ESI

EMERGENCY
SEVERITY
INDEX
Presented by:
                        OUTLINE

 What is triage
 What is ESI
 HOW ESI is generated
 What are ESI resources
 Decision points in ESI
 ESI levels one through 5
 It is an essential function in the emergency department that sorts out patients
in order of their clinical urgency.

 It allows for the allocation of the patient to the most appropriate assessment
and treatment areas

 It contributes information that will aid in describing the departmental case-

mix.

TRIAGE PROCESS FUNCTION

 THE TRIAGE
ASSESSMENT

 Triage is the first point of contact with Emergency

Department.
 The assessment should generally take no more than 2-5
minutes with a balanced aim of speed and
thoroughness.
 The assessment is a combination of:
1.presenting problem
2.general appearance of the patient
3.pertinent physiological observations
 OKEU H utilizes the concept of the Emergency Severity Index
 This system was developed by the Agency for healthcare Research and Quality
(version 4;2005)

TRIAGE SYSTEM
 EMERGENCY SEVERITY INDEX (ESI)
 five-level triage scale
  facilitates the prioritization of patients based on the urgency of the patients' conditions
  The triage nurse determines priority by posing the questions, “Who should be seen
first? And "How long can everybody wait"

 In addition, triage nurses use the ESI to also consider what resources are necessary
to get the patient through to seeing a doctor.
 Rapid identification of patient who need immediate
attention:
 Improved patient flow through the department:
  after ESI is given the patient can be directed to a
more complete assessment, registration, initial
treatment or waiting based on their acuity and
presumed resource needs.

BENEFITS OF ESI SYSTEM

 Classifies patients into 5 groups from 1(most urgent) to 5(least urgent) based on acuity
and resource needs.

     1-life threatening
     2-high risk situation

     Levels 3 to 5 are focused on resource allocation

 3-requires 2 or more resources

 4-requires 1 resource
 5-no resources are required

EMERGENCY SEVERITY INDEX

 The concept of a resource in ESI means the types of complex
interventions or diagnostic tools to separate more complex patients
from those with simpler problems .

 It is also very important to understand that "not every intervention"

performed is a resource 

WHAT IS CONSIDERED ESI RESOURCE?

The interventions considered as resources for the purpose of the ESI triage are 
 those that indicate a level of assessment or procedure beyond an examination or brief interventions by the ED
staff 
 requires significant ED staff time 
  involves personnel outside the ED (radiology)

The above mentioned will increase the patient's time in the ED and indicate the patient's complexity

DEFINITION OF A RESOURCE( FOR THE PURPOSE OF

ESI)
 The four decision
points are critical to A. Is this patient
accurate and reliable dying?
application of ESI.

C. How many
B. Is this a patient
resources will this
who shouldn't wait?
patient need?

The answers to the

D. What are the questions guide the
patient's vital signs? user to the correct
triage level

4 DECISION POINTS IN
DETERMINING ESI
 The order in which patient are seen will be determined by their ESI, not a first come first
serve basis.
 Patients assessed as unstable will be immediately placed in the resuscitation areas
 Waiting Area; patient who meets the following criteria can be asked to wait in the waiting
area:

1. ESI 3-5
2. patient has a patent airway and  does not need require  ife-  saving interventions
3. patient is hemodynamically stable,
4. no SOB, no concerning chest pain, no altered mental status  
5. not lethargic
6.

WAITING PERIOD
 DECISION POINT A
   • IS THIS PATIENT DYING? 
• IF YES THEN AUTOMATIC ESI 1

HOW DO I TELL THAT THIS PATIENT IS

DYING?
•  Requires immediate airway,
medication, or other hemodynamic
intervention

• already intubated, apneic, pulseless,
severe respiratory distress, SPO2 less
than 90%, unresponsive, acute changes
in mental status?

ESI 1
  Does this patient have a patent airway?
  is the patient breathing? 
 is there any concerns about the patient's ability to deliver oxygen to the tissues?
  Does the patient have a pulse?
  Is there any concern about the patient's pulse rate, rhythm and quality?

QUESTION TO HELP DETERMINE IF

THE PATIENT IS DYING?
                                    If patient is dying.....

 Timeliness of interventions will affect morbidity and mortality:

 It requires an all hands on deck approach with the nurse providing intensive care and the physician at the
bed side. 

 Immediate physician involvement is a key difference between ESI 1 and 2.

ESI 1
 -Cardiac Arrest
 -Respiratory Arrest
 -SPO2 < 90 in severe distress or airway compromise
 -Critically injured trauma patient who presents unresponsive
 -Severe bradycardia or tachycardia with signs instability
 -Hypotension with signs of hypoperfusion
 -Chest pain, pale, diaphoretic
 -Trauma patient who requires immediate crystalloid and colloid resuscitation
 -Baby that is flaccid
 -Anaphylactic shock
 -head bleed with unequal pupils
 Weak and dizzy with abnormal heart rate

EXAMPLES OF ESI LEVEL 1

DECISION POINT B
 'SHOULD THE PATIENT
WAIT'--ESI  LEVEL 2
Vital signs on their own are often not helpful in the identification
of high-risk patients. 
Therefore, to identify a high-risk situation a triage nurse will
always consider the patient's:
● Age,
● chief complaint and history suggestive of a problem or condition
that is serious and, unless dealt with promptly, can deteriorate
rapidly,
● presenting signs and symptoms,
● demographics,
● medical history
● current medications

While the purpose of nurse triage is not to make a medical

diagnosis, these high-risk situations are based on the triage nurse's
knowledge of possible medical diagnoses that are associated with
specific chief complaints presented.
High-risk of airway compromise should be triaged as ESI level 2.
A high-risk patient is one who is currently ventilating and oxygenating adequately but is in
respiratory distress and has the potential to rapidly deteriorate. Such as patient’s with  
 asthma,
  pulmonary embolus,
 pleural effusion,
 pneumothorax,
 foreign body aspiration,
 toxic smoke inhalation,
 or shortness of breath associated with chest pain.

SITUATIONS IN WHICH A PATIENT

SHOULD BE CONSIDERED AN ESI 2
 Ischemic type Chest pain or discomfort (elderly,diabetics)
  Need urgent electrocardiogram performed rapidly to determine the
presence of ACS and need to be identified as high-risk ESI level 2.
 Not all chest pain patients meet level-1 or level-2 criteria.

SITUATIONS IN WHICH A PATIENT

SHOULD BE CONSIDERED AN ESI 2
CONTINUED
Example :
 A 20- year-old healthy patient with chest pain, normal oxygen saturation,
cough, and fever of 38.3°C (101°F) is at low risk for ACS and does not meet
ESI level-1 or level-2 criteria. But a 20- year-old healthy patient with chest
pain who tells the triage nurse he is using cocaine should be considered high-
risk.

 A patient with chest pain that does not meet ESI level-2 criteria would be the
patient with recent upper respiratory symptoms, productive cough with chest
pain, and no other cardiovascular risk factor.

SITUATIONS IN WHICH A PATIENT SHOULD

BE CONSIDERED AN ESI 2 CONTINUED
  Mental illness
 Many patients who present with mental health problems are at
high risk because they may be a danger either to themselves,
others, or the environment.
  Patients who are suicidal, homicidal, psychotic, violent, or
present an elopement risk should be considered high-risk.
 Intoxication without signs of trauma or associated risk of
aspiration should not be assigned an ESI 2.

SITUATIONS IN WHICH A PATIENT SHOULD

BE CONSIDERED AN ESI 2 CONTINUED
Neurological
 Patients with severe headache associated with mental status changes, high blood
pressure, lethargy, fevers, or a rash should be considered high risk. Any patient with
sudden onset of speech deficits or motor weakness should also be assigned ESI level 2
as these may be signs of possible stroke.
Obstetric and gynecological
 All pregnant patients with localized abdominal pain, vaginal bleeding or discharge,
14 to 20 weeks and over should be assigned ESI level 2 and seen by a physician
rapidly (according to individual institutional policy).
 Patients with generalized cramping and bleeding with stable vital signs do not meet
ESI level-2 criteria
Abdominal pain
Abdominal pain is a frequent chief complaint in the ED. What
makes it high risk?
 elderly patient with severe abdominal pain (bowel obstructions
and GI bleeds or other GI ailments with high morbidity and
mortality rate vs young)
   assess every patient for signs and symptoms of an acute
abdomen who present to the ED with abdominal pain
considering
 History and current ratings of pain
 How long has the patient had the pain?
 Vital signs: Tachycardia
  Patients with severe
“ripping” abdominal pain
radiating to the back should
be considered to potentially
have an abdominal aortic
aneurysm.
 These patients may describe
the pain as severe, constant,
and sudden in onset and may
have a history of
hypertension.
A chief complaint of some type of visual loss which includes the
following:

• Chemical splash
•  Central retinal artery occlusion
•  Acute narrow-angle glaucoma
• Retinal detachment
• Significant trauma·          

Severe bleeding

• Rectal bleeding
• Hematemesis
• Epistaxis represent high-risk (situations and include the following:
brisk bleeding secondary to posterior nosebleed or in the patient using
warfarin or other anti-coagulant)
 Orthopedic
 Patients with signs and
symptoms of compartment
syndrome are at high risk for
extremity loss and should be as
  any extremity injury with
compromised neurovascular
function,
 partial or complete
amputations,
 gun shot or stab wound victims
Distress
 In determining whether a patient meets ESI level-2 criteria, the triage nurse
must assess for severe distress such as  
 Distraught after experiencing a sexual assault
 Exhibiting behavioural outbursts at triage
 Combative
 Victims of domestic violence
 Experiencing an acute grief reaction
 Suicidal and a flight risk 
 Pediatric Patients
 It is important to obtain an accurate history from the caregiver and evaluate the activity level of the child.
  The child who is inconsolable or withdrawn may be at high risk of serious illness.
 The following conditions are examples of high-risk situations for children:
1. Seizures
2. Severe sepsis, severe dehydration
3. Diabetic ketoacidosis
4. Suspected child abuse
5. Burns
6. Head trauma
7. Ingestions and overdoses including vitamins
8. Infant less than 30 days of age with a fever of 38°C (100.4°F) or greater
9. Sickle cell crisis
DECISION POINT C : HOW
MANY RESOURCES ARE
NEEDED?'ESI LEVEL 3
 Before assigning a patient to ESI 3 the vital signs need to be considered , the
staff need to determine whether they are within accepted parameters.

 It is a triage score where a patient requires urgent care within 30 minutes of

arrival at the hospital and needs two or more resources
 A nurse determines estimation of resources needed by the patient only after
the patient does not meet ESI 1 and ESI 2

WHAT IS ESI 3?
EXAMPLES OF
ESI 3

• Stable Fractures
• Abdominal pain that’s chronic
and not in a specific region
• Some migraines 
WELCOME TO
ESI LEVEL 4
 ESI level 4 patients are low risk patients with stable vital signs. These
patients require 1 resource and can wait to be seen by a physician.

 NB: THESE PATIENTS DO NOT REQUIRE IMMEDIATE

INTERVENTIONS!!

ESI 4
 A 15 year old with a simple thumb laceration.
Resource needed is suturing of wound.

 A healthy 25 year old female patient with

complaints of burning sensation during
urination .The patient has no PV discharge or
abdominal pain. Resource needed urine
dipstick possibly urine culture and sensitivity
plus urine HCG ,all considered one resource.

ESI LEVEL 4
EXAMPLES.
ESI 5
 ESI 5
 This ESI includes cases
that are less urgent with no
resources needed. The
patient’s condition is minor
enough that symptoms will
not be significantly
affected if assessment and
treatment are delayed.
➔ Minimal pain with no high-risk features
➔ Low risk history and now asymptomatic
➔ Minor symptoms and existing stable illness
➔ Minor symptoms of low-risk conditions
➔ Minor wounds- small abrasions, minor lacerations (not requiring
sutures)
➔ Scheduled revisit example: wound review, complex dressings
➔

CATEGORIZING ESI 5
                    CONCLUSION
  https://www.ena.org/docs/default-source/Travers, D.
A., Waller, A., Katznelson, J., & Agans, R. (2009).
Reliability and validity of the Emergency Severity
Index for pediatric triage. Academic Emergency
Medicine, 16(9), 843–849.


 Gilboy N, Tanabe T, Travers D, Rosenau AM.

Emergency Severity Index (ESI): A Triage
 Tool for Emergency Department Care, Version 4.
Implementation Handbook 2012 Edition.
 AHRQ Publication No. 12-0014. Rockville, MD. Agency
for Healthcare Research and Quality.
 November 2011.
REFERENCES  ESI. (2016, September 21). Essentials of Correctional
Nursing.
https://essentialsofcorrectionalnursing.com/2016/09/
21/emergency-triage-and-the-esi/