Emergency Severity Index (ESI) (Nursing)

by Rhonda Lawes, PhD, RN

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    00:01 What do you do when you are so overwhelmed? You have so many things to do.

    00:05 You don't know where to start.

    00:07 Well, it doesn't feel very good, but imagine how it would feel if you were the triage nurse in an emergency room.

    00:14 It could feel terrible if you had people coming at you from there tired of waiting.

    00:18 They want to be seen. They want to go home.

    00:20 They don't feel good.

    00:21 Well, they needed to come up with a system that would be systematically based in research on who needs to be seen first, not by what the patient feels, but by the severity of their illness. So that's what ESI is.

    00:37 It's an emergency severity index.

    00:40 This is a consistent, systematic tool that we can use to be safer about how we identify which patients need to be seen first.

    00:49 Because if you've ever been in a triage in a full E.R.

    00:52 waiting room, it can be really overwhelming.

    00:55 This is what helps everyone make the same decision day after day after shift after shift based on the client's needs.

    01:03 So I emergency severity index, this is a tool that's evidence based.

    01:09 That means they've looked at research and outcomes and decided this is the best tool we have up to this point.

    01:15 So it's based on the severity of illness.

    01:18 It's also based in research.

    01:20 You're going to primarily use it in the Department of E.R.

    01:23 So you might call it urgent care, but we're likely thinking about a hospital E.R.

    01:28 unit. Now, the algorithm, as you answer questions and evaluate the patient in a systematic way, this is going to give you all the clinically statistic information that you need about that patient status, health and health care needs.

    01:43 Now, it's going to put them into five groups.

    01:45 One is the group you do not want to be in, right? One is the most urgent.

    01:50 They go directly in and do not pass.

    01:52 Go five is the least urgent, which they need care, but they're going to be waiting a long period of time because their needs are not as severe.

    02:01 Remember, it's all based on acuity, not who you like, not who's the kindest, not who's the most important.

    02:07 It's all based on how sick they are and what their urgent and emergent needs are.

    02:13 So one, that's the sickest.

    02:15 They go directly back.

    02:17 Five. Those are the least urgent.

    02:19 They might need something, but they're not going to take precedence over a one, two, 3 or 4. So let's talk about what's unique about triage.

    02:28 Systems have been around for a long period of time, but this particular one with the research was funded by the Agency for Healthcare Research and Quality, the AHRQ.

    02:39 Now, you might not be impressed, but you really should.

    02:42 This is what they do now to show you how good this is or effective this is the Emergency Nurses Association have endorsed this as being an excellent evidence based tool to use to triage patients.

    02:55 So this one, remember, has five levels, one being the most severe, five being the least severe. Now, other triage systems may have three, but this one has five.

    03:07 So level one, immediate care patients, level two and three need care within 15 minutes, levels four and five need care within 30 minutes.

    03:18 Okay. Not always possible in an E.R., you're going to take all the ones before you take the twos, the threes, the fours and the fives and so on.

    03:26 But the idea of this is AI is meant to kind of decentralize medical care and make consistent, systematic decisions in determining who needs care first.

    03:36 Okay. So just for fun, let's apply this to a patient scenario.

    03:40 So you've got a patient there, a 35-year-old male.

    03:42 They've been brought in by the ambulance after a motor vehicle accident.

    03:46 Now, this client is responsive, but seems kind of dazed.

    03:50 Now there's an obvious fracture in the left leg, a minor laceration on his forehead, and he's complaining of chest pain.

    03:58 Okay. Now, most times when we read a scenario to you, it's easy to really check out.

    04:03 So what I want you to do, this is a great test taking strategy.

    04:06 Go back through that and let's read all of the descriptors.

    04:09 So what's particular or unique about this patient? They're 35, they're male.

    04:15 They came in by ambulance.

    04:17 They've been in a motor vehicle accident.

    04:20 So we're already thinking about trauma.

    04:22 They're responsive, which is good, but they're not normal.

    04:26 Right? They're days.

    04:27 You can hope they've got a fracture in their left leg, a minor laceration on their forehead, and they're complaining of chest pain.

    04:35 Wow. That's a lot.

    04:36 You almost have to know, like, where do we start? Well, you go right to the tool.

    04:39 So let's walk through this one.

    04:41 Step one, there's three steps.

    04:43 You're going to apply this.

    04:45 Step one, does the patient require immediate life saving interventions? Well, ABC, the patient is breathing, but he is dazed and he's having chest pain.

    04:56 So there could be some internal injuries.

    04:57 Remember, he was in a motor vehicle accident.

    05:00 Well, he's not in immediate respiratory or circulatory failure.

    05:03 We are kind of concerned that there is potential, however, since.

    05:07 This patient does not require immediate life-saving interventions.

    05:10 We should go on to step two before we go.

    05:13 We're walking you through the patient's breathing.

    05:16 But there are days and this and that.

    05:17 This is clinical nursing judgment.

    05:19 These are the things that you're going to learn.

    05:22 We're just explaining to you how an experienced nurse would work through triage.

    05:26 You don't put a new grad in triage, right? This is someone who's developed their assessment skills and their expertise.

    05:32 So don't get hyped up.

    05:34 Like I would know that.

    05:35 I would know that it's normal that you wouldn't know that as a nursing student.

    05:39 But that's the level we want you to grow into.

    05:42 So step one, we listed the things they're breathing, but they're dazed.

    05:46 They have some potential injuries.

    05:48 And so we're thinking we've got some real potential to need to be seen fairly quickly.

    05:53 But as for now, we're just going on to step two.

    05:55 Now, Step two is a patient in a high-risk situation? Are they confused, lethargic, or they are in severe pain or distress? Well, let's think back to this guy.

    06:06 He's post trauma from.

    06:08 He's been a pretty significant mechanism of injury.

    06:11 Right? He's been in a motor vehicle accident.

    06:14 Those are large bodies of metal that go at high speeds.

    06:17 So we know he's after that type of trauma.

    06:20 He's been in a car accident.

    06:21 So, yeah, there's potential for high risk injuries, especially ones we can't see, like internal ones. He's telling us he has chest pain.

    06:30 So that's telling us something really could be going on internally that we might not see externally yet.

    06:37 And you got that leg fracture and the laceration.

    06:40 Now, they're not the most obvious concern.

    06:42 We're always worried about airway, breathing, circulation, but still they do matter.

    06:46 And he staged.

    06:48 That's not normal.

    06:50 He's been in a traumatic accident these days.

    06:52 So he might be in some type of possible head injury or in shock.

    06:58 Okay. Those are big problems.

    06:59 So our decision here would be that he's got the high-risk complications that are a strong potential with this type of injury.

    07:08 We're going to likely make him an S1 or a level two.

    07:12 So now we have to decide, is he one or is he two? What do you think? Well, we're going to go on to step three, Right.

    07:21 If we if we didn't know in step two, like, no, I know what their number is based on my experience, me practicing using this system in step three, you ask yourself, Hey, how many different resources is a patient going to need? Are they need lab tests, EKGs, MRI, CT scan, I.V.

    07:36 fluids, imaging? What are they going to need If they're going to need a lot that kind of bumps them up the severity.

    07:42 So to help you kind of understand what we would do here, this particular patient, the one in the trauma, would likely get an x ray or possibly a CT scan for the head and chest.

    07:53 We're going to probably give them IV fluids.

    07:55 We're going to manage their pain, and they're probably going to have some lab values to kind of help us if the patient has internal injuries.

    08:02 So because this patient is kind of like in between, we would knowing all the resources they're going to need, we would make them a level two.

    08:12 So even if he wasn't a level two from the prior step, we would make him a level two because we know that he's going to require lots of resources in the E.R.

    08:21 So given that we've now decided that this patient is in level two, they would be seen urgently right after any level one, because level ones are immediate resuscitation patients, Right? Those are the ones who are coding or come in coding.

    08:37 So now what do you do as a nurse? Well, you start giving people a heads up that we need to take care of this patient and they're a level two. So you would do things like alert the trauma team and let them know the nature of his injuries.

    08:49 Start pain management, get IV access established, always critical in a patient with these types of injuries.

    08:56 Now think about the types of imaging and tests that you're going to need and collaborate with the health care provider to get those ordered continuously.

    09:03 Monitor this vital signs, get them on the get them on a cardiac monitor, get them on a pulse ox, do all those things that you can do in an E.R.

    09:11 that will help you monitor their respiratory and cardiac functions.

    09:14 Because if he starts to decompensate and to get worse, you want to know as early as possible. Now, if there's any risk of a cervical spine, make sure that it is protected until that can be ruled out.

    09:26 And then you're going to want to obviously watch for the injuries like the leg fracture or other injuries that you might assess.

    09:33 Okay. I've just given you a lot of words.

    09:35 So we went through step one and we learned about him.

    09:37 He's 35, the motor vehicle accident, the laceration, the leg.

    09:41 Step two, we thought about, hey, what kind of things does he need? Is he in a high risk situation? Is he confused or lethargic and severe distress? Well, he's in a high risk situation because he was in a car accident.

    09:53 He is kind of dazed.

    09:54 I would imagine he's having pain, even though we didn't really describe it there.

    09:57 But we established that in step two.

    10:00 Step three, We know because of the potential injuries, that he might have internal injuries. Cervical spine injury.

    10:08 We know that he's going to require a lot of resources, testing, lab work, imaging.

    10:14 So that's why we made him a level two.

    10:16 If he's a level one, he'd be like needing to be resuscitated right now.

    10:20 He's not at that point.

    10:22 So we know he's a level two, so we know where we are on high alert.

    10:26 That's how we get the trauma team.

    10:28 We make sure we're trying to manage his pain, get IV access or the tests that we know the health care provider is going to want consistently and continuously monitor him for any signs of decompensating and make sure we keep that neck and cervical spine safe and protected until that's ruled out and then deal with the leg fracture and the lacerations and the bleeding.

    10:49 Okay. So you did it.

    10:50 Congratulations. Now, after this video, you're obviously not completely prepared to be able to run a triage on your own.

    10:58 But when you do get to spend some time in triage, ask the nurses to talk you through it.

    11:02 They do this stuff almost instinctively because they've done it so many times, but they will most likely be happy to teach you how you apply this system in real life, because these triage systems are what gives us structured but a flexible approach to determine how sick or how high the acuity of the needs of the patient are.

    11:22 Why does that matter? Look who's right in the center of an ESI.

    11:27 Yes, we're all getting patient-centered care, but it's the nurse using their clinical nursing judgment based on their experience that can help move a patient to the front of the line who might experience some very difficult outcomes if it wasn't recognized that they are in trouble. And they're a process through the triage system.

    11:47 So it's really cool when you get in practice, try it, spend some time in the triage, ask to be there, work with the nurse, have them explain it to you as you go.

    11:56 And it can be a very exciting place to be because, hey, look at this scenario.

    12:00 The trauma patient with his potential injuries and his mechanism of injury, a car accident, this patient would be a high priority or a level two in the emergency department.

    About the Lecture

    The lecture Emergency Severity Index (ESI) (Nursing) by Rhonda Lawes, PhD, RN is from the course Critical Care Environment (Nursing).

    Included Quiz Questions

    1. Five
    2. Seven
    3. Three
    4. Nine
    1. Two
    2. Three
    3. One
    4. Four
    5. Five
    1. One
    2. Two
    3. Three
    4. Four
    5. Five
    1. Two
    2. One
    3. Three
    4. Four
    5. Five
    1. Three
    2. One
    3. Two
    4. Four
    5. Five
    1. Initiate intravenous access
    2. Initiate cardiac monitoring
    3. Draw blood work
    4. Call the client’s family doctor to obtain medical records
    5. Initiate referral to outpatient respiratory therapy

    Author of lecture Emergency Severity Index (ESI) (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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