Emergency Severity Index Form PDF Details

The Emergency Severity Index (ESI) Version 4 Implementation Handbook, a crucial tool for Emergency Department (ED) care, embodies an essential resource for healthcare professionals dedicated to optimizing patient flow and care quality in high-stakes environments. Distributed by the Agency for Healthcare Research and Quality (AHRQ), this handbook, along with its accompanying DVDs, is readily accessible for those seeking to enhance their understanding and application of the ESI triage tool. The ESI, a five-level triage algorithm, enables clinical practitioners to categorize ED visitors with precision based on their acuity and resource needs—distinctly incorporating considerations for pediatric patients due to their unique vulnerabilities and assessment challenges. The handbook's comprehensive coverage extends from the foundational mechanisms of the ESI to advanced implementation strategies, emphasizing the integration of professional judgment and evidence-based practice in emergency care settings. Notably, this edition introduces specialized insights into pediatric triage, reflecting a response to the community's call for guidance tailored to younger populations. In contributing to the delivery of efficient, targeted, and high-quality emergency care, the handbook serves as both a testament to the legacy of its contributors and a beacon for ongoing improvements in emergency healthcare delivery.

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Form NameEmergency Severity Index Form
Form Length114 pages
Fillable?No
Fillable fields0
Avg. time to fill out28 min 30 sec
Other namesemergency index esi, triage tool online, emergency severity index triage, emergency severity index scale

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Section

Emergency Severity Index (ESI)

A Triage Tool for Emergency

Department Care

Version 4

Implementation Handbook

2012 Edition

Where To Obtain Additional Copies of the DVDs and Handbook

Additional copies of the Emergency Severity Index (ESI) Version 4, Everything You Need to Know DVD set (AHRQ publication no. 05-0046-DVD) and this Emergency Severity Index Version 4 Implementation Handbook (AHRQ Publication No. 12-0014) can be obtained from the AHRQ Publications Clearinghouse at 1-800-358-9295 or by email to ahrqpubs@ahrq.hhs.gov. You also can view or download the handbook online at http://www.ahrq.gov.

Where To Obtain Additional Information

For additional information on the Emergency Severity Index, Version 4, please visit www.esitriage.org.

Copyright Notice

The Emergency Severity Index Version 4 Triage Algorithm (the “Algorithm”) is the intellectual property of The ESI Triage Research Team, LLC (the “Author”). The Author owns the copyright, which is on file with the United States Copyright Office. The Algorithm is the sole and exclusive property of the Author, and the Agency for Healthcare Research and Quality has a license to use and disseminate the two works derived from this algorithm: the two-DVD training set (Emergency Severity Index Version 4: Everything You Need to Know) and the implementation handbook (Emergency Severity Index (ESI),

A Triage Tool for Emergency Department Care, Version 4, Implementation Handbook, 2012 Edition). The Author hereby assures physicians and nurses that use of the Algorithm as explained in these two works by health care professionals or physicians and nurses in their practices is permitted. Each professional user of these two works is granted a royalty-free, non-exclusive, non-transferable license to use the Algorithm in their own clinical practices in accordance with the guidance in these two works provided that the Algorithm is not changed in any way.

The algorithm and the contents of the DVD set and implementation handbook may be incorporated into additional training materials developed by healthcare professionals or physicians and nurses on the condition that none of the materials or teaching aids include any technology or aids that replace, wholly or in part, critical thinking and the need for sound clinical judgment by the ultimate user, and that no fee or any other consideration is received from the ultimate user for the Algorithm, the contents of these two works, or the additional training materials.

The Algorithm has been rigorously tested and found to be both reliable and valid, as described in the research references included in these two works. However, the Author and the Agency for Healthcare Research and Quality require that the implementation and use of the Algorithm be conducted and completed in accordance with the contents of these two works using the professional judgment of authorized physicians or nurses and staff directed and supervised by them. Each health care professional who decides to use this algorithm for emergency triage purposes does so on the basis of that health care provider's professional judgment with respect to the particular patient that the provider is caring for. The Author and the Agency for Healthcare Research and Quality disclaim any and all liability for adverse consequences or for damages that may arise out of or be related to the professional use of the Algorithm by others, including, but not limited to, indirect, special, incidental, exemplary, or consequential damages, as further set forth below.

NOTE: The Authors and the Agency for Healthcare Research and Quality have made a good faith effort to take all reasonable measures to make these two works accurate, up-to-date, and free of material errors in accord with clinical standards accepted at the time of publication. Users of these two works are encouraged to use the contents for improvement of the delivery of emergency health care. Any practice described in these two works should be applied by health care practitioners in accordance with professional judgment and standards of care used in regard to the unique circumstances that may apply in each situation they encounter. The Authors and the Agency for Healthcare Research and Quality cannot be responsible for any adverse consequences arising from the independent application by individual professionals of the materials in these two works to particular circumstances encountered in their practices.

Emergency Severity Index (ESI)

A Triage Tool for Emergency

Department Care

Version 4

Implementation Handbook

2012 Edition

◆ ◆ ◆

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

and

Associate Professor of Medicine

University of South Florida, Tampa, FL

and

Co-Medical Director, Eastern EMS Council

◆ ◆ ◆

AHRQ Publication No. 12-0014 November 2011

This handbook is dedicated to our leader,

collaborator, and friend

Dr. Richard Wuerz

At the time of his death Dr. Wuerz was an Attending Physician

Associate Research Director

Department of Emergency Medicine

Brigham and Women's Hospital

Boston, MA

and

Assistant Professor of Medicine (Emergency Medicine)

Harvard Medical School

Boston, MA

Suggested Citation: 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.

ii

NOTE FROM THE DIRECTOR

The Agency for Healthcare Research and Quality (AHRQ) is pleased to bring you the Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4: Implementation Handbook, 2012 Edition. This edition of the handbook, like the previous edition, covers all details of the Emergency Severity Index—a five- level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from least to most urgent based on acuity and, unique to ESI, resource needs.

This edition introduces a new section (Chapter 6), developed in response to numerous requests for more detailed information on using the ESI algorithm with pediatric populations. The section recognizes that the needs of children in the emergency room differ from the needs of adults, including:

Different physiological and psychological responses to stressors.

More susceptibility to a range of conditions, such as viruses, dehydration, or radiation sickness.

Limited ability to communicate with care providers; thus harder to quickly and accurately assess.

In keeping with our mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans, one of AHRQ’s areas of emphasis is improved training for the health care workforce. This handbook will provide invaluable assistance to ED nurses, physicians, and administrators in the implementation of a comprehensive ESI educational program. In turn, a well-implemented ESI program will help hospital emergency departments rapidly identify patients in need of immediate attention, and better identify patients who could safely and more efficiently be seen in a fast-track or urgent-care area rather than in the main ED.

We hope that you find this tool useful in your ongoing efforts to improve the quality of care provided by your emergency department.

Carolyn M. Clancy, M.D.

Director

Agency for Healthcare Research and Quality

iii

Contributors

Cathleen Carlen-Lindauer, RN, MSN, CEN

Nancy Mecham, APRN, FNP, CEN

Clinical Nurse Specialist

Clinical Nurse Specialist

Department of Emergency Medicine

Emergency Department and Rapid Treatment Unit

Johns Hopkins Hospital

Primary Children's Medical Center

Baltimore, MD

Salt Lake City, UT

Formerly from The Lehigh Valley Hospital and

 

Health Network

Valerie Rupp, RN, MSN

Allentown, PA

Lehigh Valley Health Network

 

Allentown, Pennsylvania

Susan McDaniel Hohenhaus MA, RN, CEN,

 

FAEN

Anna Waller, ScD

Executive Director

Associate Professor

Emergency Nurses Association and ENA Foundation

Department of Emergency Medicine

Des Plaines, IL

School of Medicine

Formerly of Hohenhaus & Associates, Inc.

University of North Carolina at Chapel Hill

Wellsboro, PA and Chicago, IL

 

David Eitel, MD, MBA

Richard Wuerz, MD (deceased)

Attending Physician

Physician Advisor, Case Management

Associate Research Director

Wellspan Health System

Department of Emergency Medicine

York, PA

Brigham and Women’s Hospital

 

Boston, MA

Jessica Katznelson, MD

and

Assistant Professor

Assistant Professor of Medicine (Emergency

Division of Pediatric Emergency Medicine

Medicine)

School of Medicine

Harvard Medical School

Department of Pediatrics

Boston, MA

University of North Carolina at Chapel Hill

 

The ESI Triage Research Team would like to thank Dr. David Eitel for his foundational contributions to the ESI, including development of the algorithm and the conceptual model, and his continued focus on translating ESI research into practice, especially in emergency department operations. Thank you, Dave.

iv

Preface

The Emergency Severity Index (ESI) is a tool for use in emergency department (ED) triage. The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs.

Emergency physicians Richard Wuerz and David Eitel developed the original ESI concept in 1998. After pilot testing of the ESI yielded promising results, they brought together a number of emergency professionals interested in triage and the further refinement of the algorithm. The ESI Triage Group included emergency nursing and medical clinicians, managers, educators, and researchers. The ESI was initially implemented in two university teaching hospitals in 1999, and then refined and implemented in five additional hospitals in 2000. The tool was further refined based on feedback from the seven sites. Many research studies have been conducted to evaluate the reliability, validity, and ease of use of the ESI.

One of the ESI Triage Group's primary goals was to publish a handbook to assist emergency nurses and physicians with implementation of the ESI. The group agreed that this was crucial to preserving the reliability and validity of the tool. A draft of this handbook was in progress in 2000, when Dr. Wuerz died suddenly and unexpectedly. The remaining group members were committed to the value of ESI and carrying out Dr. Wuerz's vision for a scientifically sound tool that offers emergency departments a standardized approach to patient categorization at triage. The group completed the first edition of The Emergency Severity Index (ESI) Implementation Handbook in 2002 (published by the Emergency Nurses Association [ENA]). The group then formed The ESI Triage Research Team, LLC, and worked with the Agency for Healthcare Research and Quality, which published the second edition in 2005. This 2012 edition has been significantly updated. ESI Version 4 is presented in the current handbook. Supporting research is presented in Chapter 2. Pediatric validation research led to the addition of a new pediatrics chapter to this edition.

The handbook is intended to be a complete resource for ESI implementation. Emergency department educators, clinicians, and managers can use this practical guide to develop and conduct an ESI educational program, implement the algorithm, and design an ongoing quality improvement program. This edition of the book includes:

background information on triage acuity systems in the United States.

a summary of ESI research.

an overview of triage acuity systems in the United States and research reports using ESI.

an overview chapter describing ESI in detail: identifying high-risk patients, predicting resources, and using vital signs.

The new pediatric chapter.

Chapters on ESI implementation and quality monitoring.

Chapters with practice and competency cases, including many new cases.

The handbook can be used alone or in conjunction with the training DVD, Emergency Severity Index, Version 4: Everything You Need to Know, also produced by AHRQ.

The ESI represents a major change in the way triage is practiced; implementation of the ESI requires a serious commitment from education, management, and clinical staff. Successful implementation of this system is accomplished by committing significant resources during training and implementation. A myriad of benefits may result from a successful ESI implementation: improvements in ED operations, support for research and surveillance, and a standardized metric for benchmarking.

v

Preface

This handbook is intended only as a guide to using the ESI system for categorizing patients at triage in ED settings. Nurses who participate in an ESI educational program are expected to be experienced triage nurses and/or to have attended a separate, comprehensive triage educational program.

This handbook is not a comprehensive triage educational program. The ESI educational materials in this handbook are best used in conjunction with a triage educational program. Triage nurses also need education in institution-specific triage policies and protocols. For example, hospitals may develop policies regarding which types of patients can be triaged to fast-track. Triage protocols may also be developed, such as giving acetaminophen for fever, or ordering ankle films for patients who meet specified criteria.

vi

 

Contents

 

Chapter 1.

Introduction to the Emergency Severity Index: A Research-Based Triage Tool

.........................1

Chapter 2.

Overview of the Emergency Severity Index

7

Chapter 3.

ESI Level 2

17

Chapter 4.

ESI Levels 3-5 and Expected Resource Needs

29

Chapter 5.

The Role of Vital Signs in ESI Triage

35

Chapter 6.

The Use of ESI for Pediatric Triage

41

Chapter 7.

Implementation of ESI Triage

53

Chapter 8.

Evaluation and Quality Improvement

63

Chapter 9.

Practice Cases

71

Chapter 10.

Competency Cases

85

Appendixes

 

 

Appendix A.

Frequently Asked Questions and Post-Test Materials

 

 

for Chapters 2-8

A-1

Appendix B.

ESI Triage Algorithm Version 4

B-1

Appendix C.

Abbreviations and Acronyms

C-1

vii

Chapter 1. Introduction to the Emergency Severity Index: A Research-Based Triage Tool

Standardization of Triage Acuity in the United States

The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen. The triage nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for a medical screening examination and treatment. In 2008 there were 123.8 million visits to U.S. emergency departments (Centers for Disease Control and Prevention, 2008, tables 1, 4). Of those visits, only 18% of patients were seen within 15 minutes, leaving the majority of patients waiting in the waiting room.

The Institute of Medicine (IOM) published the landmark report, “The Future of Emergency Care in the United States,” and described the worsening crisis of crowding that occurs daily in most emergency departments (Institute of Medicine,

2006). With more patients waiting longer in the waiting room, the accuracy of the triage acuity level is even more critical. Under-categorization (under- triage) leaves the patient at risk for deterioration while waiting. Over-categorization (over-triage) uses scarce resources, limiting availability of an open ED bed for another patient who may require immediate care. And rapid, accurate triage of the patient is important for successful ED operations. Triage acuity ratings are useful data that can be used to describe and benchmark the overall acuity of an individual EDs’ case mix. This is possible only when the ED is using a reliable and valid triage system, and when every patient, regardless of mode of arrival or location of triage (i.e. at the bedside) is assigned a triage level (Welch & Davidson, 2010). By having this information, difficult and important questions such as, “Which EDs see the sickest patients?” and “How does patient acuity affect ED overcrowding?” can then be answered. There is also growing interest in the establishment of standards for triage acuity and other ED data elements in the United States to support clinical care, ED surveillance, benchmarking, and research activities (Barthell, Coonan, Finnell, Pollock, & Cochrane, 2004; Gilboy, Travers, & Wuerz, 1999; Haas et al., 2008; Handler et al., 2004; National Center for Injury Prevention and Control, 1997).

Historically, EDs in the United States did not use standardized triage acuity rating systems. Since 2000, there has been a trend toward standardization of triage acuity scales that have five levels (e.g., 1- resuscitation, 2- emergent, 3- urgent, 4- less urgent, 5- nonurgent). The Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) formed a Joint Triage Five Level Task Force in 2002 to review the literature and make a recommendation for EDs throughout the United States regarding which triage system should be used. Prior to this task force work, there were a variety of triage acuity systems in use in the United States, dominated by three-level scales (e.g., 1-emergent, 2- urgent, 3-nonurgent). The following position statement was approved in 2003 by the Board of Directors of both organizations: “ACEP and ENA believe that quality of patient care would benefit from implementing a standardized emergency department (ED) triage scale and acuity categorization process. Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid five-level triage scale” (American College of Emergency Physicians, 2010; Emergency Nurses Association, 2003). The task force published a second paper in 2005 and specifically recommended EDs use either the Emergency Severity Index (ESI) or Canadian Triage and Acuity Scale (CTAS) (Fernandes et al., 2005). Both ESI and CTAS have established reliability and validity. In 2010 the ACEP revised the original statement: “The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) believe that the quality of patient care benefits from implementing a standardized emergency department (ED) triage scale and acuity categorization process. Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid five-level triage scale such as the Emergency Severity Index (ESI)” (ACEP, 2010). Following the adoption of this position statement, the number of EDs using three-level triage systems has decreased, and the number of EDs using the five-level ESI triage system has increased significantly (McHugh & Tanabe, 2011).

Some hospitals continue to use other triage systems. In 2009, the American Hospital Association reported the following survey data in which hospitals reported which triage system they used:. ESI (57%), 3-level (25%), 4-level (10%), 5-level systems other

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