A Resource or Not A Resource...That is the question
A saline or heplock?
What is: NOT a resource
"He's 22 and on college spring break...he suddenly became ill after experiencing severe sore throat and a fever." Reports the friend of patient distressed in a wheelchair. Patient is noted to be dyspneic, drooling, and skin hot to the touch. Patient not speaking to staff and is restless in wheelchair.
What is: ESI Level 1
This patient is at a high risk for epiglottitis, which is a life threatening condition caused from edema on the vocal cords and places the patient at high risk for airway obstruction and need rapid access of am advanced airway.
"My doctor told me that I am about 6 weeks pregnant and now I think I'm having a miscarriage," reports a healthy looking 28yo female. "I started spotting this morning and now I am cramping with pain radiating to my bottom." Rated 7/10. No allergies, no PMH, medications: prenatal vitamins. Vital signs: T 98.0F, HR 120, RR 28, BP 90/60. Based on these vital sign what is the appropriate ESI level for this patient?
What is ESI Level 2. This patient meets the criteria for being up-triaged from a level 3 to a level 2 based on her vital signs. Her increased heart rate, respiratory rate, decreased blood pressure, and intensity of cramping are a concern. These factors could indicate internal bleeding from a ruptured ectopic pregnancy.
"I just turned my back for a minute!" Cried the mother of a 4 year old. The child was pulled out of the family pool by a neighbor who immediately performed mouth-mouth resuscitation. The child is now breathing spontaneously, but continues to be unresponsive. Vitals: HR 126, RR 28, BP 80/64, SP02: 96% via NRB
What is ESI Level 1. This 4 year old continues to be unresponsive. The patient will require immediate life-saving interventions to address airway, breathing, and circulation.
Placing an IO would be considered this.
What is a life-saving procedure.
A tetanus shot?
What is: NOT a resource
A 22 year old female with 10/10 abdominal pain for two days. Denies nausea, vomiting, diarrhea, or urinary frequency. Her heart rate is 84 and is eating ice cream.
What is: ESI Level 3
Patient does not need to be upgraded to ESI Level 2. She is eating ice cream and will probably require at least 2 resources. You would not give up your last bed to this patient.
"The baby has had diarrhea since yesterday. The whole family has had that GI bug that is going around," reports the mother of a 15mo. She tells you the baby has had a decreased appetite, low-grade temperature, and numerous liquid stools. The triage nurse notes sign of dehydration. No PMH, NKDA, no medications. Vital signs: T 100.4F, HR 142, RR 48, BP 76/50. What is the appropriate ESI Level based on vital signs?
What is ESI Level 2. This patient meets the criteria for at least ESI level 3. For resources he would require labs and IV fluid. Based on his vitals the triage nurse can up-triage him to an ESI level 2. For a baby this age, both heart rate and respiratory rate criteria are being violated.
A 44 yo female is retching continuously into a large basin as her son wheels her into the triage area. Her son tells you that his diabetic mother has been vomiting for the past 5 hours and now it is "just yellow stuff." "She hasn't eaten or taken her insulin," he tells you. No known drug allergies. Vitals: BP 148/70, HR 126, RR 24
What is Level 2. A 44 yo diabetic with continuous vomiting is at risk for diabetic ketoacidosis. The patient's vital signs are a concern as her heart rate and respiratory are both elevated. It is not safe for this patient to wait for an extended period of time in the waiting room.
This should not be done once a patient is seen by a provider.
What is change the ESI acuity.
Specialty consultation
What is: A resource!
A 40 yo male presents to triage with c/o gradual increase in shortness of breath over the past 2 days associated with chest pain. However, patient's wife explains that patient became unresponsive while driving en route to the ED. PMH: Colon CA. Patient's skin is warm, dry, and pale.
What is: ESI Level 1
This patient is at a high risk for complications associated with cancer. (ie. pleural effusion, CHF, further malignancy, pulmonary embolism.)
A 72 yo patient presents to the ED with her oxygen via nasal cannula for her advanced COPD. She informs the triage nurse that she has had an infected cat bite in her left hand. The hand is red, tender, and swollen. The patient has no other medical problems, uses Albuterol PRN, and takes ASA daily, NKDA. Vitals signs: T 99.6F, RR 22, BP 138/80, SPO2 91%. She denies respiratory distress. Based on the patient's vital signs, what is the appropriate ESI Level?
What is ESI Level 3. This patient will require two or more resources, labs and abx. She meets the criteria for ESI level 3. The triage nurse notices that her oxygen saturation and respiratory rate outside the accepted parameters for the adult but this patient has advanced COPD. These vital signs are not a concern so the patient will not be up-triaged but will stay an ESI level 3.
"I have this infection in my cuticle," reports a 26-year old healthy female. "It started hurting 2 days ago and today I noticed pus." The patient has a small paronychia on her 2nd finger. NKDA, T 98.8, RR 14, HR 62, BP 108/70
ESI Level 4. This patient needs to have an incision and drainage of her paronychia. She will require no other resources.
A temperature of 100.4 in a 3-month-old is considered this type of vital sign
What is danger zone
A 14 year old patient presents to the ED for a ankle pain. X-Ray confirms no fracture. The physician orders a splint and crutches. How many resources are being used?
What is: One resource!
A 25 yo female presents to triage with a chief complaint of a moderate amount of dark red vaginal bleeding, with 9/10 pain. The patient states she is 7 months pregnant and this is her fourth pregnancy. PMH: Denies
What is: ESI Level 1
She is at a high risk for placenta abruption and will need an immediate C-section to save the fetus. Abruption occurs when the placenta separates from its normal site of implantation. Primary causes include hypertension, trauma, illegal drug use, and short umbilical cord. Bleeding may be dark red or absent when hidden behind the placenta. Abruption is usually associated with pain of varying intensity.
A 34 yo obese female presents to triage complaining of generalizing abdominal pain 5/10 for 2 days. She has vomited several times and states her last bowel movement was 3 days ago. She has a history of back surgery, takes no medication, and is allergic to peanuts. Vital signs: T 97.8F, HR 104, RR 16, BP 132/80, SPO2 99%. Based on vital signs, what is the appropriate ESI level?
What is ESI Level 3. This patient will needs a minimum of two or more resources: lab, IV fluids, perhaps IV medication for nausea, and a CT scan. The triage nurse would review the patient's vital signs and consider the heart rate. The heart rate falls just outside the accepted parameter for the age of the patient but could be due to pain or exertion. In this case, the decision should be to assign the patient to ESI level 3.
"He was running after his brother, fell and cut his lip on the corner of the coffee table. There was blood everywhere," recalls the mother of a healthy 19mo. "He'll never stay still for the doctor." You notice that the baby has a 2 cm lip laceration that extends through the vermillion border. Vital signs are within normal limits for age.
What is ESI Level 3. This patient will need two or more resources. A laceration through the vermillion border requires the physician to line up the edges exactly. Misalignment can be noticeable. A healthy 19mo will probably not cooperate. In most settings he will require conscious sedation, which counts as two resources. The toddler's vital signs are within normal limits for age, so there is no reason to up-triage to ESI Level 2.
This is when it is appropriate to change an ESI acuity.
What is when there is a change in the patient's clinical status before they are seen by a provider
A 78 year old female with c/o abdominal pain, dysuria, and urinary retention. The physician orders the following: Peripheral IV Insertion, 1L 0.9% NS, 40mg PO Bentyl, CBC, CMP, UA, Foley Catheter Insertion, & CT abdomen/pelvis. How many resources are being used?
What is: 4 Resources
A 34 year old patient male patient presents to triage with RLQ pain, 5/10 all day. Pain is associated with loss of appetite, nausea, and vomiting. PMH: None. The patient appears in moderate discomfort, skin warm and dry, guarding abdomen.
What is: Initially Level 3
However the patient could be upgraded to ESI Level 2 if the vital signs were abnormal. (ie. HR greater than 100) Signs of acute appendicitis include mild-to-severe RLQ pain with loss of appetite, nausea, vomiting, low-grade fever, muscle rigidity, & LLQ pressure intensifying RLQ pain. The presence of all these symptoms + tachycardia would indicate a high risk for a surgical emergency.
"I need to see a doctor for my cough. I just can't seem to shake it. Last night I didn't get much sleep because I was coughing so much, I am just so tired," reports a 57 yo female. She tells the triage that she had a temperature of 101F last night and that she's coughing up yellow stuff. Her history includes a hysterectomy 3 years ago; she takes no medications but is allergic to Penicillin. Vital signs: T 101.4F, RR 28, HR 100, SPO2 90%. Based on vital signs, what is the patient's appropriate ESI level?
What is ESI Level 2. At the beginning of her triage assessment, this patient sounds as though she could have pneumonia. She will need two or more resources but her low oxygen saturation and increased respiratory rate are a concern. After looking at her vital signs the triage nurse should up-triage the patient to an ESI level 2.
"The smoke was just so bad and I couldn't breathe," reports a 26 yo female who entered her burning building to rescue her cat. She is alert. She is hoarse and complaining of a sore throat and cough. Dyspnea is noted. Patient has a history of asthma, uses inhalers PRN. NKDA. Vitals: T 98.0, RR 40, 91% RA, HR 114, BP 108/74.
What is ESI Level 1. From the history and presentation, this patient appears to have a significant airway injury and will require immediate intubation. Her respiratory rate is 40 and she is in respiratory distress.
Three broad questions that can be used to determine whether the patient is an ESI 2
What are:
1. Is this a high-risk situation?
2. Is the patient confused, lethargic, or disoriented?
3. Is the patient in severe pain or distress?