All things ESI
This ESI level requires immediate life saving intervention such as cardiac arrest or major trauma
What is ESI 1
CMED report
“ 30 year female active labor with frequent contractions with c/o pelvic pressure”
You hear screaming in the background
What is south….paging OB resource pager with imminent deliver bay 1 acute.
This is the primary goal of an ED triage nurse.
What is to determine how quickly a patient needs treatment
CMED Radio
59 year old male fall from 6ft with left arm pain. Vital signs are stable, GCS is 15
What is a full set of vital signs.
42 year female presents to triage requesting a work note. Denies other complaints
What is ESI of 5.
46 year old male reports LLQ abdominal pain with N/V/D for one hour.
Pt A&O times three speaking in full clear unlabored sentences ambulatory with steady gait.
PMH of HTNvitals 142/79, HR 76, SpO2 98% temp 97.9
What is Eval….ESI 3
This intervention is done on all patients who present with symptoms of chest pain/pressure, SOB, dizziness, lightheaded, palpitations…etc
What is an EKG
Ems reports 65 year female well known to ems, “always acts like this”, reports heavy drinker.
Nursing assessment: strong burning smell. Patient covered in sheet rolling around on stretcher moaning. Sheet removed pt found to have signs of burns to face, head and scalp. Pt not following commands
When asked ems report patient was smoking a cigarette and her pillow caught fireWhat is a direct to south patient
76 yr old male presents with altered mental status unknown last known well. On assessment found to be lethargic, pale with signs of respiratory distress. BP- 108/73, HR 110, RR 36, SpO2 93 on 15liters non-rebreather.
What is ESI 2….pt to South
Ems reports first time seizure witnessed by coworkers while seated at a desk. No obvious signs of trauma. blood sugar 92. Postictal on arrival.
Pt is awake alert confused following commands. Oral trauma noted. respirations even and unlabored.
Blood pressure 172/97, HR 102, RR 20, SpO2 98%.
Chart review shows patient is 34 weeks pregnant
Pt to south…ESI 2
This 4-letter Acronym is how we check for drooping, slurred speech, and arm weakness.
What is FAST
Face, Arm, Speech, and Time
Masking the patient, Isolating to decon room and notify the resource nurse
What is a positive travel screen.
25 year male presents with right ankle pain started two days ago after stepping off side walk. Reports pain with ambulation.
Pt arrives A&O times three speaking in full clear unlabored sentences. Ambulatory independently with a steady gait. Swelling notes to right ankle when compared to left. CSM intactESI 4….pt to fast track
85 year female presents to walk in triage after a trip and fall in her yard. Reports no loc, is on blood thinners. pt notes to have hematoma above left eye brow.
pt is A+O times three speaking in full clear unlabored sentences. PERRL. Ambulatory with a steady gait. Denies any pain.
BP 146/74, HR 68, RR 20, SpO2 98% Temp 98.4.
ESI 2….orange
A high rate, low blood pressure with cool clammy skin is concerning for what condition in a patient who presents with potential infection.
what is sepsis
Sudden loss of balance, trouble walking, room spinning dizziness. Symptoms started within 24 hours
What are stroke like sx
50 year female presents with generalized abdominal pain and bloating for 1 week. Reports nausea no vomiting or diarrhea. Denies fevers. Reports no appetite.
Pt arrives A&O times three speaking in full clear unlabored sentences no acute distress, ambulatory with steady gait.
Chart review shows recent dx of colon cancer no active cancer tx.
BP 136/72 HR 96, RR 20, SpO2 98% r/a temp 98.2
ESI 3….pt to orange
66 year old female fall down two steps. No loc, no blood thinners. Lac to the back of head bleeding controlled with pressure dressing. GCS 15, BP 92/50, HR 62 SpO2 98% r/a
Trauma alert…south
Under EMTALA law this MUST happen before a patient is discharged or transferred.
Cmed radio
75 yr male syncopal episode, lac to forehead bleeding controlled.
GCS 14, BP 111/62, HR 146, SpO2 95 RA
Direct patient to south. Does not meet trauma criteria