ESI and triage Flashcards
The first question a nurse would ask, in which a patient would be triaged as a ESI level 1 if the answer is yes, is…
is the patient dying?
a no would move on to the next step in the algorithm
ESI level 1 patients usually account for __-__% of ED patients
1 - 3%
Name some examples of an ESI level 1 patient
11
Severe respiratory distress
Overdose with respirations <6
Severe bradycardia/tachycardia with hypotension
Traumatic injury with hypotension
Anaphylactic reaction
Hypoglycemia with change in mental status
Chest pain, diaphoretic, with hypotension
Baby that is flaccid
Cardiac arrest
Respiratory arrest
Emergency Bipap
The second question that the nurse should ask him/herself when triaging a patient is what?
What are three other questions that support this question?
Can the patient wait?
- Is the situation high risk?
- Is the patient confused lethargic, or disoriented?
- Is the patient in severe pain or distress?
ESI level 2 patients make up about __-__% of the ED patient population.
20-30%
Name some examples of triage level 2 patients
(24)
I know, I know, it’s a lot
don’t worry, they’re broken down into individual cards later :)
- Chest pain, suspicious of coronary syndrome, with stable vitals
- Healthcare worker with a needlestick
- Signs of a stroke
- R/O ectopic pregnancy
- Fever in the immunocompromised
- Suicidal or homicidal patient
- Change in mental status
- Testicular torsion
- Spontaneous pneumothorax with elevated RR rate
- Seizure
- Patient in severe pain
- Hypertensive crisis
- Peritonsillar abscess
- Inhalation injury with airway compromise
- Hypo/Hyperglycemia
- Sepsis
- Syncope
- Urinary retention
- Sudden change or loss in vision
- Chemical splash to eyes
- Hip / extremity dislocation
- Pelvic /Femur fracture
- Infant > 28 days with a fever
- Accidental/intentional ingestion
If the patient isn’t dying and can wait, what is the third question a nurse should ask him or herself about the patient?
What are three possible answers to the question?
How many resources will the patient need?
- none
- one
- many
Name some ED services that are considered resources.
10
Labs EKG X-ray CT MRI Ultrasound IV, IM, or nebulized medications Specialty consultations Simple procedure = 1 resource (lac repair, Foley cath) Complex procedure = 2 resources (conscious sedation)
After coming to the third question (ESI level 3), name a factor that might make a nurse change their decision to a level 2?
Abnormal vital signs.
The presence of abnormal vital signs may not be enough to upgrade, as it is how meaningful to the patients condition they are.
What are some examples of ESI level 3 Horizontal patients
9
- abdominal pain
- HA/ Migraine
- Flank pain
- Vaginal bleeding with stable VS
- Painful, swollen lower leg pain with no trauma, R/O DVT
- Fractured hip
- Asthma with mild wheezing
- N/V/D
- Fractured, dislocated wrist
What are some examples of ESI level 3 Vertical patients?
6
- Nausea, no vomiting
- Cellulitis
- Low back pain
- Fall that is ambulatory
- MVA that is ambulatory
- Bronchitis
Any infant less than 28 days old that presents with a fever in considered ____ until proven otherwise and should be an ESI level __
septic
2
Any patient known to be pregnant who presents with edema and BP above 150/100 should be considered as ____ and triaged at a priority __
2
pre-eclamptic
If a patient with a head injury presents with neck pain, a blow to the head or chest, and sudden acceleration/deceleration must be considered a C-spine injury until what?
What should be done immediately?
cleared by a physician
C spine precautions should be taken immediatly
All patients less than 12 years of age must be ____, included with vital signs.
weighed
All patients with an eye injury need what?
visual acuity
Priority 2 eye injuries include
3
- sudden pain or loss of vision
- direct blow to the eye with difficulty moving the eye in all directions
- chemicals splashed into the eye
Children and adults who have lost a permanent tooth need to be triaged as a priority __
2
there is a narrow window of opportunity for reimplantation
Bleeding as a post-op complication from a tosilectomy or a tooth extraction needs to be triaged as a priority __
2
Any unstable fracture, deformity, or open fracture should be splinted prior to what?
what are three other things you should do?
going to x-ray
- remember to splint the limb as you find it
- check for pulse and circulation after splinting
- apply ice
What should you tell a person seeking medical advise through a telephone call?
It is Inspira policy to instruct patients to either come to the ED or contact their personal physician.
What should you tell a person who calls in requesting an ambulance?
instruct them to dial 9-1-1
Remove ____ distal to all injuries.
jewelry
what are the four triage questions?
- is the patient dying?
- is this a patient who shouldn’t wait?
- how many resources will this patient need?
- what are the patients vital signs?
The first question; is the patient dying?
If the answer is yes then what?
What are two other questions to help you decide?
question 1 (3)
question 2 (8)
ESI 1 1 Does the patient require an -immediate airway -medication -other hemodynamic intervention 2 Does the patient meet any of the following criteria; - already intubated - apneic - pulseless - severe respiratory distress spO2<90% - acute mental status change - unresponsive
The key difference between ESI level 1 and 2 is what?
immediate physician involvement
ESI level __ patients are seriously ill, but the emergency care nurse can initiate care through standing orders without a physician at bedside.
2
the patient needs rapid interventions but will not deteriorate immediately
Name some examples of ESI level 1 patients
16
- cardiac arrest
- respiratory arrest
- severe respiratory distress
- spO2 <90%
- unresponsive trauma
- overdose with a respiratory rate <10
- agonal or gasping respirations
- severe bradycardia or tachycardia with s/s of hypoperfusion
- hypotension with s/s of hypoperfusion
- trauma patients who require fluid resusitation
- chest pain with weak and dizzyness, hypotensive
- anaphylactic reaction
- baby that is flacid
- unresponsive with odor of alcohol
- hypoglycemia with altered mental status
after deciding that the patient does not meet the criteria for ESI level 1, what is the question that the nurse moves on to?
can the patient wait?
What is the criteria for ESI level 2?
If the patient does not meet the criteria for ESI 1, but should not wait
What are the three broad questions to ask to determine if the patient meets the criteria for ESI level 2?
- Is this a high level situation?
- Is the patient confused, lethargic, or disoriented?
- Is the patient in severe pain or distress?
True or false
High risk patients do not require a detailed physical assessment or even a full set of vitals
true
An ESI level 2 patient must remain a high priority with assessment and treatment initiated within __ minutes of arrival
10
what are some examples of an ESI level 2 patient?
6
- active chest pain, suspicious for coronary syndrome, not requiring an immediate life saving intervention, with stable vital signs
- needlestick in a healthcare worker
- signs of a stroke not meeting level 1 criteria
- rule-out ectopic pregnancy, hemodynamically stable
- a patient on chemotherapy with a fever (immunocompromised)
- suicidal or homocidal patient
When determining if a patient is confused, lethargic, or disoriented, what are two things to consider?
- Is this an acute change in level of consciousness?
- patients with a baseline of confusion do not meet level 2 criteria.
describe confused
inappropriate response to stimuli, decrease in attention span and memory
describe Lethargic
drowsy, sleeping more than usual, responds appropriately when stimulated
describe disoriented
the patient is unable to answer questions correctly about time, place, or person
name three examples of a patient who is confused, lethargic, or disoriented, and give an example of underlying cause
- New onset of confusion in an elderly patient
- A three month old whose mother reports the child is sleeping all of the time
- an adolecent that is found confused and disoriented
- The brain may be structureally or chemically compromised
although it is a deciding factor, an ESI level of 2 does not have to be assigned on ____ alone
pain
what are three things to consider when assessing pain severity?
- certain pain locations are more likely to predict life-threatening conditions
- severe pain may predict a more dangerous problem and require more timely pain control and definitive interventions
- acute pain is more likely to be dangerous than chronic or recurrent pain
Once determined that a patient does not meet the criteria for an ESI of 1 or 2, what is the next question to move on to?
How many resources will be needed in order for a physician to reach a disposition decision?
admit
discharge
transfer
Name some examples of services that are considered resources.
(9)
- Labs (any combination = 1 resource)
- EKG
- x-ray
- CT, MRI, US,
- IV fluid
- IV, IM, or nebulized medications
- specialty consultation
- Simple procedures such as laceration repair, foley cath
- Complex procedures = 2 resources
Name some examples of services that are not considered resources.
(9)
- History and physical (including pelvic exam)
- point of care testing
- saline or heplock (although IV fluids are considered resources for hydration)
- PO medications
- Tetanus immunizations
- Prescription refills
- phone call to PCP
- Simple wound care (dressings)
- crutches, splints, slings
ESI level __ require two or more resources
3
ESI level __ require one resource
4
ESI level __ require no resources
5
ESI level __ and __ can mostly be taken care of by a PA or NP in a fastrack setting
4 and 5
A patient with an ESI level of 3 maybe upgraded to 2 under what conditions
abnormal VS outside of normal parameters, at the discretion of the triage nurse
what are the three vital signs used when triaging a patient?
For children under __ years, ____ is also used
pulse, respiratory rate, and spO2 saturation.
Children under 3 body temperature is also used
A 6 month old baby with a respiratory rate of 48 could have what ESI rating?
either 2 or 3
Temperature is only included with children under __ and should exclude ESI level less acute than __
3
3
The following questions should be answered and are key components of ESI level 2 criteria
(3)
- Is this a high risk situation?
- Is the patient experiencing new onset confusion, lethargy, or disorientation?
- Is the patient experiencing severe pain or distress?
When is chest pain treated as non-cardiac?
after it has been proven otherwise
A 30 year old with bright red blood per rectum, normal vital signs, and no other risk factors should get a triage level of __
3
An elderly patient who called an ambulance because he started vomiting blood and has a heart rate of 117 and a respiratory rate of 24 meets the ESI criteria for level __
2
Name 5 cardiovascular high risk situations
- chest pain/SOB
- epigastric discomfort
- Hypertensive crisis
- Hx of angioplasty
- Very rapid or slow heart rates
chest pain is always ESI level __ and by AHA standards should have an EKG done within __ minutes
2
10
A 54 year old obese female who presents to the ED with epigastric pain and fatigue is at risk for ____ ____ ____ and should be assigned to ESI level __
acute coronary syndrome
2
Patients wiht chest pain that are physiologically unstable and require immediate intervention such as intubation or hemodynamic support should be triaged as __
1
Other high risk cardiovascular situations include
3
- hypertensive crisis
- Acute vascular arterial occlusion
- fever in a post valve replacement patient
What is a EENT high risk situation affecting an age group of 2-4 years and 20-40 years of age, with patients presenting in a “sniffing” position, inspiratory stridor, and may result in death if not treated quickly
epiglottitis
- note; do not inspect the throat
what are three possible causes for epistaxis and what ESI level should they be assigned?
hypertensive crisis
anticoagulants
recent cocaine use
ESI level 2
Patients with inhalation injuries shoudl be considered high risk for potential airway compromise. If the patient presents with significant airway distress and requires immediate intervention, they meet the criteria for ESI level __
1
Facial trauma with actual airway compromise should be triaged as ESI level __
1
Testicular pain gets an ESI level of __
2
because it could be testicular torsion
Patients with epistaxis should have this included with initial vital signs
blood pressure
Patients with compartment syndrome should be assigned an ESI level __
2
Patients with possible fractures of the pelvis, femur, hip, and extremity dislocations should be assigned an ESI level of __ if they become hemodynamically unstable
1
Name 7 high risk situations in Pediatrics
- Seizures
- Sepsis, severe dehydration
- Diabetic ketoacidosis
- child abuse, burns
- Head trauma
- vitamin/iron or other overdoses/ingestions
- infant less than 28 days of age with fever of 100.4F or 38C or greater, which will require a sepsis workup
Chronic dementia and confusion do not meet criteria for ESI level __, but is the patients Hx is unknown and the patient presents with confusion, lethargy, disorientation, assume the conditon is new and assign the ESI level of __
2
2
fever in a patient less than 4 months assign an ESI level of __ if temp is higher than 38C, or 100.4F if there is no obvious source of fever.
3
“I am about 6 weeks pregnant and I think I am having a miscarriage”, reports a healthy looking 28 yo female. “started spotting this morning and now I am cramping.
No allergies or PMHx
medications; prenatal vitamins
VS 98F, HR112, RR22, BP 90/60
This patient meets the criteria for being up triaged from a level 3 to 2 based on her vital signs. These factors could indicate internal bleeding from a ruptured ectopic pregnancy.
“My baby has had diarrhea since yesterday. The whole family has the GI bug that is going around” reports the mother of a 15 month old.
The bay has a decreased appetite, a low grade temp, and numerous liquid stools. The baby is sitting quietly on the mothers lap. Signs of dehydration are noted. No PMHx, NKDA, no medications.
VS 100.4F, HR 142, RR 48, HR 142, BP 76/50
The patient at least meets the criteria for at least ESI 3 for resources he would require labs and IV fluids.
Based on his VS the nurse can upgrade him to a level 2, being that both his HR and RR are not within normal limits.
“I need to see a doctor for my cough. I just can’t seem to shake it. Last night I didn’ get much sleep because I was coughing so much, I am just so tired,” reports a 57 yo female.
She tells you she had a temperature of 101F last night and is coughing up yellow mucus. Her Hx includes a hysterectomy 3 years ago, takes no medication but is allergic to PCN.
VS are 101F, RR 28, HR 100, SpO2 90%
At the beginning of her triage assessment, this patient sounds like she could have PNA. She will need two or more resources but her low O2 and RR are a concern. After looking at her vital signs the triage nurse should upgrade her to an ESI 2
A 34 year old female presents to triage complaining of generalized abdominal pain 6/10 for 2 days. She has vomited several times and states her last bowel movement was 3 days ago. She has a Hx of back Sx, takes o medicaitons, and has an allergy to peanuts. Her VS are 97.8F, HR 104, RR 16, BP 132/80, SpO2 99%.
This patient will need a minimum of 2 or more resources, lab, IV fluids, perhaps IV medication for nausea, and a CT scan.
The triage nurse would review the patients VS and consider the HR. The HR falls just outside the accepted parameter for the age of the patient but could be due to pain or excersion.
In this case the decision should be to assign the patient to a level of 3
A tearful 9 yo presents to triage with her mother. She sliped on an icy sidewalk and injured her right forearm. The forearm is obviously deformed but has good color, sensation, and movement. The mother reports she has no allergies and takes no medications, and is healthy.
VS are BP 100/68, HR 124, RR 32, and SpO2 99%.
This patient is experiencing pain from a fall and is obviously upset. She will require at least two resources; x-ray and orthopedic consult, and perhaps conscious sedation. Her heart rate and respiratory rate are elevated, but the triage nurse should feel comfortable assigning this patient to ESI level 3. Her VS are likely due to pain and stress.
A 72 yo patient presents to the emergency room with her O2 via n/c for her advanced COPD. She informs the triage nurse that she has an infected cat bite on her left hand. The hand is red, tender, and swollen. The patient has no other medical problems, uses an inhaler PRN, and takes an ASA daily, NKDA.
VS are 99.6 F, HR 88, RR 22, BP 138/80, SpO2 91%, and denies any respiratory distress.
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 O2 saturation and respiratory rate are outside the accepted parameters for an adult but this patient has advanced COPD.
These VS are not a concern so the patient will not be up-triaged but will stay an ESI level 3.
PB patients less than __ weeks will be evaluated in the ED.
20
OB patients more than 20 weeks who present with complaints unrelated to the pregnancy (will/ will not) be evaluated in the ED
they will be evaluated in the ED
OB patients more than 20 weeks with OB related symptoms will be evaluated for ____ ____, recieve a short triage and transferred to OB via wheelchair if ____.
presenting parts
stable
OB patients who are unstable regardless of pregnancy duration will be handled to who?
ED physician
What are 4 things to know about student drug testing in the ED
- Public school students only have to be suspected of being under the influence
- consent from the parent or gaurdian is not required
- student must be accompanied by a representitive of the school
- triage nurse will notify Occupational health during normal business hours or the on call person after hours
what is the Safe Haven policy?
3
- infants 30 days or less can be given to the hospital by parent, no questions asked
- Take the infant and confirm that it is being given voluntarily
- If the infant appears abused, neglected, or older than 30 days, contact the police.
What ESI level for a patient with Chest pain, suspicious of coronary syndrome, with stable vitals
ESI 2
What ESI level for a patient who is Healthcare worker with a needlestick
ESI 2
What ESI level for a patient with Signs of a stroke
ESI 2
What ESI level for a patient with R/O ectopic pregnancy
ESI 2
What ESI level for a patient with Fever in the immunocompromised
ESI 2
What ESI level for a patient with Suicidal or homicidal ideation
ESI 2
What ESI level for a patient with Change in mental status
ESI 2
What ESI level for a patient with Testicular torsion
ESI 2
What ESI level for a patient with Spontaneous pneumothorax with elevated RR rate
ESI 2
What ESI level for a patient with Seizure
ESI 2
What ESI level for a patient with Patient in severe pain
ESI 2
What ESI level for a patient with Hypertensive crisis
ESI 2
What ESI level for a patient with Peritonsillar abscess
ESI 2
What ESI level for a patient with Inhalation injury with airway compromise
ESI 2
What ESI level for a patient with Hypo/Hyperglycemia
ESI 2
What ESI level for a patient with Sepsis
ESI 2
What ESI level for a patient with Syncope
ESI 2
What ESI level for a patient with Urinary retention
ESI 2
What ESI level for a patient with Sudden change or loss in vision
ESI 2
What ESI level for a patient with Chemical splash to eyes
ESI 2
What ESI level for a patient with Hip / extremity dislocation
ESI 2
What ESI level for a patient with Pelvic /Femur fracture
ESI 2
What ESI level for a patient with Infant > 28 days with a fever
ESI 2
What ESI level for a patient with Accidental/intentional ingestion
ESI 2
What ESI level for a patient with Severe respiratory distress
ESI 2
What ESI level for a patient with Overdose with respirations <6
ESI 1
What ESI level for a patient with Severe bradycardia/tachycardia with hypotension
ESI 1
What ESI level for a patient with Traumatic injury with hypotension
ESI 1
What ESI level for a patient with Anaphylactic reaction
ESI 1
What ESI level for a patient with Hypoglycemia with change in mental status
ESI 1
What ESI level for a patient with Chest pain, diaphoretic, with hypotension
ESI 1
What ESI level for a patient with Baby that is flaccid
ESI 1
What ESI level for a patient with Cardiac arrest
ESI 1
What ESI level for a patient with Respiratory arrest
ESI 1
What ESI level for a patient with Emergency Bipap
ESI 1
Resource or not a resource?
-Labs (any combination = 1 resource)
Resource
Resource or not a resource?
-EKG
Resource
Resource or not a resource?
x-ray
Resource
Resource or not a resource?
Cat scan
Resource
Resource or not a resource?
MRI
Resource
Resource or not a resource?
Ultrasound
Resource
Resource or not a resource?
-IV fluid
Resource
Resource or not a resource?
IV, IM, or nebulized medications
Resource
Resource or not a resource?
-specialty consultation
Resource
Resource or not a resource?
Simple procedures such as laceration repair, foley cath
Resource
Resource or not a resource?
Complex procedures
2 resources
HA! Got you, didn’t I?
Resource or not a resource?
History and physical (including pelvic exam)
Not a resource
Resource or not a resource?
point of care testing
Not a resource
Resource or not a resource?
saline or heplock (although IV fluids are considered resources for hydration)
Not a resource
Resource or not a resource?
PO medications
Not a resource
Resource or not a resource?
Tetanus immunizations
Not a resource
Resource or not a resource?
-Prescription refills
Not a resource
Resource or not a resource?
phone call to PCP
Not a resource
Resource or not a resource?
Simple wound care (dressings)
Not a resource
Resource or not a resource?
crutches, splints, slings
Not a resource
