I love pediatrics.
A 16-year-old male wearing a swimsuit walks into the emergency department. He tells you that he dove into a pool and his face struck the bottom. You notice an abrasion on his forehead and nose as he tells you that both of his hands “feel tingly”. He is alert, anxious, pale, diaphoretic and breathing 28/min. Heart rate is 50.
Level 1. This young man has significant mechanism of injury with symptoms of spinal cord injury and neurogenic shock. He will need immediate life-saving intervention of spinal immobilization and airway management.
What is the purpose of ESI?
The purpose of ESI is to identify patients at risk of decompensation, assign acuity, and predict resources at the initial encounter.
A patient present to the ED seeking care for abdominal pain. Patient asks if he should be seen in the ED or at the clinic? Patient chooses to go to the clinic. Should this individual be registered?
Yes. Every patient that presents to the ED seeking assistance needs to be registered and noted whether they left without being seen or refused treatment.
A family of 5 presents with chief complaint of exposure to a bat. All 5 family members (2 adults and 3 children) are requesting to be seen. What do you do?
Multiple option, consider where you would room this patient and who you would communicate with.
"I ran out of my blood pressure medicine, and my doctor is on vacation. Can someone here write me a prescription?" requests a 56-year-old male with a history of HTN. Vital signs: BP 128/84, HR 76, RR 16, T 97°F.
The patient needs a prescription refill and has no other medical complaints. His blood pressure is controlled with his current medication. If at triage his blood pressure was 188/124 and he complained of a headache, then he would meet the criteria for a high-risk situation and be assigned to ESI level 2. If this patient's BP was elevated and the patient had no complaints, he or she would remain an ESI level 5. The blood pressure would be repeated and would most likely not be treated in the ED or treated with PO medications.
“I think he has an ingrown toenail” reports the mom of a healthy 11 year old boy. The boy tells you “It started hurting last week” and today he noticed” it was red and swollen”. Big toe on right foot looks mildly swollen and red around the nail. He has an appointment with his family doctor the following day that his mother does not think she can take him to. T 98.8 (36.1 C), HR 82, RR 18 BP 108/70.
Level 4. Although this child has a doctor’s appointment, he is now in the ED and will likely receive an exam and a simple procedure of excising the toenail. He is not likely to need sedation or any further diagnostics.
Can physicians and APPs triage and assign ESI levels?
If appropriately trained, yes, APPs and physicians can assign acuity. However, this is typically a nursing function. It is not appropriate for a physician or APP to assign a second ESI after the patient has been triaged by a nurse.
The patient states he will be seen in the ED, depending on how long he will have to wait. He then asks, “how long is the wait time?”
How should you respond?
Scripting at triage is appropriate to use for questions such as this one. “We will make every effort to have an ED provider see you as soon as possible. At this time, we are unable to provide you with an exact wait time, because if we get a major trauma or heart attack patient, it could possibly push your wait somewhat longer, but we do promise to get you seen as soon as possible. Thank you for your patience and understanding,” (Handel et al., 2010).
Triage Cardex.
"I was taking my contacts out last night, and I think I scratched my cornea," reports a 27-year-old female. "I'm wearing these sunglasses because the light really bothers my eyes." Her right eye is red and tearing. She rates her pain as 6/10. Vital signs are within normal limits.
Level 4
This patient will need an eye exam and will be discharged to home with prescriptions and an appointment to follow up with an ophthalmologist.
A 17-year-old handcuffed male walks into the emergency department accompanied by the police. The parents called 911 because their son was out of control: verbally and physically acting out and threatening to kill the family. He is alert, cooperative at triage and answers your questions appropriately. He is currently taking no medications. T 98F (36.7 C) HR 82 RR 14 BP 128/80
Level 2. While this young man may seem to be under control at the moment, he is still a High Risk patient. He has a history of recent violent behavior.
Can a preliminary ESI level be assigned prior to assessment?
The assignment of an ESI level is the result of a clinical decision making process that requires a history of present illness, brief focused assessment and vital sings. Assigning an ESI level without an assessment may result in undertriage. Unless the patient is in estremis, an assessment including a full set of vitals should be made before ESI level is assigned.
A visitor in the hospital parking ramp, slips and falls as she isgetting out of her car. Should the visitor be seen in the ED?
The visitor should be seen in the ED to receive treatment as she sustained an injury on hospital property.
An OB patient arrives, what do you do?
Chief complaint
OB Doctor
Patient ID (E# or DOB/NAME)
Due Date
"How far along are you?"
A 41-year-old male involved in a bicycle accident walks into the emergency department with his right arm in a sling. He tells you that he fell off his bike and landed on his right arm. His is complaining of pain in the wrist area and has a 2-centimeter laceration on his left elbow. "My helmet saved me," he tells you.
ESI level 3: Two or more resources.
At a minimum, this patient will require an x-ray of his right arm and suturing of his left elbow laceration.
A very angry father of a 3 year old boy carries his son to triage telling you that he just picked his son up after a weekend visit with his mother and that he is sure that the child has been “messed with”. He refuses to sit down with the child so that you can obtain vital signs and tells you that he better get to see the doctor NOW. The child is alert, breathing normally though he is crying, and has good color
Level 2. Although this child appears to be in no distress, we are also triaging the father in this case. The triage nurse, the child, other patients and staff are at risk of being harmed by this father. Calling security or an outside police agency may be a possibility, but it would not be prudent to allow this family to wait in the waiting area
If a nurse assigns an ESI level in triage, can you change that once you get the patient back to the room?
No, once initial data are collected and a clinical judgement is rendered in the form of an ESI assignment, that ESI level should not be changed.
An Ambulance arrives without calling report. They present to triage, and it is realized that they are a direct admit to a different hospital. Are they able to leave?
No. This patient must now be seen in the Emergency Department.
An ambulance arrives with a patient that is deceased. The patient was determined to be a DNR prior to arrival, so no resuscitation attempts were made. What should the triage RN do?
The Triage RN should assign this patient to a nurse and room number. If a patient that is a DNR status expires en route to the hospital, they must still be declared deceased by an ED physician.
A 32-year-old female presents to the emergency department complaining of shortness of breath for several hours. No past medical history, +smoker. Vital signs: RR 32, HR 96, BP 126/80, SpO2 93% on room air, T 98.6°F. No allergies, current medications include vitamins and birth control pills.
ESI level 2: High risk.
This 32-year-old female with new-onset shortness of breath is on birth control pills. She is a smoker and is exhibiting signs and symptoms of respiratory distress (SpO2 and respiratory rate.) Based on history and signs and symptoms, a pulmonary embolus, as well as other potential causes for her respiratory distress, must be ruled out.