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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.

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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

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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.

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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.

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	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

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

1