription None 4 Healthy 19-year-old patient with a sore throat. Vital signs WNL Needs an exam, culture(s)*, prescriptions One * 4 Healthy 29-year-old assigned female at birth with dysuria.
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Vitals signs WNL Needs an exam, urine, urine culture, maybe urine pregnancy, and prescriptions One ** 3 A 22-year-old assigned male at birth with right lower quadrant abdominal pain since early this morning, Vital signs WNL Needs an exam, lab studies, Intravenous fluid, abdominal computed tomography scan, and perhaps s...
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Vital signs WNL Needs exam, lab, lower extremity non-invasive vascular studies Two or more * Follow the institution’s policy on what constitutes a resource. For example, there may be a department where throat cultures are not routinely performed; instead, the patient is treated based on history and physical exam.
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If that is the case the patient would be an ESI level 5. ** All three tests count as one resource (labs) Wuerz, R., Milne, L. W., Eitel, D. R., Travers, D., & Gilboy, N. (2000). Reliability and validity of a new five-level triage instrument.
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Academic Emergency Medicine , 7 (3), 236–242 https://doi.org/10.1111/j.1553-2712.2000.tb01066.x 21 CHAPTER 5 – Decision Point C: How Many Resources? References Tanabe, P., Gimbel, R., Yarnold, P. R., & Adams, J. G. (2004). The Emergency Severity Index (version 3) 5-level triage system scores predict ED resource consump...
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Reliability and validity of a new five-level triage instrument. Academic Emergency Medicine , 7 (3), 236–242. https://doi.org/10.1111/j.1553-2712.2000.tb01066.x
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Decision Point D: High-Risk Vital Signs? CHAPTER 6 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 T o reach this point in the algorithm, the nurse has already determined that the patient does not meet ESI level-1 or level-2 criteria. For patients not meeting ESI level-1 or 2- criteria, a complete set of vital signs needs to be obtained to identify the “well- appearing ill.” Th...
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An Iranian study (Nejad et al., 2016) reported that of 551 cases who were up-triaged from ESI level 3 to 2, 88.7% had an increased respiratory rate and 97.8% had an increased respiratory or heart rate, suggesting that vital signs for ESI level 3 patients are important in identifying those who should be assigned a highe...
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Obtain a full set of vital signs to assist in determining patient acuity. This is decision point D in the algorithm (Figure 6-1). When vital signs are not obtained, the patient is at risk for being undertriaged, especially when presenting with symptoms indicating a lower acuity.
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The nurse’s ability to recognize abnormal vital signs and appropriately act on them is crucial to patient outcomes (Cioffi et al., 2006). Figure 6-1. High-Risk Vital Signs High-risk vital signs?
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< 1 mo 1–12 mo 1–3 y 3–5 y 5–12 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 D No 5, 4, 3 Patients who are immediately recognized and categorized as an ESI level 1 or 2 do not need vitals taken if it is going to delay initiation of care.
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If the patient appears unstable or presents with symptoms that necessitate immediate treatment, the patient is directly transported to the treatment room, and the treatment begins immediately. For these patients, the resuscitation team is responsible for obtaining and monitoring vital signs at the bedside.
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This would include patients who have clinical appearances that indicate high risk or need for immediate cardiovascular or respiratory intervention. These patients may appear pale, diaphoretic, or cyanotic. The nurse can obtain vital signs if it may assist in confirming the triage acuity level. Some patients may not be ...
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An awake, alert elderly patient who presents with dizziness might be found to have a life-threatening condition when a heart rate of 32 beats/minute or 180 beats/minute is discovered during vital sign measurement.
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