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The Emergency Severity Index

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The Emergency Severity Index The Emergency Severity Index Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e- module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract One of the main challenges encountered by emergency departments is determining how to appropriately triage patients. Although some systems only take into account a single determining factor, the Agency for Healthcare Research and Quality promotes a system that considers both the acuity of patients’ health care problems as well as the number of resources needed to treat them. This system provides emergency departments with a unique tool to ensure that the most at-risk patients are being seen and treated in the most efficient manner. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content 0.5 hours (30 minutes). Statement of Learning Need Statistics have shown that a majority of U.S. patients wait over 15 minutes in a waiting room and that there is crowding in emergency rooms. Triaging quickly and effectively is a way to avoid unsafe waits and to address needed resources. It is important for emergency department clinicians to be trained in triage in order to determine what patients cannot wait to be treated, and to know the difference between a time sensitive issue to treat a life- threatening condition and what can be assigned a lesser critical or urgent need for treatment. Course Purpose To provide health clinicians with knowledge of the Emergency Severity Index 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com guidelines and best practice principles for emergency triage. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Emergency department (ED) clinicians use the Emergency Severity Index (ESI) and its triage algorithm primarily to a. eliminate all decision-making in the emergency room. b. rate their performance after a patient is discharged. c. rate the intensity of care needed for a patient. d. determine whether a patient should be admitted to the ED. 2. True or False: The Emergency Severity Index (ESI) rates patient acuity from level 1 to level 5, with level 5 being the least emergent. a. True b. False 3. Level 1 of the Emergency Severity Index (ESI) a. does not require immediate physician involvement. b. involves non-lifesaving intervention. c. a Level 1 patient is always conscious. d. requires immediate, lifesaving intervention. 4. An apneic condition refers to a. an abdominal injury. b. the suspension of breathing that is external. c. a Level 2 rating on the ESI. d. a constant change in air volume in the lungs. 5. If gas exchange between the environment and lungs are impeded, permanent damage can occur to the _____________ in as few as three minutes without adequate ventilation. a. heart b. vascular tissue c. brain d. lungs 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction The Emergency Severity Index is a tool that includes five levels for use in the triage of patients arriving to an emergency department. Emergency clinicians use the emergency severity index and its triage algorithm to rate the intensity of care needed for patients. This measurement of needed care is referred to as patient acuity. Patient acuity is rated from most emergent (level 1) to least emergent (level 5). The Emergency Severity Index guides evaluation of the resources needed relative to the acuity level. This makes it unique among other assessment tools used to evaluate patients in an emergency department. The Emergency Severity Index is a valuable tool to ensure that clinical care meets standards of patient safety, as well as to assist emergency staff to make good decisions and to effectively operate an emergency department based on clinical research and best practice. ESI Triage Fundamentals The Emergency Severity Index (ESI) triage algorithm has been developed to determine the acuity level or intensity of care needed for a patient.1,2 Funding for the initial development of the ESI index came from the Agency for Healthcare Research and Quality (AHRQ).3 The ESI consists of various levels of care (level 1 to level 5) relative to the severity of emergency conditions and interventions needed to lower morbidity and mortality. Level 1 Level 1 of the ESI index requires immediate, lifesaving intervention. It can require emergency airway, medications, and hemodynamic interventions; and it can include any of the following conditions.4 • Already Intubated 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Apnea • Pulselessness • Severe Respiratory Distress • SPO2 Less Than 90 • Acute Mental Status Changes • Unresponsiveness For the above conditions, intubation will be required to support resuscitation efforts. Intubation involves a process of inserting an endotracheal (ET) tube through the mouth and into the airway so that the patient can be placed on a ventilator for assistance with breathing. The ET tube is connected to a ventilator for breathes to be delivered since the patient is unable to breathe independently or without assistance.5 Apnea or an apneic condition refers to the suspension of breathing that is external. There is no movement of the muscles involved in respiration during apnea. The volume in the lungs does not change. Depending on the level of airway expansion, gas exchange between the environment and lungs could be impeded. Permanent damage can occur to the brain in as few as three minutes without adequate ventilation. Death can occur after a few more minutes unless ventilation is restored.6 When considering the ESI level it’s important for Emergency Department (ED) staff to understand its purpose. As mentioned, the ESI allows ED staff to evaluate resources needed relative to patient acuity in order to safely provide patient care. A triage team member (generally a nurse) starts by looking at the patient acuity level only. If a patient is not at a level 1 or 2 on the ESI, the triage team member goes on to evaluate expected resources needed. The determination is then made whether the patient is level 3, 4, or 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5. The use of the ESI should be by clinicians with experience in emergency department triage, and is meant for use by a clinician who has been trained to triage ED patients.7 Triage is a process where trained clinicians determine the priority of ED treatment for patients. It is based on the severity of patient condition. To triage effectively clinicians must attempt to use ED resources that may be insufficient for the number of patients requiring immediate treatment. The triage staff determine the priority of treatment in an ED.8 Triage staff are assigned to evaluate patient acuity by determining stability of vital functions and the potential threat to life, an organ or limb. An estimation is made of the need for resources based on previous experiences with patients who have similar complaints and injuries. Triage staff are trained to understand: 1) Resources needed to meet patient care requirements,
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