IMPLEMENTATION HANDBOOK 2020 EDITION ESIEMERGENCY SEVERITY INDEX A Triage Tool for Emergency Department Care Version 4 Contents 3 IMPLEMENTATION HANDBOOK 2020 EDITION ESIEMERGENCY SEVERITY INDEX A Triage Tool for Emergency Department Care Version 4 Nicki Gilboy RN, MS, CEN, FAEN Associate Chief Nursing Officer for Emergency Medicine UMass Memorial Medical Center Worcester, MA Paula Tanabe, PhD, MSN, MPH, RN Associate Professor Schools of Nursing and Medicine Duke University Durham, NC Debbie Travers, PhD, RN, FAEN, CEN Assistant Professor, Health Care Systems and Emergency Medicine Schools of Nursing and Medicine University of North Carolina Chapel Hill, NC Alexander M. Rosenau, DO, CPE, FACEP Senior Vice Chair, Department of Emergency Medicine Lehigh Valley Health Network, Allentown, PA Associate Professor of Medicine University of South Florida, Tampa, FL Co-Medical Director, Eastern EMS Council Emergency Nurses Association 930 E. 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Editorial and Production Credits Director, Content Development: Nicole Williams, MSN, RN-BC Senior Product Manager: Mark Kardon eLearning Manager: Ken Loredo Nurse Content Manager: Katrina Ceci, MSN, RN, TCRN, CPEN, NPD-BC, CEN Nursing Education Specialist: Stephanie Klavohn, BSN, RN, CEN, TCRN Developmental Editor: Chris Zahn, Ph.D. Graphic Artist: Lauren Hamm Cover Image: © Antishock/iStock/Getty Images Printed in the United States of America 24 23 22 21 20 10 9 8 7 6 5 4 3 2 1 Contents 5 Contents Preface xiii Acknowledgments ix CHAPTER 1 Introduction to the Emergency Severity Index: A Research-Based Triage Tool 1 Standardization of Triage Acuity in the U.S. 1 History of the Emergency Severity Index 2 Research on the Emergency Severity Index 2 Benefits of the Emergency Severity Index 4 References 5 CHAPTER 2 Overview of the Emergency Severity Index 7 Decision Point A: Does the Patient Require Immediate Lifesaving Intervention? 9 Decision Point B: Should the Patient Wait? 11 Decision Point C: Resource Needs 12 Decision Point D: The Patient's Vital Signs 13 Summary 15 References 15 CHAPTER 3 ESI Level 2 17 1. Is This a High-Risk Situation? 18 2. Is the Patient Experiencing New Onset Confusion, Lethargy, or Disorientation? 22 3. Is the Patient Experiencing Severe Pain or Distress? 22 Special Situations 25 Summary 25 References 25 vi Contents CHAPTER 4 ESI Levels 3–5 and Expected Resource Needs 27 Resource Predictions 27 What Constitutes a Resource? 28 Resources in Context 29 Summary 30 References 30 CHAPTER 5 The Role of Vital Signs in ESI Triage 33 Are Vital Signs Necessary at Triage? 33 Using Vital Signs with ESI Triage 34 Vital Signs and Pediatric Fever 35 Case Examples 35 Summary 37 References 37 CHAPTER 6 Use of the ESI for Pediatric Triage 39 Background and Research 39 Pediatric Triage Assessment: What Is Different for Pediatric Patients? 40 A Standardized Approach to Pediatric Triage Assessment 41 Assigning ESI Levels for Pediatric Patients 43 Pediatric Patient Case Studies 46 Summary 46 References 47 CHAPTER 7 Implementation of ESI Triage 49 Decision-Making and Planning 49 Policies and Procedures 50 Planning ESI Education 51 Implementation Day 55 Post-Implementation 55 References 55 CHAPTER 8 Evaluation and Quality Improvement 57 ESI Triage Quality Indicators and Thresholds 58 Contents vii ESI Triage Data Collection 59 Summary 61 References 61 CHAPTER 9 ESI Practice Cases 63 Practice Cases 63 Practice Cases: Answers and Discussion 70 CHAPTER 10 Competency Cases 77 Set A Competency Cases 77 Set B Competency Cases 79 Set A Competency Cases – Answers 80 Set B Competency Cases – Answers 82 APPENDIX A Frequently Asked Questions and Post-Quiz Materials for Chapters 2–8 85 Chapter 2 85 Chapter 3 85 Chapter 4 88 Chapter 5 90 Chapter 6 92 Chapter 7 93 Chapter 8 93 APPENDIX B ESI Triage Algorithm, v4 95 APPENDIX C Initialisms, Abbreviations, and Acronyms 97 Index 99 viii Contents Preface The Emergency Severity Index (ESI) is a tool for use in come full circle, again being published by the Emergency Nurses emergency department (ED) triage. The ESI triage algorithm Association. yields rapid, reproducible, and clinically relevant stratification The handbook is intended to be a complete resource for ESI of patients into five groups, from level 1 (most urgent) to level 5 implementation. Emergency department educators, clinicians, (least urgent). The ESI provides a method for categorizing ED and managers can use this practical guide to develop and patients by both acuity and resource needs. conduct an ESI educational program, implement the algorithm, Emergency physicians Richard Wuerz and David Eitel and design an ongoing quality improvement program. developed the original ESI concept in 1998. After pilot testing The Emergency Severity Index represented a major change in of the ESI yielded promising results, they brought together a the way triage is practiced. Implementation of the ESI requires number of emergency professionals interested in triage and the a serious commitment from education, management, and further refinement of the algorithm. The ESI Triage Group clinical staff. Successful implementation of this system is included emergency nursing and medical clinicians, managers, accomplished by committing significant resources during educators, and researchers. The ESI was initially implemented in training and implementation. A myriad of benefits may result two university teaching hospitals in 1999 and then refined and from a successful ESI implementation: improvements in ED implemented in five additional hospitals in 2000. The tool was operations, support for research and surveillance, and a further refined based on feedback from the seven sites. Many standardized metric for benchmarking. research studies have been conducted to evaluate the reliability, validity, and ease of use of the ESI. This handbook is intended only as a guide to using the ESI system for categorizing patients at triage in ED settings. Nurses One of the ESI Triage Group's primary goals was to publish a who participate in an ESI educational program are expected to handbook to assist emergency nurses and physicians with be experienced triage nurses and/or to have attended a separate, implementation of the ESI. The group agreed that this was comprehensive triage educational program. This handbook is crucial to preserving the reliability and validity of the tool. A not a comprehensive triage educational program. The ESI draft of this handbook was in progress in 2000 when Dr. Wuerz educational materials in this handbook are best used in died suddenly and unexpectedly. The remaining group conjunction with a triage educational program. Triage nurses members were committed to the value of ESI and carrying out also need education in institution-specific triage policies and Dr. Wuerz's vision for a scientifically sound tool that offers protocols. For example, hospitals may develop policies regarding emergency departments a standardized approach to patient which types of patients can be triaged to fast-track. Triage categorization at triage. The group completed the first edition of protocols may also be developed, such as giving acetaminophen The