Emergency Severity Index (ESI)

A Triage Tool for Emergency

Department Care

Version 4

New!

Pediatrics Section

Implementation Handbook

2012 Edition
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.

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.
Emergency Severity Index (ESI)

ATriageTool 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

ii

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.
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 fivelevel 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
Cathleen Carlen-Lindauer, RN, MSN, CEN

Clinical Nurse Specialist

Department of Emergency Medicine

Johns Hopkins Hospital

Baltimore, MD

Formerly from The Lehigh Valley Hospital and

Health Network

Allentown, PA

Susan McDaniel Hohenhaus MA, RN, CEN,

FAEN

Executive Director

Emergency Nurses Association and ENA Foundation

Des Plaines, IL

Formerly of Hohenhaus & Associates, Inc.

Wellsboro, PA and Chicago, IL

David Eitel, MD, MBA

Physician Advisor, Case Management

Wellspan Health System

York, PA

Jessica Katznelson, MD

Assistant Professor

Division of Pediatric Emergency Medicine

School of Medicine

Department of Pediatrics

University of North Carolina at Chapel Hill

Nancy Mecham, APRN, FNP, CEN

Clinical Nurse Specialist

Emergency Department and Rapid Treatment Unit

Primary Children's Medical Center

Salt Lake City, UT

Valerie Rupp, RN, MSN

Lehigh Valley Health Network

Allentown, Pennsylvania

Anna Waller, ScD

Associate Professor

Department of Emergency Medicine

School of Medicine

University of North Carolina at Chapel Hill

Richard Wuerz, MD (deceased)

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

iv

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.

Contributors
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

Preface
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
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 (undertriage) 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

1

Chapter 1. Introduction to the Emergency

Severity Index: A Research-BasedTriageTool
than ESI (6%), 2-level or other triage system (1%),

no triage (1%) (McHugh & Tanabe, 2011). The

Centers for Disease Control and Prevention National

Center for Health Statistics reports national level

data regarding ED visits (Niska, Bhuiya, & Xu, 2010).

The report now categorizes arrival acuity as five

levels based on how urgently patients need to be

seen by the physician or healthcare provider and

includes the following categories: immediate

(immediately), emergent (1-14 minutes), urgent (15-

60 minutes), semi-urgent (1-2 hours), and nonurgent (2-24 hours). While this time-based

categorization system has not been validated, it

provides national-level data of acuity case mix upon

presentation.

History of the Emergency

Severity Index

The ESI is a five-level triage scale developed by ED

physicians Richard Wuerz and David Eitel in the U.

S. (Gilboy, Travers, & Wuerz, 1999; Wuerz, Milne,

Eitel, Travers, & Gilboy, 2000). Wuerz and Eitel

believed that a principal role for an emergency

department triage instrument is to facilitate the

prioritization of patients based on the urgency of

treatment for the patients' conditions. The triage

nurse determines priority by posing the question,

"Who should be seen first?" Wuerz and Eitel realized,

however, that when more than one top priority

patient presents at the same time, the operating

question becomes, "How long can each patient

safely wait?"

The ESI was developed around a new conceptual

model of ED triage. In addition to asking which

patient should be seen first, triage nurses use the ESI

to also consider what resources are necessary to

move the patient to a final disposition (admission,

discharge, or transfer). The ESI retains the traditional

foundation of initially evaluating patient urgency,

and then seeks to maximize patient streaming:

getting the right patient to the right resources at the

right place and the right time.

Version 1 of the ESI was originally implemented at

two university-based EDs in 1999. In 2000, the ESI

was revised with input from ED clinicians to include

pediatric patient triage criteria, and then version 2

was implemented in five additional hospitals

(including non-university teaching and community

settings). Based on feedback from nurses and

physicians using the ESI at these sites, along with

the best available scientific evidence, the ESI was

further refined in 2001 as version 3 (Wuerz et al.,

2001). Limitations in ESI levels 1 and 2 criteria were

noted in version 3. Tanabe et al, conducted a

prospective research study of 571 ESI level-2 patients

at five hospitals. Twenty percent of level-2 patients

received immediate, life-saving interventions. The

study team concluded that such patients would

benefit from being classified as ESI level 1. The ESI

Research Team revised ESI level 1 criteria

accordingly, resulting in ESI version 4, the most

current version of the triage algorithm (Tanabe et

al., 2005), which is included in this Implementation

Manual.

Emergency physicians and nurses in the United

States and Canada have conducted several research

studies in which the reliability and validity of the

ESI have been assessed. Like the Australasian,

Canadian, and United Kingdom scales, ESI triage has

five levels. ESI is different in both its conceptual

approach and practical application. The underlying

assumption of the triage scales from Australia,

Canada, and the United Kingdom is that the

purpose of triage is to determine how long the

patient can wait for care in the ED. Clear definitions

of time to physician evaluation are an integral part

of both algorithms. This represents a major

difference between ESI and the CTAS and the

Australasian Triage Scale (ATS). The ESI does not

define expected time intervals to physician evaluation.

The ESI is unique in that it also, for less acute

patients, requires the triage nurse to anticipate

expected resource needs (e.g., diagnostic tests and

procedures), in addition to assessing acuity. The ESI

triage levels are outlined in Figure 1-1. The process

of categorizing ED patients using the ESI will be

described in detail in subsequent chapters. Briefly,

acuity judgments are addressed first and are based

on the stability of the patient's vital functions, the

likelihood of an immediate life or organ threat, or

high risk presentation. For patients determined not

to be at risk of high acuity and deemed “stable,”

expected resource needs are addressed based on the

experienced triage nurse's prediction of the resources

needed to move the patient to an appropriate

disposition from the ED. Resource needs can range

from none to two or more; however, the triage nurse

never estimates beyond two defined resources.

Research on the Emergency

Severity Index

In order for a triage system to be widely adopted

and used, it must have excellent reliability and

validity. Researchers have focused on the evaluation

2

Chapter 1. Introduction to the Emergency Severity Index: A Research-BasedTriageTool
of these constructs. (Pedhazur & Schmelkin, 1991;

Waltz, Strickland, & Lenz, 1991). Reliability is the

consistency, or agreement, among those using a

rating system. Two types of reliability pertain to ED

triage acuity ratings. Inter-rater reliability is a

measure of reproducibility: will two different nurses

rate the same patient with the same triage acuity

level? Intra-rater reliability is an indication of

whether the same nurse, over time, will rate the

same patient with the same acuity level. Validity is

the accuracy of the rating system and assesses how

well the system measures what it is intended to

measure. The validity of acuity levels is an

indication of whether or not, for example, the level

of “non-urgent” is an accurate assessment of the

lack of urgency or acuity of an ED patient's problem.

Validity assessments of triage use proxy measures of

acuity that have included admission rates, resource

utilization, and 6-month mortality. If many patients

with low acuity triage levels are admitted to the

hospital, the triage system is not valid. The same

would be true for very high acuity levels. If many

high acuity patients were discharged home, the

triage system is most likely not valid.

In a pilot study of ESI version 1 ratings for 493 triage

encounters at two Boston hospitals in 1998,

researchers found that the system was both valid

and reliable (Wuerz et al., 2000). The patients were

triaged simultaneously by the triage nurse using the

traditional three-level scale and by the research

nurse who used version 1 of the ESI. After this

triage, an investigator triaged the patients again

using the ESI. The investigator was blinded to the

research nurse’s ESI rating, and used only the

written triage note to make the triage decision.

Triage levels were strongly associated with resources

used in the ED and with outcomes such as

hospitalization. Higher acuity patients (ESI levels 1

and 2) consumed more resources and were more

likely to be admitted to the hospital than those with

lower acuity ratings (ESI levels 4 and 5). Inter-rater

reliability between the research nurse and the

investigator was found to be good, with 77 percent

exact agreements and 22 percent within one triage

level.

The reliability of the ESI has been evaluated in

several studies, using the kappa statistic to measure

inter-rater reliability. Results using kappa statistics

can range from 0 (no agreement) to 1 (perfect

agreement). At one of the two original ESI sites, a

study was conducted to compare the reliability of

triage ratings of a three-level scale with the ESI

version 1. (Travers, Waller, Bowling, Flowers, &

Tintinalli, 2002). Reliability improved from an

inconsistent level for the three-level system

(weighted kappa of 0.53) to an acceptable level for

the five-level ESI (weighted kappa of 0.68).

In another study, researchers examined the

reliability and validity of ESI version 2 during and

after implementation of the system into triage

practice at seven hospitals in the Northeast and

Southeast. During the ESI triage education program,

more than 200 triage nurses at the seven sites were

asked to rate 40 case studies using the ESI (Eitel,

Travers, Rosenau, Gilboy, & Wuerz, 2003). The study

results indicated substantial inter-rater reliability

with kappa statistics ranging from 0.70 to 0.80.

Three hundred eighty-six triage decisions on actual

patients were also evaluated and found to have high

inter-rater reliability, with weighted kappa statistics

ranging from 0.69 to 0.87. In another study at a

Midwestern, urban ED, researchers evaluated the

reliability of the ESI version 3 for 403 actual patient

triages and found a kappa kappa statistic of 0.89

(Tanabe, Gimbel, Yarnold, Kyriacou, & Adams,

2004).

Researchers have also compared inter-rater reliability

of the ESI triage system with the CTAS (Worster et

al., 2004). Ten Canadian nurses were randomly

assigned to initial ESI version 3 or CTAS refresher

training, and then rated 200 case studies with the

ESI or CTAS, respectively. Both groups had excellent

inter-rater reliability, with kappas of 0.89 (ESI) and

0.91 (CTAS).

The validity of the ESI has been evaluated by

examination of outcomes for several thousand

patients. The studies found consistent, strong

correlations of the ESI with hospitalization, ED

length of stay, and mortality (Eitel et al., 2003;

Tanabe et al., 2004; Wuerz, 2001; Wuerz et al.,

2001). The ESI also has been found to have

moderate correlations with physician evaluation and

management codes and nursing workload measures

(Travers et al., 2002). The ESI has been shown to

facilitate meaningful comparisons of case mix

between hospitals. A stratified random sample of

200 patients was selected from each of the seven

initial ESI hospitals, and case mix was compared

(Eitel et al., 2003). As expected, there was a higher

percentage of high acuity patients at the tertiary

care centers, compared with a higher percentage of

low resource patients at the community hospitals. In

a survey of nursing staff at the two original

university teaching hospitals, responses to the

implementation of the ESI were positive (Wuerz et

al., 2001). The nurses reported that the ESI was

easier to use and more useful in prioritizing patients

for treatment than the former three-level systems in

use at the two sites.

3

Chapter 1. Introduction to the Emergency Severity Index: A Research-BasedTriageTool
The performance of ESI in pediatric patients has also

been evaluated. Travers et al (2009) have conducted

the largest evaluation of ESI in pediatric patients

(Travers, Waller, Katznelson, & Agan, 2009).

Reliability was evaluated using both written case

scenarios and actual patient triages at five different

sites. The validity of ESI was assessed in a group of

1173 pediatric patients using hospital admission,

resource consumption and ED length of stay. Interrater reliability for written case scenarios was 0.77

and 0.57 for live triages, suggesting room for

improvement in educational training of ED nurses.

Validity of triage categories in pediatric patients was

established with outcome measures of

hospitalization, resource utilization, and ED length

of stay. The outcomes from this study suggested the

need for additional education of ED nurses in the

area of overall pediatric triage, which led to the

inclusion of a pediatric chapter in this new edition

of the ESI handbook. In a separate investigation, 16

ED physicians and 17 ED nurses scored 20 pediatric

written case scenarios (Durani, Breecher, Walmsley,

Attia, & Loiselle, 2009). Overall inter-rater reliability

was excellent (weighted kappa=.93).

Several studies have evaluated the performance of

ESI with an elderly population. In a study of 929

patients age 65 or older with a total of 1,087 ED

visits over a 1-month period in 2004, ED resource

utilization, ED length of stay, hospital admission,

and 1-year survival were assessed. The ESI algorithm

performed well in all areas (Baumann & Strout,

2007). In a separate investigation of 782 patients >

65 years of age, the accuracy of ESI to identify

elderly patients requiring a life-saving intervention

was investigated (Platts-Mills et al., 2010). While

specificity was high (99%), sensitivity was poor

(42%). This suggests further evaluation of the

performance of ESI in elderly patients may be

warranted.

The ESI has been translated into several languages

and evaluated for reliability and validity. Good interand intra-rater reliability (weighted kappas of .73

and .65) was found when evaluated in the

Netherlands (Storm-Versloot, Ubbink, Chin a Choi,

& Luitse, 2009). The ESI was translated into German

and researchers found excellent inter-rater reliability

(k=0.985) and good validity with comparisons of ESI

triage levels and number of resources used,

hospitalization, and death (Grossman et al, 2011). In

a separate evaluation in an urban European country,

validity of the ESI categories was established with the

number of resources used and proportion of patients

requiring hospital admission (Elshove-Bolk, van

Rijswijck, Simons, van Vugt, 2007). Van der Wulp

and colleagues compared validity of predicting

admission between the ESI and Manchester triage

systems. Both systems demonstrated good predictive

ability with ESI scoring higher (van der Wulp,

Schrijvers, van Stel, 2009). Finally, validity assessed

by hospitalization was compared between ESI and

the Taiwan Triage System (TTS). ESI was better able

to discriminate patient acuity and hospitalization

when compared with the TTS (Chi & Huang, 2006).

Benefits of the Emergency

Severity Index

The ESI has been implemented by hospitals in

different regions of the country, by university and

community hospitals, and by teaching and

nonteaching sites. ED clinicians, managers and

researchers at those sites have identified several

benefits of ESI triage over conventional three-level

scales. In 2008, the National Opinion Research

Center conducted a survey of 935 persons who

requested ESI training materials from the Agency for

Healthcare Research and Quality. Respondents were

asked to rate their satisfaction with ESI as a triage

tool as well as to compare ESI with other triage tools.

Overall, ratings of satisfaction were high;

respondents reported ESI was simple to use, reduced

the subjectivity of the triage decision, and was more

accurate than other triage systems (Friedman, Singer,

Infante, Oppenheimer, West, & Siegel, in press).

One benefit of the ESI is the rapid identification of

patients that need immediate attention. The focus of

ESI triage is on quick sorting of patients in the

setting of constrained resources. ESI triage is a rapid

sorting into five groups with clinically meaningful

differences in projected resource needs and,

therefore, in associated operational needs. Use of the

ESI for this rapid sorting can lead to improved flow

of patients through the ED. For example, level 1 and

2 patients can be taken directly to the treatment area

for rapid evaluation and treatment, while lower

acuity patients can safely wait to be seen.

Other benefits of the ESI include determination of

which patients do not need to be seen in the main

ED and those who could safely and more efficiently

be seen in a fast-track or urgent care area. For

example, in many hospitals, the triage policy

stipulates that all ESI level-4 and level-5 patients can

be sent to either the medical fast track or minor

trauma areas of the ED. The triage policy may also

allow for some level-3 patients to be sent to urgent

care (UC), such as patients needing simple migraine

4

Chapter 1. Introduction to the Emergency Severity Index: A Research-BasedTriageTool
headache treatment. ESI level-3 patients triaged to

UC and all patients sent to the acute area from UC

for more serious conditions are monitored in the

quality improvement program. Nurses using the ESI

have reported that the tool facilitates

communication of patient acuity more effectively

than the former three-level triage scales used at the

sites (Wuerz et al., 2001). For example, the triage

nurse can tell the charge nurse, "I need a bed for a

level-2 patient," and through this common

language, the charge nurse understands what is

needed without a detailed explanation of the

patient by the triage nurse. Hospital administrators

can use the case mix in real time to help make

decisions regarding the need for additional resources

or possibly diverting ambulance arrivals. If a waiting

room has multiple level-2 patients with long waits,

the hospital may need to develop a plan for the

disposition of those patients who are waiting for an

inpatient bed and occupying space in the ED.

The ESI also has been used as the foundation for ED

policies that address specific populations. For

example, the psychiatric service at one site is

expected to provide consults for level-2 and level-3

patients with psychiatric complaints within 30

minutes of notification and for level-4 and level-5

patients within 1 hour. At another site, the ESI has

been incorporated into a policy for patients greater

than 20 weeks pregnant who present to the ED.

Patients rated at ESI levels 1 and 2 are treated in the

ED by emergency medicine with an obstetrical

consult. Those rated 3, 4, or 5 are triaged to the

labor and delivery area of the hospital.

Standardization of ED triage acuity data using the

ESI is beneficial for secondary uses of ED data. For

example, ED crowding researchers have

incorporated the ESI into metrics for measuring and

predicting ED crowding (Bernstein, Verghese, Leung,

Lunney, Perez, 2003). Wider adoption of the ESI by

U.S. hospitals could lead to the establishment of a

true standard for triage acuity assessment, which

will facilitate benchmarking, public health

surveillance, and research.

References

American College of Emergency Physicians (2010). ACEP

policy statements: Triage scale standardization. Dallas,

TX: American College of Emergency Physicians.

Retrieved June 1, 2011, from http://www.acep.org/

Content.aspx?id=29828&terms=triage%scale.

Barthell EN, Coonan K, Finnell J, Pollock D, Cochrane D

(2004). Disparate systems, disparate data: integration,

interfaces and standards in emergency medicine

information technology. Acad Emerg Med. 11(11):1142-

1148.

Baumann MR, Strout TD (2007). Triage of geriatric

patients in the emergency department: validity and

survival with the Emergency Severity Index. Ann Emerg

Med. 49:234-240.

Bernstein SL, Verghese V, Leung W, Lunney AT, Perez I

(2003). Development and validation of a new index to

measure emergency department crowding. Acad Emerg

Med. 10(9):938-942.

Centers for Disease Control and Prevention (2008).

National Hospital Ambulatory Medical Care Survey: 2008

Emergency department summary tables. Retrieved June

6, 2011 from http://www.cdc.gov/nchs/data/ahcd/

nhamcs_emergency/nhamcsed2008.pdf.

Chi CJ, Huang CM (2006). Comparison of the Emergency

Severity Index (ESI) and the Taiwan Triage System in

predicting resource utilization. J Formos Med Assoc.

105(8):617-625.

Durani Y, Breecher D, Walmsley D, Attia MW, Loiselle JM

(2009). The Emergency Severity Index version 4

reliability in pediatric patients. Pediatr Emerg Care.

25(8):504-507.

Eitel DR, Travers DA, Rosenau A, Gilboy N, Wuerz RC

(2003). The Emergency Severity Index version 2 is

reliable and valid. Acad Emerg Med. 10(10):1079-1080.

Elshove-Bolk J, Mencl F, van Rijswijck BTF, Simons MP,

van Vugt AB (2007). Validation of the Emergency

Severity Index (ESI) in self-referred patients in a

European emergency department. Emerg Med. 24:170-

174.

Emergency Nurses Association (2003). Position statements:

ENA board approves statement on joint ENA/ACEP

five-level triage task force. Des Plaines, IL. Retrieved

February 10, 2005, from www.ena.org/about/position.

Fernandes C, Tanabe P, Gilboy N, Johnson L, McNair R,

Rosenau A, Sawchuk P, Thompson DA, Travers DA,

Bonalumi N, Suter RE (2005). Five level triage: A report

from the ACEP/ENA Five Level Triage Task Force. JEN.

31(1):39-50.

Friedman Singer R, Infante AA, Oppenheimer CC, West

CA, Siegel B (in press). The use of and satisfaction with

the Emergency Severity Index. JEN.

Gilboy N, Travers DA, Wuerz RC (1999). Reevaluating

triage in the new millennium: A comprehensive look at

the need for standardization and quality. JEN.

25(6):468-473.

5

Chapter 1. Introduction to the Emergency Severity Index: A Research-BasedTriageTool
Grossman FF, Nickel CH, Christ M, Schneider K, Spirig R,

Bingisser R (2011). Transporting clinical tools to new

settings: Cultural adaptation and validation of the

Emergency Severity Index in German. Ann Emerg Med.

57(3): 257-264.

Institute of Medicine of the National Academies (2006,

June). The Future of Emergency Care in the United States

Health System. Consensus Report, http://www.iom.edu/

Activities/Quality/emergencycare.aspx. Washington,

DC: Institute of Medicine.

Haas SW, Travers D, Tintinalli JE, Pollock D, Waller A,

Barthell E, Burt C, Chapman W, Coonan K, Kamens D,

McClay J (2008). Towards vocabulary control for chief

complaint. Acad Emerg Med. 15(5):476-482.

Handler JA, Adams JG, Feied CF, Gillam M, Vozenilek J,

Barthell E, Davidson SJ (2004). Emergency medicine

information technology consensus conference:

executive summary. Acad Emerg Med. 11:1112-1113.

McHugh M, Tanabe P (2011, June). The Emergency

Severity Index is the most commonly used triage

system in the U.S. Presented at the Society of Academic

Emergency Medicine Annual Meeting, Boston, MA.

National Center for Injury Prevention and Control (1997).

Data elements for emergency department systems.

(Release 1.0). Atlanta, GA: Centers for Disease Control

and Prevention.

Niska R, Bhuiya F, Xu J (2010). National Hospital

Ambulatory Medical Care Survey: 2007 Emergency

Department Summary. (National Health Statistics

Reports: no. 26). Hyattsville, MD: National Center for

Health Statistics.

Pedhazur EJ, Schmelkin LP (1991). Measurement, design and

analysis: An integrated approach. Hillsdale, NJ: Erlbaum.

Platts-Mills TF, Travers D, Biese K, McCall B, Kizer S,

LaMantia M, Busby-Whitehead J, Cairns CB (2010).

Accuracy of the Emergency Severity Triage instrument

for identifying elder emergency department patients

receiving an immediate life-saving intervention. Acad

Emerg Med. 17:238-243.

Storm-Versloot MN, Ubbink D T, Chin a Choi V, Luitse

JSK (2009). Observer agreement of the Manchester

Triage System and the Emergency Severity Index: a

simulation study. EMJ. 26:556-560.

Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams JG

(2004). Reliability and validity of scores on the

emergency severity index version 3. Acad Emerg Med.

11(1):59-65.

Tanabe P, Travers D, Gilboy N, Rosenau A, Sierzega G,

Rupp V, Martinovich Z, Adams JG (2005). Refining

Emergency Severity Index (ESI) triage criteria, ESI v4.

Acad Emerg Med. 12(6):497-501.

Travers DA, Waller AE, Bowling JM, Flowers D, Tintinalli J

(2002). Five-level triage system more effective than

three-level in tertiary emergency department. JEN.

28(5):395-400.

Travers DA, Waller AE, Katznelson J, Agan R (2009).

Reliability and validity of the Emergency Severity Index

for Pediatric Triage. Acad Emerg Med.16:843-849.

Van der Wulp I, Schrijvers AJP, van Stel HF (2009).

Predicting admission and mortality with the

Emergency Severity Index and the Manchester Triage

System: A retrospective observational study. EMJ.

26:506-509.

Welch S, Davidson S (2010). Exploring new intake models

for the emergency department. Am J Med Qual.

25(3):172-180.

Worster A, Gilboy N, Fernandes CM, Eitel D, Eva K,

Geisler R, Tanabe P (2004). Assessment of inter-observer

reliability of two five-level triage and acuity scales: A

randomized controlled trial. Canadian Journal of

Emergency Medicine. 6(4):240-245.

Wuerz R (2001). Emergency Severity Index triage category

is associated with six-month survival. ESI triage study

group. Acad Emerg Med. 8(1):61-64.

Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000).

Reliability and validity of a new five-level triage

instrument. Acad Emerg Med. 7(3):236-242.

Wuerz R, Travers D, Gilboy N, Eitel DR, Rosenau A,

Yazhari R (2001). Implementation and refinement of

the Emergency Severity Index. Acad Emerg Med.

8(2):170-176.

6

Chapter 1. Introduction to the Emergency Severity Index: A Research-BasedTriageTools
The Emergency Severity Index (ESI) is a simple to

use, five-level triage algorithm that categorizes

emergency department patients by evaluating both

patient acuity and resource needs. Initially, the

triage nurse assesses only the acuity level. If a

patient does not meet high acuity level criteria (ESI

level 1 or 2), the triage nurse then evaluates

expected resource needs to help determine a triage

level (ESI level 3, 4, or 5). The ESI is intended for use

by nurses with triage experience or those who have

attended a separate, comprehensive triage

educational program.

Inclusion of resource needs in the triage rating is a

unique feature of the ESI in comparison with other

triage systems. Acuity is determined by the stability

of vital functions and the potential threat to life,

limb, or organ. The triage nurse estimates resource

needs based on previous experience with patients

presenting with similar injuries or complaints.

Resource needs are defined as the number of

resources a patient is expected to consume in order

for a disposition decision (discharge, admission, or

transfer) to be reached. Once oriented to the

algorithm, the triage nurse will be able to rapidly

and accurately triage patients into one of five

explicitly defined and mutually exclusive levels.

This chapter presents a step-by-step description and

overview of how to triage using the ESI algorithm.

Subsequent chapters explain key concepts in more

detail and provide numerous examples to clarify the

finer points of ESI.

Algorithms are frequently used in emergency care.

Most emergency clinicians are familiar with the

algorithms used in courses such as Basic Life

Support, Advanced Cardiac Life Support, and the

Trauma Nursing Core Course. These courses present

a step-by-step approach to clinical decision making

that the clinician is able to internalize with practice.

The ESI algorithm follows the same principles.

Each step of the algorithm guides the user toward

the appropriate questions to ask or the type of

information to gather. Based on the data or answers

obtained, a decision is made and the user is directed

to the next step and ultimately to the determination

of a triage level.

A conceptual overview of the ESI algorithm is

presented in Figure 2-1 to illustrate the major ESI

decision points. The ESI algorithm itself is shown in

Figure 2-1a. The algorithm uses four decision points

(A, B, C, and D) to sort patients into one of the five

triage levels. Triage with the ESI algorithm requires

an experienced ED nurse, who starts at the top of

the algorithm. With practice, the triage nurse will be

able to rapidly move from one ESI decision point to

the next.

The four decision points depicted in the ESI

algorithm are critical to accurate and reliable

application of ESI. The figure shows the four

decision points reduced to four key questions:

A. Does this patient require immediate life-saving

intervention?

B. Is this a patient who shouldn't wait?

C. How many resources will this patient need?

D. What are the patient's vital signs?

7

Chapter 2. Overview of the Emergency

Severity Index

patient dying? 1

5 4

3

2

shouldn’t wait?

how many resources?

none one many

vital signs

Figure 2-1. Emergency Severity Index Conceptual

Algorithm, v. 4

yes

yes

no

no

no

consider

©ESI Triage Research Team, 2004. Reproduced with

permission.

A

B

C

D
The answers to the questions guide the user to the

correct triage level.

Decision Point A: Does the

Patient Require Immediate

Life-Saving Intervention?

Simply stated, at decision point A (Figure 2-2) the

triage nurse asks, “Does this patient require

immediate life saving intervention?” If the answer is

“yes,” the triage process is complete and the patient

is automatically triaged as ESI level 1. A “no” answer

moves the user to the next step in the algorithm,

decision point B.

The following questions are used to determine

whether the patient requires an immediate lifesaving intervention:

• Does this patient have a patent airway?

• Is the patient breathing?

• Does the patient have a pulse?

8

Chapter 2. Overview of the Emergency Severity Index

Figure 2-1a. ESITriage Algorithm

©ESI Triage Research Team, 2004. Reproduced with permission.

A. Immediate life-saving intervention required: airway, emergency medications, or

other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO

NOT count); and/or any of the following clinical conditions: intubated, apneic,

pulseless, severe respiratory distress, SPO2<90, acute mental status changes, or

unresponsive.

Unresponsiveness is defined as a patient that is either:

(1) nonverbal and not following commands (acutely); or 

(2) requires noxious stimulus (P or U on AVPU) scale.

B. High risk situation is a patient you would put in your last open bed. 

Severe pain/distress is determined by clinical observation and/or patient rating of

greater than or equal to 7 on 0-10 pain scale.

C. Resources: Count the number of different types of resources, not the individual 

tests or x-rays (examples: CBC, electrolytes and coags equals one resource; CBC

plus chest x-ray equals two resources).

Resources

• Labs (blood, urine)

• ECG, X-rays

• CT-MRI-ultrasound-angiography

• IV fluids (hydration) 

• IV or IM or nebulized medications 

• Specialty consultation 

• Simple procedure =1

(lac repair, foley cath)

• Complex procedure =2

(conscious sedation) 

Not Resources

• History & physical (including pelvic)

• Point-of-care testing

• Saline or heplock

• PO medications

• Tetanus immunization

• Prescription refills

• Phone call to PCP

• Simple wound care 

(dressings, recheck)

• Crutches, splints, slings

D. Danger Zone Vital Signs

Consider uptriage to ESI 2 if any vital sign criterion is exceeded.

Pediatric Fever Considerations

1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)

1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F)

3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), 

or incomplete immunizations, or no obvious source of fever

© ESI Triage Research Team, 2004 – (Refer to teaching materials for further clarification)

Figure 2-2. Decision Point A: Is the Patient Dying?
• Is the nurse concerned about the pulse rate,

rhythm, and quality?

• Was this patient intubated pre-hospital because

of concerns about the patient's ability to

maintain a patent airway, spontaneously breathe,

or maintain oxygen saturation?

• Is the nurse concerned about this patient's ability

to deliver adequate oxygen to the tissues?

• Does the patient require an immediate

medication, or other hemodynamic intervention

such as volume replacement or blood?

• Does the patient meet any of the following

criteria: already intubated, apneic, pulseless,

severe respiratory distress, SpO2 < 90 percent,

acute mental status changes, or unresponsive?

Research has demonstrated that the triage nurse is

able to accurately predict the need for immediate

lifesaving interventions (Tanabe, et al., 2005). Table

2-1 lists interventions that are considered lifesaving

and those that are not, for the purposes of ESI triage.

Interventions not considered lifesaving include

some interventions that are diagnostic or

therapeutic, but none that would save a life.

Lifesaving interventions are aimed at securing an

airway, maintaining breathing, supporting

circulation or addressing a major change in level of

consciousness (LOC).

The ESI level-1 patient always presents to the

emergency department with an unstable condition.

Because the patient could die without immediate

care, a team response is initiated: the physician is at

the bedside, and nursing is providing critical care.

ESI level-1 patients are seen immediately because

timeliness of interventions can affect morbidity and

mortality.

9

Chapter 2. Overview of the Emergency Severity Index

 Life-saving Not life-saving

Airway/breathing • BVM ventilation Oxygen administration

 • Intubation • nasal cannula

 • Surgical airway • non-rebreather

 • Emergent CPAP 

 • Emergent BiPAP

ElectricalTherapy • Defibrillation Cardiac Monitor

 • Emergent cardioversion 

 • External pacing

Procedures • Chest needle decompression DiagnosticTests

 • Pericardiocentesis • ECG

 • Open thoracotomy • Labs

 • Intraoseous access • Ultrasound

 • FAST (Focused abdominal

 scan for trauma)

Hemodynamics • Significant IV fluid resuscitation • IV access

 • Blood administration • Saline lock for medications

 • Control of major bleeding

Medications • Naloxone • ASA

 • D50 • IV nitroglycerin

 • Dopamine • Antibiotics

 • Atropine • Heparin

 • Adenocard • Pain medications

 • Respiratory treatments with

 beta agonists

Table 2-1. Immediate Life-saving Interventions
Immediate physician involvement in the care of the

patient is a key difference between ESI level-1 and

ESI level-2 patients. Level-1 patients are critically ill

and require immediate physician evaluation and

interventions. When considering the need for

immediate lifesaving interventions, the triage nurse

carefully evaluates the patient’s respiratory status

and oxygen saturation (SpO2). A patient in severe

respiratory distress or with an SpO2 < 90 percent

may still be breathing, but is in need of immediate

intervention to maintain an airway and

oxygenation status. This is the patient who will

require the physician in the room ordering

medications such as those used for rapid sequence

intubation or preparing for other interventions for

airway and breathing.

Each patient with chest pain must be evaluated

within the context of the level-1 criteria to

determine whether the patient requires an

immediate life-saving intervention. Some patients

presenting with chest pain are very stable. Although

they may require a diagnostic electrocardiogram

(ECG) within 10 minutes of arrival, these patients

do not meet level-1 criteria. However, patients who

are pale, diaphoretic, in acute respiratory distress or

hemodynamically unstable do meet level-1 criteria

and will require immediate life-saving interventions.

When determining whether the patient requires

immediate life-saving intervention, the triage nurse

must also assess the patient's level of responsiveness.

The ESI algorithm uses the AVPU (alert, verbal, pain,

unresponsive) scale (Table 2-2). The goal for this part

of the algorithm is to identify the patient who has a

recent and/or sudden change in level of conscience

and requires immediate intervention. The triage

nurse needs to identify patients who are non-verbal

or require noxious stimuli to obtain a response. ESI

uses the AVPU scale and patients that score a P

(pain) or U (unresponsive) on the AVPU scale meet

level-1 criteria. Unresponsiveness is assessed in the

context of acute changes in neurological status, not

for the patient who has known developmental

delays, documented dementia, or aphasia. Any

patient who is unresponsive, including the

intoxicated patient who is unresponsive to painful

stimuli, meets level-1 criteria and should receive

immediate evaluation. An example of a recent

mental status change that would require immediate

intervention would be a patient with decreased

mental status who is unable to maintain a patent

airway or is in severe respiratory distress.

An ESI level-1 patient is not always brought to the

emergency department by ambulance. The patient

or his or her family member may not realize the

severity of the illness and, instead of calling an

ambulance, may drive the patient to the emergency

department. The patient with a drug overdose or

acute alcohol intoxication may be dropped at the

front door. Infants and children, because they are

“portable,” may be brought to the ED by car and

carried into the emergency department. The

experienced triage nurse is able to instantly identify

this critical patient. With a brief, “across-the-room”

assessment, the triage nurse recognizes the patient

that is in extremis. Once identified, this patient is

taken immediately to the treatment area and

resuscitation efforts are initiated.

Patients assessed as an ESI level 1 constitute

approximately 1 percent to 3 percent of all ED

patients (Eitel, et al., 2003; Wuerz, Milne, Eitel,

Travers, & Gilboy, 2000; Wuerz, et al., 2001). Upon

arrival, the patient's condition requires immediate

life saving interventions from either the emergency

physician and nurse or the trauma or code team.

From ESI research we know that most ESI level-1

10

Chapter 2. Overview of the Emergency Severity Index

AVPU 

level Level of consciousness

A Alert.The patient is alert, awake and

 responds to voice.The patient is oriented

 to time, place and person.The triage

 nurse is able to obtain subjective

 information.

V Verbal.The patient responds to verbal

 stimuli by opening their eyes when

 someone speaks to them.The patient is

 not fully oriented to time, place, or

 person.

P Painful.The patient does not respond to

 voice, but does respond to a painful

 stimulus, such as a squeeze to the hand

 or sternal rub. A noxious stimulus is

 needed to elicit a response.

U Unresponsive.The patient is nonverbal

 and does not respond even when a

 painful stimulus is applied

Emergency Nurses Association, 2000.

Table 2-2 Four Levels of the AVPU Scale
patients are admitted to intensive care units, while

some die in the emergency department (Eitel, et al.,

2003; Wuerz, 2001). A few ESI level-1 patients are

discharged from the ED, if they have a reversible

change in level of consciousness or vital functions

such as with hypoglycemia, seizures, alcohol

intoxication, or anaphylaxis.

Examples of ESI level 1:

• Cardiac arrest

• Respiratory arrest

• Severe respiratory distress

• SpO2 < 90

• Critically injured trauma patient who presents

unresponsive

• Overdose with a respiratory rate of 6

• Severe respiratory distress with agonal or gaspingtype respirations

• Severe bradycardia or tachycardia with signs of

hypoperfusion

• Hypotension with signs of hypoperfusion

• Trauma patient who requires immediate

crystalloid and colloid resuscitation

• Chest pain, pale, diaphoretic, blood pressure

70/palp.

• Weak and dizzy, heart rate = 30

• Anaphylactic shock

• Baby that is flaccid

• Unresponsive patient with a strong odor of

alcohol

• Hypoglycemia with a change in mental status

• Intubated head bleed with unequal pupils

• Child that fell out of a tree and is unresponsive

to painful stimuli

Decision Point B: Should the

Patient Wait?

Once the triage nurse has determined that the

patient does not meet the criteria for ESI level 1, the

triage nurse moves to decision point B (Figure 2-3)

At decision point B, the nurse needs to decide

whether this patient is a patient that should not

wait to be seen. If the patient should not wait, the

patient is triaged as ESI level 2. If the patient can

wait, then the user moves to the next step in the

algorithm.

Three broad questions are used to determine

whether the patient meets level-2 criteria:

1. Is this a high-risk situation?

2. Is the patient confused, lethargic or disoriented?

3. Is the patient in severe pain or distress?

The triage nurse obtains pertinent subjective and

objective information to quickly answer these

questions. A brief introduction to ESI level-2 criteria

is presented here, while a more detailed explanation

of which patients meet ESI level-2 criteria will be

presented in Chapter 3.

Is This a High-Risk Situation?

Based on a brief patient interview, gross

observations, and finally the “sixth sense” that

comes from experience, the triage nurse identifies

the patient who is high risk. Frequently the patient's

age and past medical history influence the triage

nurse's determination of risk.

A high-risk patient is one whose condition could

easily deteriorate or who presents with symptoms

suggestive of a condition requiring time-sensitive

treatment. This is a patient who has a potential

threat to life, limb or organ. A high-risk patient does

not require a detailed physical assessment or even a

full set of vital signs in most cases. The patient may

describe a clinical portrait that the experienced

triage nurse recognizes as a high-risk situation. An

example is the patient who states, “I never get

headaches and I lifted this heavy piece of furniture

and now I have the worst headache of my life.” The

triage nurse would triage this patient as ESI level 2

because the symptoms suggest the possibility of a

subarachnoid hemorrhage.

11

Chapter 2. Overview of the Emergency Severity Index

Figure 2-3. Decision Point B: Should the Patient

Wait?
When the patient is an ESI level 2, the triage nurse

has determined that it would be unsafe for the

patient to remain in the waiting room for any

length of time. While ESI does not suggest specific

time intervals, ESI level-2 patients remain a high

priority, and generally placement and treatment

should be initiated rapidly. ESI level-2 patients are

very ill and at high risk. The need for care is

immediate and an appropriate bed needs to be

found. Usually, rather than move to the next

patient, the triage nurse determines that the charge

nurse or staff in the patient care area should be

immediately alerted that they have an ESI level 2.

Unlike with level-1 patients, the emergency nurse

can initiate care through protocols without a

physician immediately at the bedside. The nurse

recognizes that the patient needs interventions but

is confident that the patient's clinical condition will

not deteriorate. The nurse can initiate intravenous

(IV) access, administer supplemental oxygen, obtain

an ECG, and place the patient on a cardiac monitor,

all before a physician is needed. Although the

physician does not need to be present immediately,

he or she should be notified that the patient is there

and is an ESI 2.

Examples of high-risk situations:

• Active chest pain, suspicious for acute coronary

syndrome but does not require an immediate

life-saving intervention, stable

• A needle stick in a health care worker

• Signs of a stroke, but does not meet level-1

criteria

• A rule-out ectopic pregnancy, hemodynamically

stable

• A patient on chemotherapy and therefore

immunocompromised, with a fever

• A suicidal or homicidal patient

Chapter 3 contains additional information on highrisk situations.

Is the Patient Confused, Lethargic, or

Disoriented?

This is the second question to be asked at decision

point B. Again the concern is whether the patient is

demonstrating an acute change in level of

consciousness. Patients with a baseline mental status

of confusion do not meet level-2 criteria.

Examples of patients who are confused, lethargic, or

disoriented:

• New onset of confusion in an elderly patient

• The 3-month-old whose mother reports the child

is sleeping all the time

• The adolescent found confused and disoriented

Each of these examples indicates that the brain may

be either structurally or chemically compromised.

Is the Patient in Severe Pain or

Distress?

The third question the triage nurse needs to answer

at decision point B is whether this patient is

currently in pain or distress. If the answer is "no,"

the triage nurse is able to move to the next step in

the algorithm. If the answer is "yes," the triage nurse

needs to assess the level of pain or distress. This is

determined by clinical observation and/or a selfreported pain rating of 7 or higher on a scale of 0 to

10. When patients report pain ratings of 7/10 or

greater, the triage nurse may triage the patient as

ESI level 2, but is not required to assign a level-2

rating.

Pain is one of the most common reasons for an ED

visit and clearly all patients reporting pain 7/10 or

greater do not need to be assigned an ESI level-2

triage rating. A patient with a sprained ankle

presents to the ED and rates their pain as 8/10.This

patient’s pain can be addressed with simple nursing

interventions: wheelchair, elevation and application

of ice. This patient is safe to wait and should not be

assigned to ESI level 2 based on pain.

In some patients, pain can be assessed by clinical

observation:

• Distressed facial expression, grimacing, crying

• Diaphoresis

• Body posture

• Changes in vital signs – hypertension (HTN),

tachycardia, and increased respiratory rate

The triage nurse observes physical responses to acute

pain that support the patient's rating. For example,

the patient with abdominal pain who is diaphoretic,

tachycardic, and has an elevated blood pressure or

the patient with severe flank pain, vomiting, pale

skin, and a history of renal colic are both good

examples of patients that meet ESI level-2 criteria.

12

Chapter 2. Overview of the Emergency Severity Index
The triage nurse should also consider the question,

“Would I give my last open bed to this patient?” If

the answer is yes, then the patient meets the criteria

for ESI level 2.

Chapter 3 provides additional information on

ESIlevel 2 and pain.

Severe distress can be physiological or psychological.

Examples of distress include the sexual assault

victim, the victim of domestic violence, the

combative patient, or the bipolar patient who is

currently manic.

ESI level-2 patients constitute approximately 20

percent to 30 percent of emergency department

patients (Travers, et al., 2002; Wuerz, et al., 2001;

Tanabe, Gimbel, et al., 2004). Once an ESI level-2

patient is identified, the triage nurse needs to ensure

that the patient is cared for in a timely manner.

Registration can be completed by a family member

or at the bedside. ESI level-2 patients need vital signs

and a comprehensive nursing assessment but not

necessarily at triage. Placement in the treatment area

is a priority and should not be delayed to finish

obtaining vital signs or asking additional questions.

ESI research has shown that 50 to 60 percent of ESI

level-2 patients are admitted from the ED (Wuerz, et

al., 2001).

Decision Point C: Resource

Needs

If the answers to the questions at the first two

decision points are "no," then the triage nurse

moves to decision point C (Figure 2-4).

The triage nurse should ask, “How many different

resources do you think this patient is going to

consume in order for the physician to reach a

disposition decision?” The disposition decision

could be to send the patient home, admit to the

observation unit, admit to the hospital, or even

transfer to another institution. This decision point

again requires the triage nurse to draw from past

experiences in caring for similar emergency

department patients. ED nurses need to clearly

understand that the estimate of resources has to do

with standards of care and is independent of type of

hospital (i.e., teaching or non-teaching) location of

the hospital (urban or rural), or which provider is

working that day. A patient presenting to any

emergency department should consume the same

general resources in one ED as in any other ED.

Considering the patient's brief subjective and

objective assessment, past medical history, allergies,

medications, age, and gender, how many different

resources will be used in order for the physician to

reach a disposition? In other words, what is typically

done for the patient who presents to the emergency

department with this common complaint? The

triage nurse is asked to answer these questions based

on his or her assessment of the patient and should

not consider individual practice patterns, but rather

the routine practice in the particular ED.

To identify resource needs, the triage nurse must be

familiar with emergency department standards of

care. The nurse must be knowledgeable about the

concept of “prudent and customary.” One easy way

to think about this concept is to ask the question,

“Given this patient's chief complaint or injury,

which resources are the emergency physician likely

to utilize?” Resources can be hospital services, tests,

procedures, consults or interventions that are above

and beyond the physician history and physical, or

very simple emergency department interventions

such as applying a bandage. Further explanations

and examples are provided in Chapter 4.

A list of what is and is not considered a resource for

purposes of ESI triage classification can be found in

Table 2-3. ESI level-3 patients are predicted to

require two or more resources; ESI level-4 patients

are predicted to require one resource; and ESI level-5

patients are predicted to require no resources (Table

2-4).

Research has shown that ESI level-3 patients make

up 30 percent to 40 percent of patients seen in the

emergency department (Eitel et al., 2003; Wuerz et

al., 2001). ESI level 3 patients present with a chief

complaint that requires an in-depth evaluation. An

example is patients with abdominal pain. They

often require a more in-depth evaluation but are felt

to be stable in the short term, and certainly may

13

Chapter 2. Overview of the Emergency Severity Index

Figure 2-4. Resource Prediction
have a longer length of stay in the ED. ESI level 4

and ESI level 5 make up between 20 percent and 35

percent of ED volume, perhaps even more in a

community with poor primary care access.

Appropriately trained mid-level providers with the

right skills mix could care for these patients in a

fast-track or express care setting, recognizing that a

high proportion of these patients have a traumarelated presenting complaint.

Decision Point D:The Patient's

Vital Signs

Before assigning a patient to ESI level 3, the nurse

needs to look at the patient’s vital signs and decide

whether they are outside the accepted parameters

for age and are felt by the nurse to be meaningful. If

the vital signs are outside accepted parameters, the

triage nurse should consider upgrading the triage

level to ESI level 2. However, it is the triage nurse's

decision as to whether or not the patient should be

upgraded to an ESI level 2 based on vital sign

abnormalities. This is decision point D.

14

Chapter 2. Overview of the Emergency Severity Index

Resources Not resources

Labs (blood, urine) History & physical

 (including pelvic)

ECG, X-rays Point-of-care testing

CT-MRI-ultrasound

angiography

IV fluids (hydration) Saline or heplock

IV, IM or nebulized PO medications

medications Tetanus immunization

 Prescription refills

Specialty consultation Phone call to PCP

Simple procedure = 1 Simple wound care

(lac repair, Foley cath) (dressings, recheck)

Complex procedure = 2 Crutches, splints,

(conscious sedation) slings

Table 2-3. ESI Resources

ESI Level Patient Presentation Interventions Resources

5 Healthy 10-year-old child with poison ivy Needs an exam and prescription None

5 Healthy 52-year-old male ran out of blood Needs an exam and prescription None

 pressure medication yesterday; BP 150/92

4 Healthy 19-year-old with sore throat Needs an exam, throat culture, Lab (throat

 and fever prescriptions culture)*

4 Healthy 29-year-old female with a urinary Needs an exam, urine, and urine Lab (urine,

 tract infection, denies vaginal discharge culture, maybe urine hCG, and urine C&S,

 prescriptions urine hCG)**

3 A 22-year-old male with right lower Needs an exam, lab studies, 2 or more

 quadrant abdominal pain since early IV fluid, abdominal CT, and 

 this morning + nausea, no appetite perhaps surgical consult 

3 A 45-year-old obese female with left lower Needs exam, lab, lower extremity 2 or more

 leg pain and swelling, started 2 days non-invasive vascular studies 

 ago after driving in a car for 12 hours

* In some regions throat cultures are not routinely performed; instead, the patient is treated based on

history and physical exam. If that is the case the patient would be an ESI level 5.

** All 3 tests count as one resource (Lab).

Table 2-4. Predicting Resources
Vital sign parameters are outlined by age in Figure 2-

5. The vital signs used are pulse, respiratory rate,

and oxygen saturation and, for any child under age

3, body temperature. Using the vital sign criteria,

the triage nurse can upgrade an adult patient who

presents with a heart rate of 104, or this patient can

remain ESI level 3. A 6-month-old baby with a cold

and a respiratory rate of 48 could be triaged ESI level

2 or 3. Based on the patient's history and physical

assessment, the nurse must ask if the vital signs are

enough of a concern to say that the patient is high

risk and cannot wait to be seen. Chapter 5 explains

vital signs in detail and gives examples.

Temperature is only included with children under

age 3. Significant fever may exclude young children

from categories 4 and 5. This will help identify

potentially bacteremic children and avoid sending

them to a fast track setting or keeping them waiting

a prolonged time. Pediatric fever guidelines are

described in detail in Chapter 5.

Does Time to Treatment

Influence ESI Triage Categories?

An estimate of how long the patient can wait to be

seen by a physician is an important component of

most triage systems. The Australasian and Canadian

Triage Systems both require patients to be seen by a

physician within a specific time period, based on

their triage category. ESI does not mandate specific

time standards in which patients must be evaluated

by a physician. However, patients who meet criteria

for ESI level 2 should be seen as soon as possible; it

is up to the individual institution to determine

specific policies for what constitutes “as soon as

possible.”

Frequently, there may be confusion between

institutional policy and “flow or process of patient

care” and ESI triage level. Examples of patient

scenarios in which flow and triage category may

seem to conflict are presented below

Often trauma patients present to the triage nurse

after sustaining a significant mechanism of injury,

such as an unrestrained passenger in a high-speed

motor vehicle crash. The patient may have left the

crash scene in some way other than by ambulance

and presents to triage with localized right upper

quadrant pain with stable vital signs. This patient is

physiologically stable, walked into the ED, and does

not meet ESI level-1criteria. However, the patient is

at high risk for a liver laceration and other

significant trauma, so should be triaged as ESI level

2.

Frequently, EDs have trauma policies and trauma

response level categorization that will require rapid

initiation of care. Triage and trauma response level

are both important and should be recorded as two

different scores. While the triage nurse recognizes

this is a physiologically stable trauma patient and

correctly assigns ESI level 2, she should facilitate

patient placement and trauma care as outlined by

the trauma policy. The patient is probably stable for

another 10 minutes and does not require immediate

life-saving interventions. If the same patient

presented with a blood pressure of 80 palpable, the

patient would be triaged as ESI level 1 and require

immediate hemodynamic, life-saving interventions.

Another example of policies that may affect triage

level is triage of the patient with stable chest pain. If

the patient is physiologically stable but experiencing

chest pain, that is potentially an acute coronary

syndrome. The patient meets ESI level-2 criteria. He

or she does not require immediate life-saving

interventions but is a high-risk patient. Care is timesensitive; an ECG should be performed within 10

minutes of patient arrival. Often, EDs will have a

policy related to rapid initiation of an ECG. While

care of these patients should be rapidly initiated, the

ECG is not a life-saving intervention, it is a

diagnostic procedure. If the triage nurse were to

triage all chest pain patients as ESI level 1, it would

be difficult to prioritize the care for true ESI level-1

patients who require immediate life-saving

15

Chapter 2. Overview of the Emergency Severity Index

Figure 2-5. Danger Zone Vital Signs
interventions. But the patient with chest pain who

presents to triage diaphoretic, with a blood pressure

of 80 palpable would meet ESI level-1 criteria.

The third example of time-sensitive care is a patient

who presents with signs of an acute stroke. For

example, the patient who reports left arm weakness

meets the criteria for ESI level 2, and the stroke team

needs to be activated immediately. Time to

computed tomography (CT) completion is a quality

measure that must be met. But the patient with

signs of stroke that is unable to maintain an airway

meets ESI level-1 criteria. The stroke team would

also be activated.

Finally, a somewhat different scenario is an elderly

patient who fell, may have a fractured hip, arrives

by private car with family, and is in pain. The

patient does not really meet ESI level-2 criteria but is

very uncomfortable. The triage nurse would

categorize the patient as ESI level 3 and probably

place the patient in an available bed before other ESI

level-3 patients. Ambulance patients may also

present with a similar scenario. Arriving by

ambulance is not a criterion to assign a patient ESI

level 1 or 2. The ESI criteria should always be used

to determine triage level without regard to method

of arrival.

In general, care of ESI level-2 patients should be

rapidly facilitated and the role of the charge nurse

or flow manager is to know where these patients can

be placed in the treatment area on arrival. All level-2

patients are still potentially very ill and require rapid

initiation of care and evaluation. The triage nurse

has determined that it is unsafe for these patients to

wait. Patients currently may be stable, but may have

a condition that can easily deteriorate; initiation of

diagnostic treatment may be time sensitive (stable

chest pain requires an ECG within 10 minutes of

arrival); or the patient may have a potential major

life or organ threat. ESI level-2 patients are still

considered to be very high risk.

In the current atmosphere of ED crowding, it is not

uncommon for the triage nurse to be in a situation

of triaging many ESI level-2 patients with no open

ED rooms in which to place the patients. In these

situations, the triage nurse may be tempted to

“under-triage.” This can lead to serious, negative

patient outcomes and an underrepresentation of the

ED's overall case mix. When faced with multiple ESI

level-2 patients simultaneously, the triage nurse

must evaluate each patient according to the ESI

algorithm. Then, the nurse can “triage” all level-2

patients to determine which patient(s) are at highest

risk for deterioration, in order to facilitate patient

placement based on this evaluation. For example,

the patient with chest pain would be brought in

before the patient with a kidney stone.

Summary

In summary, the ESI is a five-level triage system that

is simple to use and divides patients by acuity and

resource needs. The ESI triage algorithm is based on

four key decision points. The experienced ED RN

will be able to rapidly and accurately triage patients

using this system.

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

References

Eitel DR, Travers DA, Rosenau A, Gilboy N, Wuerz RC

(2003). The emergency severity index version 2 is

reliable and valid. Acad Emerg Med.10(10):1079-1080.

Emergency Nurses Association (2007). TraumaNnursing

Core Course (Provider Manual), 6th ed. Des Plaines, IL:

Emergency Nurses Association.

Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams J

(2004). Reliability and validity of scores on the

Emergency Severity Index version 3. Acad Emerg Med.

11:59-65.

Tanabe P, Gimbel R, Yarnold PR, Adams J (2004). The

emergency severity index (v. 3) five level triage system

scores predict ED resource consumption. JEN. 30:22-29.

Tanabe P, Travers D, Gilboy N, Rosenau A, Sierzega G,

Rupp V, et al (2005). Refining Emergency Severity

Index triage criteria, ESI v4. Acad Emerg Med. 12(6):497-

501.

Travers D, Waller AE, Bowling JM, Flowers D, Tintinalli J

(2002). Five-level triage system more effective than

three-level in tertiary emergency department. JEN.

28(5):395-400.

Wuerz R (2001). Emergency severity index triage category

is associated with six-month survival. ESI triage study

group. Acad Emerg Med. 8(1):61-64.

Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000).

Reliability and validity of a new five-level triage

instrument. Acad Emerg Med. 7(3):236-242.

Wuerz R, Travers D, Gilboy N, Eitel DR, Rosenau A,

Yazhari R (2001). Implementation and refinement of

the emergency severity index. Acad Emerg Med.

8(2):170-176.

16

Chapter 2. Overview of the Emergency Severity Index
ESI level-2 criteria are the most frequently

misinterpreted criteria. This chapter expands on the

information contained in Chapter 2 and discusses in

greater detail the decision-making process required

to determine which patients meet ESI level-2

criteria. A complete understanding of level-2 criteria

is critical to avoid both under- and over-triage of

patients.

ED nurses are often reluctant to assign level 2 to

patients who meet criteria when the ED is crowded

and there are long waits. It is important for nurses

to understand that the triage nurse’s primary

responsibility is to assign the correct triage level. A

patient who is under-triaged may wait for prolonged

periods before being evaluated by a physician. This

delay in care may result in negative patient

outcomes. These cases are the type most frequently

involved in litigation.

Triage nurses without sufficient ED experience may

be at risk for over-triaging patients. While it is

always safer to over-triage than to under-triage, overtriage presents its own set of problems. If a nurse

triages most patients as ESI level 2, beds will not be

available for true level-1 and level-2 patients when

needed, and physician and nurse colleagues will

begin to lose confidence in the nurse, his or her

triage levels, and eventually, the validity of ESI. If

the algorithm is not used independently of the

number and type of patients surging into an ED,

then the accurate application of data for off-line

planning will be subverted. When a hospital is

implementing the ESI in an ED, a considerable time

should be devoted to explaining which types of

patients should be categorized ESI level 2. In this

chapter, we highlight common patient presentations

that meet ESI level-2 criteria.

After the triage nurse has determined that the

patient does not require immediate life-saving

intervention, he or she must then decide whether

the patient should wait. When making this decision,

the triage nurse should consider the following

questions: “Would I use my last open bed for this

patient?” or “Would I make an alternative bed for

this patient in the hallway due to the criticality and

time sensitivity of appropriate intervention?”

Patients who meet ESI level-1 criteria require

immediate resuscitation. Patients who meet ESI

level-2 criteria should have their placement rapidly

facilitated. ESI does not specify timeframe to

physician evaluation, unlike many other triage

systems. However, it is understood that level-2

patients should be evaluated as soon as possible.

The following three questions, also listed in Figure

3-1, should be answered and are key components of

ESI level-2 criteria:

• Is this a high-risk situation?

• Is the patient experiencing new onset confusion,

lethargy, or disorientation?

• Is the patient experiencing severe pain or

distress?

An experienced triage nurse will always assess the

patient's chief complaint, presenting signs and

symptoms, demographics, and medical history to

attempt to identify a high-risk situation.

While the purpose of nurse triage is not to make a

medical diagnosis, these situations are based on the

experienced triage nurse's knowledge of possible

medical diagnoses that are associated with specific

chief complaints. A good source of information

about the signs and symptoms of various medical

diagnoses is the Emergency Nursing Core

Curriculum (Emergency Nurses Association [ENA],

2007) or other emergency nursing textbooks. The

following discussion provides some selected

examples of high-risk situations. This discussion is

not intended to be an exhaustive list.

1. Is This a High-Risk Situation?

The ability to recognize a high-risk situation is a

critical element of the triage decision-making

process, regardless of the triage system used. ESI

highlights the importance of recognizing high-risk

situations and uses the triage nurse’s expertise and

experience to identify patients at high risk.

Little has been written about how ED triage nurses

make decisions. Knowledge and experience are

necessary but not sufficient. Novice triage nurses are

taught symptom clustering such as the cardiac

17

Chapter 3. ESI Level 2

Figure 3-1. Patient Assessment
cluster of chest pain with nausea, shortness of

breath, and diaphoresis. From prior clinical

situations, ED nurses put together “clinical

portraits.” The nurses store patient scenarios in

which they were involved in some way. For

example, the scenario of a patient with fever, stiff

neck, and a meningococcal rash should trigger

recognition of meningitis, a high-risk situation. The

nurse should then have a high index of suspicion

when a patient with a similar set of complaints

presents to triage.

Vital signs are not always helpful in the

identification of high-risk patients. More frequently,

patients present to the ED with a chief complaint,

signs and symptoms, or history suggestive of a

problem or condition that is serious and, unless

dealt with promptly, can deteriorate rapidly. These

are considered high-risk situations and often

interpretation of the patient’s vital sign data is not

required to make the decision that this patient

scenario is high-risk. For example, a patient who

states that he is allergic to peanuts and just came

from a restaurant with throat tightening can be

triaged as ESI level 2 (if he does not meet level-1

criteria), prior to obtaining vital signs. The patient is

at high risk for anaphylaxis and requires rapid

evaluation. Often, patient age, past medical history,

and current medications influence the perceived

severity of the chief complaint. For example, a frail

elderly patient with severe abdominal pain is at a

much higher risk of morbidity and mortality than a

previously healthy 20-year-old. The elderly patient

with abdominal pain should be classified as ESI level

2, while the 20-year-old with stable vital signs will

usually be classified as ESI level 3.

It is common for the triage nurse to identify a highrisk situation which may be supported by abnormal

vital signs. For example, a patient with a fever and

productive cough may have a respiratory rate of 32

and an oxygen saturation of 90 percent. The

experienced triage nurse uses knowledge and

expertise to recognize that this patient probably has

pneumonia and is at high risk for oxygen

desaturation.

Inexperienced ED nurses are not likely to

consistently identify high-risk situations and make

accurate triage decisions because they have not

incorporated symptom clustering and clinical

portraits into their practices; such approaches are

key in identifying the high-risk patient situation.

Following are specific examples of high-risk

situations.

Abdominal and Gastrointestinal

Abdominal pain is the most frequent chief

complaint evaluated in the ED. What distinguishes

high-risk abdominal pain? A good history and

assessment of current pain rating, respiratory rate,

and heart rate, as well as patient demographics, are

important elements to consider that will help

determine the presence of a high-risk situation.

Pain rating is only one of many factors to consider.

Tachycardia, respiratory distress, pallor, bloating,

bleeding, general appearance or hypotension that

accompanies severe abdominal pain can represent

shock and would place the patient at high risk. The

elderly patient with severe abdominal pain presents

another potentially high-risk situation. Often the

elderly experience bowel obstructions,

gastrointestinal bleeds, and other abdominal

complications associated with significantly higher

morbidity and mortality than younger patients.

Several important assessment questions can help the

triage nurse determine whether or not the patient

meets high-risk criteria. These include the following:

• How long has the patient had the pain?

• How does the patient describe their pain?

• What made the patient come to the ED today?

• Has the patient had severe nausea, vomiting, or

diarrhea?

• Other symptoms, such as fever or loss of

appetite?

• Is the patient dehydrated?

Patients with severe "ripping" abdominal pain

radiating to the back are at high risk for an

abdominal aortic aneurysm (AAA). Patients with an

AAA describe the pain as severe, constant, and

sudden in onset and may have a history of HTN.

Though other less imminently life threatening

diagnoses such as pancreatitis can masquerade as an

AAA, it is the high-risk nature of an AAA that

defines this presentation as an ESI 2.

Patients with abdominal pain are often considered

ESI level 3 at the beginning of the triage interview,

and after the discovery of tachycardia or other risk

factors, the triage nurse may determine that the

patient is indeed high-risk. This is described further

in Chapter 4.

18

Chapter 3. ESI Level 2
Vomiting blood or a chief complaint of blood per

rectum should be seriously considered and evaluated

in the context of vital signs. A 30-year-old with

bright red blood per rectum, normal vital signs is

appropriately an emergency but does not warrant an

ESI level-2 designation. All five ESI levels are

appropriate for emergency care within an ED

setting. But the elderly patient who called an

ambulance because he started vomiting blood and

has a heart rate of 117 and a respiratory rate of 24 is

high-risk and does meet ESI level-2 criteria.

Cardiovascular

Chest pain is also a very common chief complaint

evaluated in EDs. The presentation of acute

coronary syndromes (ACS) is not always specific,

and it is sometimes difficult to determine the risk of

ACS at triage. Many EDs do not obtain ECGs at

triage. It is important to remember that unless the

ECG is interpreted by a physician prior to the triage

nurse assessment, it will not alter the triage nurse

decision. The mere decision by the triage nurse that

the patient should have an ECG can be interpreted

that the patient meets ESI level-2 criteria, high risk

for cardiac ischemia. Patients who have an episode

of chest or epigastric discomfort, with or without

accompanying symptoms, usually will need an ECG

performed rapidly to determine the presence of ACS

and need to be identified as high-risk ESI level 2.

It is also important for the triage nurse to

incorporate knowledge of gender differences in the

presentational symptoms characteristic of heart

disease. The 54-year-old obese female who presents

to the ED with epigastric pain and fatigue is at risk

of ACS and should be assigned to ESI level 2—highrisk.

Patients with chest pain who are physiologically

unstable and require immediate interventions such

as intubation or hemodynamic support should be

triaged as ESI level 1. Not all chest pain patients

meet level-1 or level-2 criteria. For example, a 20-

year-old healthy patient with chest pain, normal

oxygen saturation, cough, and fever of 101° 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. Another example of

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 factors.

Each patient must be assessed individually. Again,

careful listening, vigilance, and experience are

helpful since certain entities including thoracic

aortic dissection can occur from childhood through

adulthood.

Other potentially high-risk cardiovascular situations

include hypertensive crisis, acute vascular arterial

occlusions, and patients who present with a fever

post valve replacement.

Nose and Throat

Patients who are drooling and/or striderous may

have impending airway loss. Although less

common, epiglottitis, a foreign body (airway foreign

body or esophageal foreign body in a child) and

peritonsilar abscess place patients at risk for airway

compromise. These are extremely high-risk patients.

Patients with either of these complaints are in

immediate danger of airway compromise and

require immediate intervention. ESI level-1 criteria

are met.

When patients with epistaxis present, the triage

nurse should obtain a blood pressure, although this

is not in the ESI algorithm. Epistaxis can be caused

by uncontrolled HTN. Several etiologies of epistaxis

represent high-risk situations and include the

following: brisk bleeding secondary to posterior

nose bleed or in the patient using warfarin or other

anti-coagulant. In these situations patients are ESI

level 2.

Environmental

Patients with inhalation injuries from closed space

smoke inhalation or chemical exposure should

be considered high-risk for potential airway

compromise. If the patient presents with significant

airway distress and requires immediate intervention,

they meet level-1 criteria.

Patients with third-degree burns should also be

considered high-risk and be assigned ESI level 2. It is

possible that they will require transfer to a burn

center for definitive care.

General Medical

Several other general medical complaints need to be

considered for possible high-risk situations. These

medical complications include:

• Diabetic ketoacidosis

• Hyper- or hypoglycemia

19

Chapter 3. ESI Level 2
• Sepsis

• Complaints of syncope or near syncope

• A variety of other electrolyte disturbances

Patients with diabetes should have a bedside test of

glucose performed at triage whenever possible to

identify possible hyperglycemic emergencies. If the

glucose level is high, patients may be at risk for

diabetic ketoacidosis or hyperosmolar hyperglycemic

state (HHS). Conversely, patients may have very low

glucose readings that also place them in a high-risk

category. The unconscious patient with critically

high or low blood sugar is considered an ESI level 1.

The most common electrolyte abnormality is

hyperkalemia, which is a very high-risk situation

that can lead to serious cardiac dysrhythmias.

Hyperkalemia might be suspected in any renal

dialysis patient. Near syncope is a very common

complaint which should be carefully assessed,

especially in context of patient demographics and

past medical history. Finally, oncology patients with

a fever are considered immunosuppressed, especially

when undergoing chemotherapy. They are at risk for

sepsis and should be identified as high-risk and

rapidly evaluated.

Genitourinary

Renal dialysis patients unable to complete dialysis

often have a variety of electrolyte disturbances

which place them at high risk. Testicular torsion is

another one of the life or limb, permanent time

sensitive clinical situations capable of producing

permanent organ loss. Males with testicular torsion

will complain of severe pain, are easily recognized,

and require rapid evaluation and surgical

intervention in addition to rapid pain control. Such

a patient should not be assigned to the waiting area,

but must be seen right away.

Mental Health

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, or violent or present an elopement risk

should be considered high-risk.

Intoxication without signs of trauma or associated

risk of aspiration does not represent a high-risk

criterion. The intoxicated patient needs to be

carefully assessed for signs of trauma or behavioral

issues related to alcohol use or past medical history,

which could represent a high-risk situation; ESI

level 2.

Neurological

Patients with severe headache associated with

mental status changes, high blood pressure,

lethargy, fevers, or a rash should be considered highrisk. Any patient with sudden onset of speech

deficits or motor weakness should also be assigned

ESI level 2. Patients with these symptoms may be

experiencing an acute stroke and immediate

evaluation is critical. Time from onset of symptoms

is a critical factor in determining treatment options,

in particular fibrinolytic therapies. A patient with no

past medical history of headaches who presents to

the emergency department with the sudden onset of

a severe “worst headache of my life,” should be

identified as at high risk for a sub-arachnoid bleed.

The patient will often describe exactly what they

were doing when the headache began, typically after

exertion, such as lifting, having a bowel movement,

or having sexual intercourse.

Seizures are another common chief complaint.

Sometimes patients arrive by ambulance and are

already post-ictal. All patients with a reported

seizure meet ESI level-2 criteria and should not wait

for a prolonged period of time; they may experience

another seizure.

Obstetrical and Gynecological

Females with abdominal pain or vaginal bleeding

should be carefully assessed and vital signs obtained

if there is no obvious life threat. Pregnancy history

and last menstrual period should always be

ascertained from all females of childbearing age.

Patients may not recognize that they are pregnant,

so the triage nurse should consider pregnancy a

possibility in the assessment of female patients. In

early pregnancy, the triage nurse should assess for

signs and symptoms of ectopic pregnancy and

spontaneous abortion. 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.

The triage nurse should assess for signs and

symptoms of abruptio placentae and placenta previa

in late pregnancy.

20

Chapter 3. ESI Level 2
A postpartum patient with a chief complaint of

heavy vaginal bleeding should also be assigned ESI

level 2 and seen by a physician urgently. Any female

patient, whether pregnant or postpartum, who

presents with significant hemodynamic instability

and is in need of immediate life-saving

interventions should be triaged as ESI level 1.

Ocular

Conditions that may be associated with a chief

complaint of some type of visual loss include:

• Chemical splash

• Central retinal artery occlusion

• Acute narrow-angle glaucoma

• Retinal detachment

• Significant trauma

A chemical splash to the eye (especially if unknown,

a base, or an acid) is an immediate threat to vision

which may result in permanent deficit. Chemical

splashes to the eye, particularly alkali, necessitate

immediate flushing to prevent further damage to

the cornea. As with any immediate time-sensitive

threat to life or limb, this constitutes a very high

priority level-2 patient. The triage nurse should

facilitate immediate irrigation regardless of bed

availability.

Trauma to the eye can result in a globe rupture and

hyphema. All these conditions require immediate

evaluation and treatment to prevent further

complications or deterioration. Patients with

significant trauma to the eye, sudden partial or full

loss of vision, are at high risk for permanent damage

to the eye and should be triaged at ESI level 2.

Orthopedic

Patients with signs and symptoms of compartment

syndrome are at high risk for extremity loss and

should be assigned ESI level 2. Other patients with

high-risk orthopedic injuries include any extremity

injury with compromised neurovascular function,

partial or complete amputations, or trauma

mechanisms identified as having a high risk of

injury such as serious acceleration, deceleration,

pedestrian struck by a car, and gun shot or stab

wound victims.

Patients with possible fractures of the pelvis, femur,

or hip and other extremity dislocations should be

carefully evaluated and vital signs considered. These

fractures can be associated with significant blood

loss. Again, hemodynamically unstable patients who

need immediate life-saving intervention such as

high-level amputations meet ESI level-1 criteria.

Pediatric

It is not uncommon for the triage nurse to be

uncomfortable when making triage acuity decisions

about children, especially infants. 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:

• Seizures

• Severe sepsis, severe dehydration

• Diabetic ketoacidosis

• Suspected child abuse

• Burns

• Head trauma

• Ingestions and overdoses including vitamins

• Infant less than 30 days of age with a fever of

100.4° F or 38° C, or greater

• Sickle cell crisis

See Chapter 6 for a detailed discussion in the use of

ESI for triage of patients less than 18 years of age.

Respiratory

Many respiratory complaints place patients at high

risk. Patients with mild-to-moderate distress should

be further evaluated for respiratory rate and pulse

oximetry to determine whether they should be

categorized ESI level 2. Patients in severe respiratory

distress who require immediate lifesaving

intervention such as intubation meet level-1 criteria.

The high-risk patient is one who is currently

ventilating and oxygenating adequately but is in

respiratory distress and has the potential to rapidly

deteriorate. Potential etiologies of respiratory distress

may include asthma, pulmonary embolus, pleural

effusion, pneumothorax, foreign body aspiration,

toxic smoke inhalation, or shortness of breath

associated with chest pain.

21

Chapter 3. ESI Level 2
Toxicological

Most patients who present with an overdose should

be rapidly evaluated and represent a high-risk

situation. It is often difficult to determine which

drugs were taken and the quantities consumed. A

patient who is apneic on arrival or requires other

immediate lifesaving interventions should be

categorized an ESI level 1; all other admitted

overdoses should be considered ESI level 2.

Transplant

A transplant patient who comes to the ED for a

non-transplant related issue, such as a laceration to

a finger, is not automatically ESI level 2. The nurse

needs to assess the situation and assign the

appropriate triage level. Ill patients who are status

post-organ transplant are immunocompromised and

considered high-risk. They can present with organ

rejection, sepsis, or other complications. Patients

who are on a transplant list are also usually

considered high-risk.

Trauma

Traumatic events may involve high-risk injuries that

may not be immediately obvious. Any mechanism

of injury associated with a high risk of injury should

be categorized ESI level 2. If a trauma patient

presents with unstable vital signs and requires

immediate intervention, the patient should be

triaged as ESI level 1. Serious injury results from the

transfer of mechanical or kinetic energy and is

caused by acceleration forces, deceleration forces, or

both. Victims of motor vehicle and motorcycle

crashes, falls, and gunshot and stab wounds are

examples of blunt and penetrating trauma, which

should be assessed carefully for potential for serious

injury.

The triage nurse should obtain the following details

regarding the injury, as pertinent:

• Mechanism of injury

• When the injury occurred

• Loss of consciousness

• Head injured patient returning/presenting with

symptoms of increase intracranial pressure

(headache/vomiting)

• Age of the patient

• Distance the patient fell or jumped

• How fast the vehicle was moving

• Location of penetrating injury

• Number of gunshots heard

• Type of weapon

Again, the nurse will use his or her knowledge of the

biomechanics and mechanism of injury to assess the

patient and decide whether the patient meets ESI

level-2 criteria. Gunshot wounds to the head, neck,

chest, abdomen, or groin usually require trauma

team evaluation and immediate interventions and

should be triaged using ESI criteria. If the patient

requires immediate intervention, they should be

triaged as ESI level 1. If the patient does not meet

level-1 criteria, but has a high-risk situation, they

should be triaged as ESI level 2. In EDs that are also

trauma centers, trauma criteria and ESI triage criteria

should be treated separately and patients should be

assigned both an ESI level and a trauma level, which

may or may not be the same. For example, a patient

made level 1 trauma by mechanism, who has stable

vital signs and no complaints, would be an ESI level

2, high-risk mechanism. This patient would not

meet ESI level 1 criteria, because he or she does not

require a life-saving intervention. These

circumstances are often misinterpreted by ED

nurses, and it is important to stress this.

Wound Management

Several factors signal a high-risk wound. These

include: uncontrolled bleeding, arterial bleeding,

and partial or full amputations. Most wounds do

not meet the criteria for ESI level 2. A patient with a

stab wound requires careful assessment including

neurovascular status. Any uncontrolled bleeding

that requires immediate lifesaving intervention to

stabilize the patient meets level-1 criteria.

The examples of high-risk situations above are

summarized in Table 3-1.

22

Chapter 3. ESI Level 2
23

Chapter 3. ESI Level 2

System Demographics, Chief Complaint ESI 2:Yes/No

 Rationale

Abdomen 88-year-old female with severe right lower Yes. High risk for acute abdominal

 quadrant abdominal pain, vital signs stable. emergency which is associated with a

 high mortality in the elderly.

 22-year-old male with generalized abdominal No. Symptoms are more indicative of

 pain, nausea, vomiting, and diarrhea for 3 gastroenteritis than an acute surgical

 days, vital signs stable. emergency. Patient is stable to wait.

 45-year-old female who has been vomiting Yes. High risk for gastrointestinal

 blood and is tachycardic. bleeding and patient can deteriorate

 rapidly.

 22- year-old female noticed a spot of blood No.This patient most likely has a

 on toilet paper this a.m. after having a hemorrhoid and this is not a high-risk

 bowel movement. Has a history of situation.

 hemorrhoids.

Cardiovascular 35-year-old female with a sudden onset of Yes. High risk for possible

 palpitations, anxious, heart rate of 160, supraventricular tachycardia.

 blood pressure of 120/70. 

 35-year-old female with sudden onset of No.This patient may be having an

 palpitations, anxious, heart rate of 90, anxiety attack.

 blood pressure of 120/70. 

 65-year-old female with sudden onset of Yes. High risk for possible myocardial

 shortness of breath and discomfort in ischemia.

 chest for 3 hours. 

 45-year-old male with generalized fatigue, No.This patient has classic non-cardiac

 chest pain when coughing, productive cough symptoms, despite having chest pain.

 with green sputum, fever and chills for 4 days.

 52-year-old male with sudden onset of pain to Yes. High risk for acute arterial

 left foot, a history of diabetes requiring insulin occlusion.

 therapy; left foot is cold to touch, and the

 nurse is unable to palpate a pulse in the foot.

Eye, ENT 65-year-old female with sudden onset of Yes. All complaints with sudden loss

 loss of vision. of vision are high-risk.

 22-year-old male patient with trauma to eye Yes. High risk for globe rupture or

 in a bar fight, unable to open eye. other trauma.

General 40-year-old female diabetic with vomiting Yes. At high risk for diabetic

medicine for 2 days. ketoacidosis which requires rapid

 evaluation and management.

 69-year-old male who is weak and dizzy, and Yes. High risk for hyperkalemia and

 undergoes regular kidney dialysis. other electrolyte imbalances.

 29-year-old female with a recent history of Yes. High risk for hypertensive

 headaches, blood pressure of 210/120, and emergency.

 no known history of HTN. 

 55-year-old male with a laceration to the No. Patient will not require emergent

 thumb. Blood pressure of 204/102, known treatment of his blood pressure, but

 history of HTN and admits to skipping a few will require re-evaluation of his anti-

 doses of blood pressure medication, denies hypertensive dose and agents.

 other complaints. 

Table 3-1. Examples of Possible High-risk Situations

continued
24

Chapter 3. ESI Level 2

System Demographics, Chief Complaint ESI 2:Yes/No

 Rationale

Genitourinary 22-year-old male with sudden onset of severe Yes. High risk for testicular torsion vs.

 left testicle pain. epididymitis.

 29-year-old female with a 3-day history of No.This patient most likely has a

 urinary frequency and voiding in small urinary tract infection which does not

 amounts. require rapid evaluation.

Gynecological 24-year-old female, 8 weeks pregnant, left Yes. High risk for possible ectopic

 lower quadrant abdominal pain and spotting. pregnancy.

 24-year-old female with severe left lower Yes. High risk for ectopic pregnancy,

 quadrant pain abdominal, denies vaginal unless the triage nurse can confirm

 bleeding. the absence of pregnancy.

 32-year-old female with generalized abdominal No. Most likely this is a threatened

 cramping and vaginal bleeding, 14 weeks abortion which does not require

 pregnant, vital signs stable. emergent evaluation with stable vital

 signs.

Mental Health 19-year-old female who is combative and Yes. High risk for safety and this patient

 hostile. should not be left in the waiting room.

 22-year-old male with suicidal thoughts. Yes. High risk for patient injury if left

 alone.

 35-year-old female who was brought in by the Yes. High risk for a serious head

 police, alcohol on breath, unsteady gait, a injury.

 large laceration to head, slurred speech but 

 oriented. 

 52-year-old female feeling overwhelmed and No.This patient is not at high risk.

 requesting a referral to counseling. Denies 

 homicidal or suicidal thoughts. Alert, oriented, 

 and cooperative.

Neurological 35-year-old female with a severe headache, Yes. High risk for possible meningitis;

 stiff neck, rash, temperature 102.0. rapid deterioration is common.

 55-year-old male with a sudden onset of Yes. High risk for subarachnoid

 worst headache of life after stressful activity. hemorrhage.

 52-year-old male with sudden onset of Yes. High risk for acute stroke.

 slurred speech. 

 33-year-old male with “pins and needles” No. Does not require rapid evaluation.

 feeling to right first and second fingers for 

 several weeks.F

Oncologic 40-year-old female with lymphoma, currently Yes. High risk for neutropenia and

 receiving chemotherapy, and a temperature infection

 of 102.2.

 66-year-old male with lung cancer, reports Yes. High risk for pleural effusion,

 increasing shortness of breath over the past pulmonary embolus and other

 few days. Just completed chemotherapy 2 emergent conditions.

 weeks ago.

 60- year-old female who cut finger while No. Not a high-risk situation.

 slicing a bagel. Currently receiving radiation 

 for breast cancer.

Table 3-1. Examples of Possible High-risk Situations (Continued)

continued
25

Chapter 3. ESI Level 2

System Demographics, Chief Complaint ESI 2:Yes/No

 Rationale

Pediatric 9-month-old baby with vomiting and diarrhea. No. While may be dehydrated, this

 She is able to drink, has a wet diaper, and is does not appear to be a high-risk

 fussy and crying tears during triage. situation.

 9-month-old baby with vomiting and diarrhea. Yes.This baby is at high-risk.

 She is unable to drink, hasn’t wet a diaper for 

 several hours, is unable to hold anything 

 down, and has very dry mucous membranes.

 6-year-old male with a sudden onset of Yes. Moderate respiratory distress

 wheezing that is audible during triage without indicates a possible high risk for

 auscultation, oxygen saturation of 97% on deterioration.

 room air, and is in moderate respiratory

 distress.

 14-day-old baby with a fever of 100.8F. Yes. Infants in the first 30 days of life

 with a fever greater than100.4 are at

 high risk for bacteremia.

Respiratory 5-year-old female presents with drooling and Yes. High risk for an airway

 difficulty swallowing. management problem such as

 epiglotitis, peri-tonsillar abscess,

 foreign body, angioedema.

 25-year-old male with mild wheezing, oxygen No.This is not a high-risk situation.

 saturation of 98% on room air, no obvious 

 respiratory distress. Recent upper respiratory 

 infection.

 20-year-old tall thin male with sudden onset Yes.Tall thin young males are at risk

 of severe shortness of breath after coughing. for spontaneous pneumothorax.

Trauma 45-year-old male involved in a motor vehicle Yes. At high-risk for a traumatic brain

 crash immediately prior to arrival. Unable to injury and possible epidural

 remember the events, moderately severe hematoma.

 headache.

 17-year-old male with a stab wound to groin, Yes. High risk for vascular injury.

 bleeding controlled. 

 34-year-old female involved in a low speed Yes. High risk for maternal and fetal

 motor vehicle crash while driving. injuries.

 32 weeks pregnant, denies complaints. 

 6-year-old male fell from the top of the Yes. High-risk situation.

 monkey bars today. Reports a 1 minute loss

 of consciousness at the time. Patient is

 vomiting, and was sent by pediatrician for

 head scan.

Table 3-1. Examples of Possible High-risk Situations (Continued)
2. Is the Patient Experiencing

New Onset Confusion,

Lethargy, or Disorientation?

The second question to consider when determining

whether a patient meets level-2 criteria is, “Does the

patient have new onset confusion, lethargy, or

disorientation?” Altered mental status is another

frequent chief complaint. Family members, friends,

or paramedics may accompany these patients to the

ED. At decision point B of the ESI algorithm, the

presence of confusion, lethargy, or disorientation

refers to new onset or an acute alteration in level of

consciousness (LOC). Chronic dementia and chronic

confusion do not meet criteria for ESI level 2. For

example, if an elderly patient with dementia

presents with a possible fractured hip, they do not

meet level 2 criteria because the dementia is not

considered to be of new onset.

Confusion, lethargy, or disorientation may be

caused by a variety of serious medical conditions

including stroke, transient ischemic attack, or other

structural pathology to the brain, metabolic or

electrolyte imbalances such as hypoglycemia or

hyponatremia or toxicological conditions. Other

examples of patients who may meet ESI level 2

criteria include patients with diabetic ketoacidosis,

patients experiencing an acute psychotic episode, or

an otherwise healthy adult or child with new onset

confusion.

This portion of the algorithm is usually very clear

and leaves very little open to interpretation. If the

patient's history is unknown, and the patient

presents to triage confused, lethargic, or disoriented,

the triage nurse should assume this condition is new

and select ESI level 2 as the triage category. Again, if

the patient has new onset confusion, lethargy, or

disorientation and requires an immediate life-saving

intervention as previously described, the patient

then meets ESI level-1 criteria (e.g., new onset

confusion and difficulty maintaining an airway).

3. Is the Patient Experiencing

Severe Pain or Distress?

The third and final question to address when

determining whether the patient meets level-2

criteria is, “Is the patient experiencing severe pain or

distress?” In 2009, the Emergency Nurses

Association (ENA), the American College of

Emergency Physicians, the American Society of Pain

Management Nursing, and the American Pain

Society Board of Directors each approved a joint

position statement which articulates 14 core

principles of optimal pain management that EDs

can strive for. One principle promotes the rapid

administration of analgesics (American College of

Emergency Physicians, 2009; ENA, 2009). While

rapid treatment of pain is important, careful

discussion of this criteria and its use in ESI is

warranted.

Pain

The patient should be assessed for the presence of

severe pain or distress. All patients who have a pain

rating of 7/10 or greater should be considered for

meeting ESI level-2 criteria. This is the second most

frequently misinterpreted criteria of ESI. Not all

patients with a pain score of >7 should be

triaged as ESI level 2. It is up to the discretion of

the triage nurse to determine whether the clinical

condition and pain rating in combination warrant a

rating of ESI level 2. In general, it is helpful to ask,

“Can I do anything at triage to help decrease the

pain?” For example, a patient who had a heavy

metal object fall on his toe may rate the pain a

10/10. Indeed, the patient may have a fracture and

be experiencing severe pain. The patient probably

has done nothing to try to relieve the pain prior to

arrival in the ED. The correct triage level for this

patient would be ESI level 4. Only one defined

resource (remember, “resources” in the context of

ESI triage refers to those items defined as a resource)

will be needed (an x ray). Of course, in addition to

the defined resource, good medical care will require

adequate pain relief. The triage nurse should

implement comfort measures at triage including ice,

elevation, and analgesics (if standing orders are in

place) to reduce the pain. The triage nurse should

believe the patient's pain is 10/10 and address the

pain at triage. However, this patient can wait to be

seen and you would certainly not use your last open

bed for this patient. It is not possible to manage

pain at triage for patients with renal colic, cancer, or

sickle cell crisis. These patients should be triaged as

ESI level 2 and rapid placement should be facilitated

whenever possible.

In summary, the triage nurse assesses not only the

pain intensity rating provided by the patient, but

also the chief complaint, past medical history,

physiologic appearance of the patient, and what

interventions can be provided at triage to decrease

pain, when determining a triage category.

26

Chapter 3. ESI Level 2
Examples of patients for whom the triage nurse

could use severe pain criteria to justify an ESI level-2

rating include:

• A patient with 10/10 flank pain who is writhing

at triage

• An 80-year-old female with 7/10 generalized

abdominal pain with severe nausea

• A 30-year-old patient in acute sickle cell pain

crisis

• An oncology patient with severe pain

• Any full- or partial-thickness burn that will

require immediate pain control

• Females, and more commonly males, with acute

urinary retention

All ED patients are to be assessed for pain and asked

to rate their pain using a scale such as the visual

analog scale. Many triage nurses are uncomfortable

with documenting a patient’s pain rating and then

having the patient wait to be seen. It is important

for the triage nurse to understand that the patient’s

self-reported pain rating is only one piece of the

pain assessment. Triage nurses should assign ESI

level 2 if the patient reports a pain rating of 7/10 or

greater and the triage nurse's subjective and

objective assessment confirms that the patient's pain

requires interventions that are beyond the scope of

triage. The triage nurse concludes that it would be

inappropriate for this patient to wait and would

assign this patient to the last open bed.

Distress

Finally, in determining whether a patient meets ESI

level-2 criteria, the triage nurse must assess for

severe distress, which is defined as either

physiological or psychological. In addition to pain,

patients experiencing severe respiratory distress meet

criteria for ESI level 2 for physiological disturbances.

Examples of severe psychological distress include

patients who are:

• Distraught after experiencing a sexual assault

• Exhibiting behavioral outbursts at triage

• Combative

• Victims of domestic violence

• Experiencing an acute grief reaction

• Suicidal and a flight risk (this patient also meets

high-risk criteria)

These are patients that the triage nurse usually

prefers to have placed in the treatment area

immediately to address the acute issue expeditiously.

Additionally this will serve to avoid persons in the

waiting room from becoming agitated.

Special Situations

Many EDs now have special alert processes that

initiate a team approach to a specific time-sensitive

problem. Clinical syndromes response therefore may

include immediate activation of alerts such as

myocardial infarction alert, stroke alert, sepsis alert,

and trauma alert. These are hospital specific,

protocol driven responses. Patients that qualify for

alert activation are automatically high-risk and

therefore at least an ESI 2. For example, a patient

may present to triage awake, alert, and oriented,

complaining of left sided weakness; the patient does

not meet ESI level-1 criteria bus is at high risk for a

stroke. This patient meets ESI level-2 criteria. If

deteriorating or in extremis, the patient would be

labeled an ESI 1.

Summary

We have reviewed the key components and

questions that need to be answered to determine

whether a patient meets ESI level-2 criteria. It is

critical that the triage nurse consider these questions

as he or she triages each patient. Missing a high-risk

situation may result in an extended waiting period

and potentially negative patient outcomes. Many

high-risk situations have not been discussed and are

beyond the scope of this handbook. With ESI level

2, the role of the triage nurse is to gather subjective

and objective information from the patient, analyze

it, and decide whether this patient has a high-risk

situation.

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

27

Chapter 3. ESI Level 2
References

Emergency Nurses Association (2007). Emergency Nursing

Core Curriculum (6th ed.), Jordan KS, editor. DesPlaines,

IL.

American College of Emergency Physicians (2009).

Optimizing the Treatment of Pain in Patients with Acute

Presentations: Joint Statement by the American College of

Emergency Physicians, American Pain Society, American

Society for Pain Management Nursing, and the Emergency

Nurses Association. Retrieved June 6, 2011 from

http://www.acep.org/Content.aspx?id=48089.

Emergency Nurses Association (2009). Optimizing the

Treatment of Pain in Patients with Acute Presentations:

Joint Statement by the American College of Emergency

Physicians, American Pain Society, American Society for

Pain Management Nursing, and the Emergency Nurses

Association. Retrieved June 6, 2011 from

http://www.ena.org/about/position/jointstatements/

Pages/Default.aspx.

28

Chapter 3. ESI Level 2
Traditionally, comprehensive triage has been the

dominant model for triage acuity assignment in U.S.

emergency departments (Gilboy, 2010; Gilboy,

Travers, & Wuerz, 1999). Triage acuity rating systems

have been based solely on the acuity of the patient,

determined through the nurse's assessment of vital

signs, subjective and objective information, past

medical history, allergies, and medications. Such

systems require the nurse to assign an acuity level

by making a judgment about how sick the patient is

and how long the patient can wait to be seen by a

provider.

The ESI triage system uses a novel approach that

includes not only the nurse’s judgments about who

should be seen first, but also, for less acute patients

(those at ESI levels 3 through 5), calling on the

nurse to add predictions of the resources that are

likely to be used to make a disposition for the

patient.

This chapter includes background information on

the inclusion of resource predictions in the ESI and

a description of what constitutes a resource.

Examples are given of patients rated ESI levels 3 to 5

and the resources that each patient is predicted to

need.

Estimation of resource needs begins only after it has

been determined that the patient does not meet ESI

level 1 or 2 criteria. The nurse then predicts the

number of resources a patient will need in order for

a disposition to be reached. When Wuerz and Eitel

created the ESI triage system, they included resource

utilization to provide additional data and allow a

more accurate triage decision. They believed that an

experienced emergency department (ED) triage

nurse would be able to predict the nature and

number of tests, therapeutic interventions, and

consultations that a patient would need during

his/her ED stay. Studies of ESI implementation and

validation have verified that triage nurses are able to

predict ED patients’ resource needs (Eitel, Travers,

Rosenau, Gilboy, & Wuerz, 2003; Tanabe, Gimbel,

Yarnold, & Adams, 2004). One study was conducted

at seven EDs representing varied regions of the

country, urban and rural areas, and academic and

community hospitals. Nurses were able to predict

how many ESI-defined resources the ED patients

required 70 percent of the time. That is, experienced

triage nurses can reasonably predict at triage how

many resources patients will require to reach ED

disposition; more importantly, they can discriminate

at presentation low versus high resource intensity

patients. This differentiation by resource

requirements allows for much more effective

streaming of patients at ED presentation into

alternative operational pathways within the ED, that

is, the parallel processing of patients. Research has

also established that ESI triage levels correlate with

important patient outcomes, including admission

and mortality rates (Eitel et al., 2003).

Again, it is important to note that resource prediction

is only used for less acute patients. At decision points A

and B on the ESI algorithm (Figure 4-1), the nurse

decides which patients meet criteria for ESI levels 1

29

Chapter 4. ESI Levels 3-5 and Expected

Resource Needs

Figure 4-1. ESITriage Algorithm, v. 4

©ESI Triage Research Team, 2004. Reproduced with

permission.
and 2 based only on patient acuity. However, at

decision point C, the nurse assigns ESI levels 3 to 5

by assessing both acuity and predicted resource

needs. Thus, the triage nurse only considers

resources when the answers to decision points A and

B are "no."

To identify ED patients’ resource needs, the triage

nurse must have familiarity with general ED

standards of care, and specifically with what

constitutes prudent and customary emergency care.

An easy way to think about this concept is to ask

the question, "Given this patient's chief complaint,

what resources are the emergency providers likely to

utilize?" Another way to look at this is to consider,

“What is it going to take for a disposition to be

reached?” Disposition can be admission, discharge,

or transfer.

The triage nurse uses information from the brief

subjective and objective triage assessment--as well as

past medical history, medications, age, and gender--

to determine how many different resources will be

needed for the ED provider to reach a disposition.

For example, a healthy teenage patient with a

simple leg laceration and no prior medical history

would need only one resource: suturing. On the

other hand, an older adult with multiple chronic

medical problems and no history of dizziness who

presents with a head laceration from a fall will

clearly need multiple resources: suturing,

blood/urine tests, ECG, head CT, or consultations

with specialists. Accurate use of ESI triage is

contingent on the nurse’s ability to accurately

predict resources and as such is best performed by

an experienced emergency nurse.

Guidelines for the categorization of resources in the

ESI triage system are shown in Table 4-1. ESI levels

3, 4, and 5 are differentiated by the nurse's

determination of how many different resources are

needed to make a patient disposition. On the basis

of the triage nurse's predictions, patients who are

expected to consume no resources are classified as

ESI level 5, those who are likely to require one

resource are ESI level 4, and those who are expected

to need two or more resources are designated as ESI

level 3. Patients who need two or more resources

have been shown to have higher rates of hospital

admission and mortality and longer lengths of stay

in the ED (Eitel et al., 2003; Tanabe, Gimbel,

Yarnold, Kyriacou, & Adams, 2004).

Though the list of resources in Table 4-1 is not

exhaustive, it provides general guidance on the

types of diagnostic tests, procedures, and therapeutic

treatments that constitute a resource in the ESI

system. Emergency nurses who use the ESI are

cautioned not to become overly concerned about

the definitions of individual resources. It is

important to remember that ESI requires the triage

nurse to merely estimate resources that the patient

will need while in the ED. The most common

resources are listed in Table 4-1; however a

comprehensive list of every possible ED resource is

neither practical nor necessary. In fact, all that is

really necessary for accurate ESI rating is to predict

whether the patient will need no resources, one

resource, or two or more resources. Once a triage

nurse has identified two probable resources, there is

no need to continue to estimate resources. Counting

beyond two resources is not necessary.

The essence of the ESI resource component is to

separate more complex (resource-intensive) patients

from those with simpler problems. The

interventions considered as resources for the

purposes of ESI triage are those that indicate a level

of assessment or procedure beyond an exam or brief

interventions by ED staff and/or involve personnel

outside of the ED. Resources that require significant

ED staff time (such as intravenous medication

administration or chest tube insertion) and those

that require staff or resources outside the ED (such

as x rays by the radiology staff or surgical consults)

increase the patient's ED length of stay and indicate

30

Chapter 4. ESI Levels 3-5 and Expected Resource Needs

Resources Not resources

Labs (blood, urine) History & physical

 (including pelvic)

ECG, X rays Point-of-care testing

CT-MRI-ultrasound

angiography

IV fluids (hydration) Saline or heplock

IV, IM or nebulized PO medications

medications Tetanus immunization

 Prescription refills

Specialty consultation Phone call to PCP

Simple procedure = 1 Simple wound care

(lac repair, Foley cath) (dressings, recheck)

Complex procedure = 2 Crutches, splints,

(conscious sedation) slings

Table 4-1. Resources for the ESITriage System
that the patient's complexity, and, therefore, triage

level is higher.

There are some common questions about what is

considered an ESI resource. One question often

asked is about the number of blood or urine tests

and x rays that constitute a resource. In the ESI

triage method, the triage nurse should count the

number of different types of resources needed to

determine the patient's disposition, not the number

of individual tests:

• A complete blood count (CBC) and electrolyte

panel comprise one resource (lab test).

• A CBC and chest x ray are two resources (lab test,

x ray).

• A CBC and a urinalysis are both lab tests and

together count as only one resource.

• A chest x ray and kidneys, ureters, and bladder x

ray are one resource (x ray).

• Cervical-spine films and a computerized

tomography (CT) scan of the head are two

resources (x ray and CT scan).

It is important for emergency nurses to understand

that not every intervention they perform can be

counted as a resource. For example crutch walking

education, application of a sling and swath, or

application of a knee immobilizer all take time but

do not count as a resource. If, for example a splint

did count, patients with sprained ankles would be

triaged as ESI level 3 (x ray and splint application).

While the application of a splint can certainly take

time, it is important to remember the only purpose

of resource prediction with ESI is to sort patients

into distinct groups and help get the right patient to

the right area of the ED. Another example is a

patient with a laceration who may require suturing

and a tetanus booster If a tetanus booster (IM

medication) “counted,” any patient with a

laceration who needed suturing and a tetanus

booster would meet ESI Level 3 criteria. In many

EDs, ESI level-3 patients are not appropriate for a

fast track or urgent care area. Remember, triage level is

not a measure of total nursing workload intensity; it is a

measure of presentational acuity.

Another common question about ESI resources

relates to the fact that eye irrigation is also

considered a resource. Patients with a chemical

splash usually meet ESI level-2 criteria because of the

high-risk nature of the splash, so eye irrigation is

not a key factor in their ESI rating. However, if the

eye problem was due to dust particles in the eye, the

patient would not necessarily be high risk. In this

type of patient, the eye irrigation would count as a

resource and the patient would meet ESI level-4

criteria. The eye exam does not count as a resource

because it is considered part of the physical exam.

Another frequent question posed by clinicians is

related to the items listed as “not resources” in Table

4-1. The purpose of the list is to assist triage nurses

with quick, accurate sorting of patients into five

clinically distinct levels (Wuerz, Milne, Eitel, Travers

& Gilboy, 2000). As such, items listed as not being

resources include physical exams, point-of-care tests,

and interventions that tend not to lead to increased

length of stay in the ED or indicate a higher level of

complexity. Since the standard of care is that all ED

patients undergo a basic history and physical exam,

an exam does not constitute a resource for ESI

classification. For the female patient with abdominal

pain, a pelvic exam would be part of the basic

physical exam. A patient with an eye complaint

would need a slit lamp exam as part of the basic

physical exam. The strength of the ESI is its

simplicity; the true goal of the resource

determination is to differentiate the more

complicated patients needing two or more resources

(level 3 or above) from those with simpler problems

who are likely to need fewer than two resources

(level 4 or 5). Emergency nurses should not try to

complicate ESI by concentrating overly on resource

definitions. Usually, a patient requires either no

resources, one resource, or two or more resources.

Though resource consumption may vary by site,

provider, and even individual patient, triage nurses

are urged to make the ESI resource prediction by

thinking about the common approaches to the most

common presenting problems. Ideally, a patient

presenting to any emergency department should

consume the same general resources. For example, a

provider seeing a hemodynamically stable 82-yearold nursing home resident who has an in-dwelling

urinary catheter and a chief complaint of fever and

cough will most likely order blood and urine tests

and a chest x ray. The triage nurse can accurately

predict that the patient needs two or more resources

and therefore classify the patient as ESI level 3.

There may be minor variations in operations at

different EDs, but this will rarely affect the triage

rating. For example, some departments do

pregnancy tests in the ED (point of care testing is

not a resource by ESI) and others send them to the

lab (a resource by ESI). However, patients rarely have

the pregnancy test as their only resource, so most of

31

Chapter 4. ESI Levels 3-5 and Expected Resource Needs
those patients tend to have two or more resources in

addition to the pregnancy test. One ED practice

variation that may result in different ESI levels for

different sites is the evaluation of patients with an

isolated complaint of sore throat. At some hospitals

it is common practice to obtain throat cultures (one

resource, ESI level 4), while at others it is not (no

resources, ESI level 5). Evidence-based practice

guidelines are being used more and more to

determine the need for x rays or other

interventions. One example is the use of the Ottawa

Ankle Rules. These are validated rules used to

determine the need for an x ray of the ankle for

patients that present with ankle injuries.

Institutional adoption of these rules into practice

varies. Institutions that use these rules at triage may

obtain fewer x rays when compared with

institutions that do not routinely use these rules.

When counting resources the triage nurse should

not consider which physician, nurse practitioner or

physician’s assistant is working. There are practice

differences among providers but the triage nurse has

to focus on what is prudent and customary.

Temperature is an important assessment parameter

for determining the number of resources for very

young children. This subject will be covered in

Chapter 5.

From a clinical standpoint, ESI level 4 and 5 patients

are stable and can wait several hours to be seen by a

provider. However, from a customer service

standpoint, these patients are perhaps better served

in a fast-track or urgent care area. Mid-level

practitioners with the appropriate skills mix and

supervision could care for level-4 and level-5

patients. With ESI, level-5 patients can sometimes be

"worked in" for a quick exam and disposition by the

provider, even if the department is at capacity. Often

triage policies clearly state ESI level-4 or -5 patients

can be triaged to an urgent care or fast-track area.

In summary, the ESI provides an innovative

approach to ED triage with the inclusion of

predictions about the number of resources needed to

make a patient disposition. Consideration of

resources is included in the triage level assignment

for ESI level-3, -4, and -5 patients, while ESI level-1

and 2 decisions are based only on patient acuity.

Examples of ESI level-3, -4, and -5 patients are

shown in Table 4-2. Practical experience has

demonstrated that resource estimation is very

beneficial in helping sort the large number of

patients with non-acute presentations. Common

questions about resources are addressed in the

Chapter 4 Frequently Asked Questions section of

Appendix A.

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

References

Eitel DR, Travers DA, Rosenau A, Gilboy N, Wuerz RC

(2003). The emergency severity index version 2 is

reliable and valid. Acad Emerg Med. 10(10):1079-1080.

Gilboy N. (2010). Triage. In PK Howard and RA Steinmann

(Eds) Sheehy’s Emergency Nursing Principles and Practice

(59-72). St. Louis: Mosby.

Gilboy N, Travers DA, Wuerz RC (1999). Reevaluating

triage in the new millennium: A comprehensive look at

the need for standardization and quality. JEN.

25(6):468-473.

Tanabe P, Gimbel R, Yarnold PR, Adams J (2004). The

emergency severity index (v. 3) five level triage system

scores predict ED resource consumption. JEN. 30:22-29.

Tanabe P, Gimbel R, Yarnold PR, Kyriacou D, Adams J

(2004). Reliability and validity of scores on the

Emergency Severity Index Version 3. Acad Emerg Med.

11:59-65.

Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000).

Reliability and validity of a new five-level triage

instrument. Acad Emerg Med. 7(3):236-242.

32

Chapter 4. ESI Levels 3-5 and Expected Resource Needs
33

Chapter 4. ESI Levels 3-5 and Expected Resource Needs

Scenario Predicted Resources ESITriage Category

 (ESI Resources in italic)

Right lower quadrant pain: ESI Resources = 2 or more 3

22-year-old male, right lower quadrant abdominal Exam

pain since early this morning, also nausea, Laboratory studies

and no appetite. IV fluid

 Abdominal CT

 (possible) Surgery Consult

Left lower leg pain: ESI Resources = 2 or more 3

45-year-old obese female with left lower leg pain Exam

& swelling which started 2 days ago, after driving Laboratory studies

in a car for 12 hours. Lower extremity non-invasive

 vascular studies

 (possible) Anticoagulant therapy

Ankle injury: ESI Resources = 1 4

Healthy, 19-year-old female who twisted her ankle Exam

playing soccer. Edema at lateral malleolus, hurts Ankle x-ray

to bear weight. Ace wrap

 Crutch-walking instruction 

Urinary tract infection symptoms: ESI Resources = 1 4

Healthy, 29-year-old female with UTI symptoms, Exam

appears well, afebrile, denies vaginal discharge. Urine & urine culture

 (possible) Urine hCG

 Prescriptions

Poison ivy: ESI Resources = none 5

Healthy 10-year-old child with 'poison ivy' Exam

on extremities. Prescription

Prescription refill: ESI Resources = none 5

Healthy 52-year-old who ran out of blood pressure Exam

medication yesterday. BP 150/84. No acute Prescription

complaints.

Table 4-2. Examples of Resources for ESI Levels 3-5
Introduction

In this chapter, we focus on decision point D—the

patient’s vital signs. To reach this point in the ESI

algorithm, the triage nurse has already determined

that the patient does not meet ESI level-1 or level-2

criteria and that he or she will require two or more

resources. Since the patient requires two or more

resources, he or she meets the criteria for at least an

ESI level 3. It is at this point in the algorithm that

vital signs data are considered and the triage nurse

must assess the patient's heart rate, respiratory rate,

oxygen saturation, and, for children under age 3,

temperature (see Chapter 6 for more detailed

information concerning the use of ESI for pediatric

triaging). If the danger zone vital sign limits are

exceeded (as illustrated in decision point D, Figure

5-1, the triage nurse must strongly consider uptriaging the patient from a level 3 to a level 2.

It is always the decision of the experienced triage

nurse to determine whether the patient meets

criteria for ESI level 2, based on his or her past

medical history, current medications, and subjective

and objective assessment that includes general

appearance. This decision is based on the triage

nurse's clinical judgment and knowledge of normal

vital sign parameters for all ages and the influence

of factors such as medications, past medical history,

and pain level.

Are Vital Signs Necessary at

Triage?

Prior to the advent of five-level triage in the United

States, tradition dictated that every patient

presenting to an emergency department should

have a set of vital signs taken before triage-level

assignment. Vital signs were considered an integral

component of the initial nursing assessment and

were often used as a decision-making tool. In a

traditional three-level triage system, vital signs

helped determine how long a patient could wait for

treatment (i.e., if no abnormal vital signs were

present, in many cases, the patient could wait a

longer period of time). Essentially, ESI level-1 and

level-2 patients often are taken to an area with

immediate staff attention prior to the point in triage

when vital signs would normally be taken.

There is frequently discussion about why vital signs

are not a more important part of ESI criteria. Vital

signs are important; however, they are not always

helpful in determining an initial triage level. An

objective assessment of the patient, including the

patient’s chief complaint, is often sufficient to

categorize the patient as a high-acuity patient (ESI

level 1 or 2), or low-acuity patient (ESI level 3, 4, or

5). However, the ESI Triage Research Team

recommends obtaining a full set of vital signs at

triage, including temperature, heart and respiratory

rates, and blood pressure. Nurses are accustomed to

this practice, and we have found that when vital

signs are not obtained at triage, in particular for

lower acuity chief complaints, they may never be

obtained during the ED stay. Furthermore automatic

BP cuffs and pulse monitors rapidly accomplish this

task in most emergency departments.

More recently, newer triage models, including ESI,

advocate selective use of vital signs at triage (Gilboy,

Travers, Wuerz, 1999). Initial vital signs are not a

mandatory component of other five-level triage

systems and in general are not reported during the

triage phase of a level-1 or level-2 patient (i.e., those

patients with the highest acuity). For example, the

Guidelines for Implementation of the Australasian Triage

Scale in Emergency Departments states that “vital signs

should only be measured at triage if required to

estimate urgency, or if time permits” (Australasian

College for Emergency Medicine [ACEM], 2000).

Similarly, the Canadian Triage and Acuity Scale

upholds the need for vital signs if, and only if, they

are necessary to determine a triage level (in the cases

of levels 3, 4, and 5) as time permits (Beveridge et

al., 2002). The Manchester Triage Group uses

specific vital-sign parameters as discriminators

35

Chapter 5.The Role of Vital Signs in ESITriage

Figure 5-1. Danger Zone Vital Signs
within a presentational flow chart. The vital-sign

parameter is one of the factors that help the triage

nurse assign an acuity level.

Vital signs are not always the most informative

method to determine triage acuity. At least one

study has suggested that vital signs are not always

necessary in the initial assessment of the patient at

triage. In 2002, Cooper, Flaherty, Lin, and Hubbell

examined the use of vital signs to determine a

patient's triage status. They considered age and

communication ability as factors. Twenty-four

different U.S. emergency departments and more

than 14,000 patients participated in that study. Final

results demonstrated that vital signs changed the

level of triage acuity status in only eight percent of

the cases. When further examining individual age

groups, pediatric patients aged 2 or younger showed

the largest variation in triage decision with an 11.4-

percent change once vital signs were collected.

Using Vital Signs with ESI

Triage

Using ESI triage, the only absolute requirement for

vital signs assessment at triage is for patients who

meet level-3 criteria. Vital sign assessment at triage is

optional for patients triaged as ESI level 1, 2, 4, or 5.

While the ESI system does not require vital signs

assessment on all patients who present to triage,

local policies may dictate a different procedure.

Factors such as staffing levels, case mix, and local

resources influence individual hospital policies

regarding vital signs at triage and are beyond the

scope of this handbook. In general when triaging a

stable patient, it is never wrong to obtain a set of

vital signs, unless you delay placement to obtain

vital signs. The developers of the ESI and the current

ESI research team believe that experienced ED nurses

can use vital sign data as an adjunct to sound

clinical judgment when rating patients with the ESI.

There is limited evidence on the ability of abnormal

vital signs to predict serious illness. The ESI has been

revised over time to reflect changes in the available

evidence and recommendations from the literature.

The ESI working group initially used the systemic

inflammatory response syndrome (SIRS) literature

(Rangel-Frausto et al., 1995) in developing the

danger zone vital sign box and accompanying

footnotes.

The first version of the ESI used the SIRS criteria to

include a heart rate of greater than 90 (for adults) as

an absolute indicator to up-triage from ESI level 3 to

level 2 (Wuerz, Milne, Eitel, Travers, Gilboy, 2000).

The SIRS research was based on predictors of

mortality in an intensive care unit population.

Based on an excess of false positives using these

criteria for ED patients at the initial ESI hospitals,

the heart rate cutoff was changed to 100 in ESI

version 2, and nurses were instructed to consider uptriage to ESI 2 for adult patients with heart rates

greater than 100 (Gilboy, Tanabe, Travers, Eitel,

Wuerz, 2003; Wuerz et al., 2001). Additionally,

pediatric vital signs were added to the danger zone

vital signs box (American College of Emergency

Physicians [ACEP], 2003).

When using ESI as a triage system, vital signs

assessment is not necessary in the triage area for

patients who are immediately categorized as level 1

or 2. If the patient appears unstable or presents with

a chief complaint that necessitates immediate

treatment, then transport of the patient directly to

the treatment area should be expedited. For these

patients, the resuscitation team is responsible for

obtaining and monitoring vital signs at the bedside.

This would include patients that have clinical

appearances that indicate high risk or need for

immediate cardiovascular or respiratory

intervention. These patients may appear pale,

diaphoretic, or cyanotic. The triage nurse always has

the option to perform vitals in the triage area, if an

open bed is not immediately available or if he or she

feels that the vital signs may assist in confirming the

triage acuity level.

Some patients may not be identified initially as ESI

level 1 until vital signs are taken. For example, an

awake, alert elderly patient who complains of

dizziness might be found to have a life-threatening

condition when a heart rate of 32 or 180 is

discovered during vital sign measurement. In this

case, the patient should be assigned ESI level 1 no

matter how “good” the patient appears.

As shown in the ESI algorithm in Chapter 2, if

patients do not meet ESI level-1 or level-2 criteria,

the triage nurse comes to decision point C. The

nurse then determines how many resources the

patient is expected to need in the ED. If the patient

is expected to need one or no defined resources, he

or she can be assigned an ESI level of 4 or 5 and no

vital sign assessment is necessary. But if the patient

is expected to need two or more resources, then the

nurse comes to decision point D and vital signs

should be assessed.

Vital signs can play a more important role in the

evaluation of some patients at triage, especially

36

Chapter 5.The Role of Vital Signs in ESITriage
those triaged as ESI level 3. The range of vital signs

may provide supporting data for potential indicators

of serious illness. If any of the danger zone vital signs

are exceeded, it is recommended that the triage nurse

consider up-triaging the patient from level 3 to level 2.

Vital signs explicitly included in ESI triage include

heart rate, respiratory rate, and oxygen saturation

(for patients with potential respiratory compromise).

Temperature is specifically used in ESI triage for children

under age 3. It is important to note that when

considering abnormal vital signs, blood pressure is

not included in the ESI algorithm. This does not

mean that the triage nurse should not take a blood

pressure or a temperature on older children or adults

but that these vital signs are not necessarily helpful

in selecting the appropriate triage acuity level.

Vital Signs and Pediatric Fever

As shown in Figure 5-2, note D of the ESI algorithm

addresses pediatric fever considerations for ESI

triage. This section incorporates recommendations

from the American College of Emergency

Physicians’ Clinical Policy for Children Younger Than

Three Years Presenting to the Emergency Department

With Fever (ACEP, 2003), reapproved in 2009 by

ACEP Board of Directors.

The ESI Triage Research Team recommends that vital

signs in all patients under age 3 be assessed at triage.

For patients in this age group, vital sign evaluation,

including temperature measurement, is essential to

the overall assessment (Baraff, 2000). This helps to

differentiate ESI level-2 and level-3 patients and

minimize the risk that potentially bacteremic

children will be sent to an express care area or

otherwise experience an inappropriate wait.

Remember, if a patient is in immediate danger or

high risk, he or she will be assigned to either ESI

level 1 or 2.

Table 5-1 provides direction for the triage nurse in

using the ESI to assess the febrile child and

determine the most appropriate triage level. The

generally accepted definition of fever is a rectal

temperature greater than 38.0° C (100.4° F) (ACEP,

2003; Baraff et al., 1993). The infant less than 28

days old with a fever should be considered high risk

and assigned to at least ESI level 2. There are no

clear guidelines for the infant between 28 days and

3 months of age. The ESI research team

recommends triage nurses rely on local hospital

guidelines. We suggest that the nurse consider

assigning at least an ESI level 2 for such patients.

Version 4 of the ESI incorporates a different set of

pediatric fever guidelines for children ages 3-to-36

months. These pediatric fever considerations pertain

37

Chapter 5.The Role of Vital Signs in ESITriage

D. Danger Zone Vital Signs

Consider up-triage to ESI 2 if any vital sign criterion is exceeded.

Pediatric Fever Considerations

1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)

1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F)

3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F),

incomplete immunizations, or no obvious source of fever.

Age Temperature ESI level

1 - 28 days Fever over 100.4° F 2

 (38.0° C)

1 - 3 months Fever over 100.4° F Consider 2

 (38.0° C)

3 - 36 months Fever over 102.2° F Consider 3

 (39.0° C) (see text)

Table 5-1. ESI PediatricTemperature Criteria

Figure 5-2. Danger Zone Vital Signs
to highly febrile children, defined as those with a

fever of greater than 39.0° C (102.2° F) (ACEP, 2003).

When triaging a child between 3 and 36 months of

age who is highly febrile, it is important for the

triage nurse to assess the child's immunization status

and whether there is an identifiable source for the

fever.

The patient with incomplete immunizations or with

no identifiable source for the fever should be

assigned to at least ESI level 3. If the patient has an

identifiable source for the fever and his or her

immunizations are up to date, then a rating of 4 or

5 is appropriate. For example, a 7-month-old who is

followed by a pediatrician has had the Haemophilus

influenza type b vaccine and presents with a fever

and pulling on his ear could be assigned to an ESI

level 5.

Case Examples

The following case studies are examples of how vital

signs data are used in ESI triage:

“My doctor told me I am about 6 weeks pregnant

and now I think I am having a miscarriage,” reports

a healthy looking 28-year-old female. “I started

spotting this morning and now I am cramping.” No

allergies; no PMH; medications: prenatal vitamins.

Vital signs: T 98° F, HR 112, RR 22, BP 90/60.

This patient meets the criteria for being up-triaged

from a level 3 to a level 2 based on her vital signs.

Her increased heart rate, respiratory rate, and

decreased blood pressure are a concern. These

factors could indicate internal bleeding from a

ruptured ectopic pregnancy.

“The baby has had diarrhea since yesterday. The

whole family has had that GI bug that is going

around,” reports the mother of a 15-month-old. She

tells you the baby has had a decreased appetite, a

low-grade temperature, and numerous liquid stools.

The baby is sitting quietly on the mother’s lap. The

triage nurse notes signs of dehydration. No PMH, no

known drug allergies, no medications. Vital signs: T

100.4° F, HR 178, RR 48, BP 76/50.

Prior to vital sign assessment, this baby meets the

criteria for ESI level 3. Based on vital sign

assessment, the triage nurse should up-triage him to

an ESI level 2. For a baby this age, both heart rate

and respiratory rate criteria are violated.

“I need to see a doctor for my cough. I just can't

seem to shake it. Last night I didn't get much sleep

because I was coughing so much. I am just so tired,”

reports a 57-year-old female. She tells you that she

had a temperature of 101° last night and that she is

coughing up this yellow stuff. Her history includes a

hysterectomy 3 years ago; she takes no medications

but is allergic to Penicillin. Vital signs: T 101.4°, RR

36, HR 100, SpO2 90 percent.

At the beginning of her triage assessment, this

patient sounds as though she could have

pneumonia. She will need two or more resources but

her low oxygen saturation and increased respiratory

rate are a concern. After assessing vital signs, the

triage nurse should up-triage the patient to an ESI

level 2.

A 34-year-old obese female presents to triage

complaining of generalized abdominal pain (pain

scale rating: 6/10) for 2 days. She has vomited

several times and states her last bowel movement

was 3 days ago. She has a history of back surgery,

takes no medications, and is allergic to peanuts.

Vital signs: T 97.8° F, HR 104, RR 16, BP 132/80,

SpO2 99 percent.

This patient will need a minimum of two or more

resources: lab, IV fluids, perhaps IV medication for

nausea, and a CT scan. The triage nurse would

review the patient's vital signs and consider the

heart rate. The heart rate falls just outside the

accepted parameter for the age of the patient but

could be due to pain or exertion. In this case, the

decision should be to assign the patient to ESI

level 3.

A tearful 9-year-old presents to triage with her

mother. She slipped 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,

takes no medications, and is healthy. Vital signs: BP

100/68, HR 124, RR 32, and SpO2 99 percent.

This child is experiencing pain from her 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

vital sign changes are likely due to pain and distress.

38

Chapter 5.The Role of Vital Signs in ESITriage
A 72-year-old patient presents to the ED with

oxygen via nasal cannula for her advanced chronic

obstructive pulmonary disease (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

albuterol prn, and takes an aspirin daily, No known

drug allergies. Vital signs: T 99.6° F, HR 88, RR 22,

BP 138/80, SpO2 91 percent. She denies respiratory

distress.

This patient will require two or more resources: labs

and IV antibiotics. She meets the criteria for ESI

level 3. The triage nurse notices that her oxygen

saturation and respiratory rate are outside the

accepted parameters for the adult but this patient

has advanced COPD. These vital signs are not a

concern so the patient should not be up-triaged but

will stay an ESI level 3. If this patient had any type

of respiratory complaint, she should be up-triaged to

ESI level 2 due to the low SpO2, which may or may

not be normal for this particular patient.

A 25-year-old patient presents to the ED triage nurse

with a chief complaint of nausea, fever, chills, and

sore throat for several days associated with decreased

ability to take fluids. He denies any past medical

history or taking any medications. Vital signs: T:

102.3, HR 124, RR 20, BP 125-80, SpO2 99% on RA.

This patient will require two or more resources: IV

fluids and medications. His HR violates vital sign

parameters; however, this is most likely due to his

fever. He should not be up-triaged and should be

assigned ESI level 3. The triage nurse should

administer acetaminophen at triage if the ED has

such a policy.

A 19-year-old patient arrives by Emergency Medical

Services (EMS) having an anxiety attack. She was in

court and began to feel lightheaded and dizzy; the

paramedics were called. Upon arrival she is hyperventilating, crying, and unable to speak in

sentences. She also states she has not felt well

recently and has nausea and vomiting. She denies

any past medical history. Vital signs: T 98.6, HR 108,

RR 40, BP 130/80, SpO2 100% on RA.

This patient may require two or more resources; IV

fluids and medications. While her HR and RR

violate vital sign criteria, she should be triaged as ESI

level 3. The triage nurse would not give this patient

the last monitored bed as she is stable to wait. The

nurse should assist the patient in slowing down her

breathing.

Summary

The information in this chapter provides a

foundation for understanding the role of vital signs

in the Emergency Severity Index triage system. We

addressed the special case of patients under 36

months of age. Further research is necessary to

clarify the best vital sign thresholds used in

emergency department triage.

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

References

American College of Emergency Physicians (2003).

Clinical policy for children younger than 3 years

presenting to the emergency department with fever.

Ann Emerg Med. 43(4):530-545.

Australasian College for Emergency Medicine (2000) The

Australasian Triage Scale. Retrieved June 6, 2011, from

http://www.acem.org.au/media/policies_and_guidelines

/P06_Aust_Triage_Scale_-_Nov_2000.pdf.

Australasian College for Emergency Medicine (2000)

Guidelines for the Implementation of the Australasian

Triage Scale in Emergency Departments. Retrieved June 6,

2011, from http://www.acem.org.au/

infocentre.aspx?docId=59

Baraff LJ (2000) Management of fever without source in

infants and children. Ann Emerg Med. 36:602-614.

Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken GH,

Powell KR, Schriger DL (1993). Practice guideline for

the management of infants and children 0 to 36

months of age with fever without source. Ann Emerg

Med. 22:1198-1210.

Beveridge R., Clarke B, Janes L, Savage N, Thompson J,

Dodd G, ... Vadeboncoeur, A. (2002). Implementation

guidelines for the Canadian Emergency Department Triage

and Acuity Scale (CTAS). Retrieved June 7, 2011, from

http://www.caep.ca/

template.asp?id=98758372CC0F45FB826FFF49812638D

D

Cooper R., Flaherty H, Lin E, Hubbell K (2002). Effect of

vital signs on triage decisions. Ann Emerg Med. 39:223-

232.

Gilboy N, Travers DA, Wuerz RC (1999). Reevaluating

triage in the new millennium: A comprehensive look at

the need for standardization and quality. JEN.

25(6):468-473.

39

Chapter 5.The Role of Vital Signs in ESITriage
Gilboy N, Tanabe P, Travers DA, Eitel DR, Wuerz RC

(2003). The Emergency Severity Index Implementation

Handbook: A Five-Level Triage System. Des Plaines, IL:

Emergency Nurses Association.

Rangel-Frausto M, Pittet D, Costigan M, Hwang T, Davis

C, Wenzel R (1995). The natural history of the systemic

inflammatory response syndrome (SIRS): A prospective

study. JAMA. 273:117-123.

Stedman's Medical Dictionary (26th ed) (1995). Baltimore:

Williams & Wilkins.

Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000).

Reliability and validity of a new five-level triage

instrument. Acad Emerg Med, 7(3):236-242.

Wuerz R, Travers D, Gilboy N, Eitel DR, Rosenau A,

Yazhari R (2001). Implementation and refinement of

the emergency severity index. Acad Emerg Med,

8(2):170-176.

40

Chapter 5.The Role of Vital Signs in ESITriage
This chapter addresses the use of the Emergency

Severity Index (ESI) algorithm for triage of patients

less than 18 years of age. The chapter incorporates

issues identified during a study conducted by the

Pediatric ESI Research Consortium (Travers et al.,

2006) and from a review of the pediatric triage

literature (Hohenhaus et al., 2008), both of which

were funded by the Health Services and Resources

Administration (HRSA). The chapter can help

general hospital and pediatric nurses quickly and

accurately assess children in the ED triage setting.

The chapter is meant to serve as guidance for all

hospitals regarding use of the ESI for pediatric triage.

It is not intended to serve as a substitute for a course

on pediatric triage or pediatric emergency care, nor

for local policies regarding triage (e.g., whether or

not febrile children are treated with anti-pyretics at

triage if they go to the waiting room).

Introduction

In the current emergency department (ED)

environment of crowding, emerging infectious

diseases, and natural disasters, it is important to

have a reliable triage system in place that allows for

rapid and accurate assessment of patients. This is

particularly important for the most vulnerable ED

populations, which include children. Nationwide,

there are an estimated 30 million ED visits per year

for patients under 18 years of age, accounting for

one-fourth of all ED visits (Middleton & Burt, 2006).

Children’s physiological and psychological responses

to stressors are not the same as those of adults, and

they are more susceptible to a range of injuries and

illnesses, from viruses to dehydration to radiation

sickness. Given their often limited ability to

communicate with care providers, children can be

more difficult to rapidly and accurately assess than

their adult counterparts.

Triage tools such as the ESI algorithm are designed

to prioritize ED patients for treatment. The earliest

version of the ESI was intended for use only with

patients greater than age 14 (Wuerz et al., 2000). In

2000, specific pediatric vital sign criteria were added

to the ESI version 2; this version is intended for

triage of patients of any age (Wuerz et al., 2001).

While the ESI has been shown to produce valid,

reliable triage of the general ED population, recent

studies of its utility for pediatric patients indicate

room for improvement. Hinrichs and colleagues

(2005) found low intra- and inter-rater reliability

among nurses using the ESI for infant triage. In

another single-site study of ESI version 3, researchers

conducted a retrospective chart review of pediatric

triage decisions and found variable reliability among

triage nurses, nurse investigators, and physician

investigators with a moderate level of agreement

(Baumann et al., 2005).

The information in this chapter is based on the

results of the multi-center study of pediatric triage

and a comprehensive review of the pediatric

literature. The Pediatric ESI Research Consortium

conducted a large, multi-center study of the ESI for

pediatric triage and found that, while the overall

reliability of ESI version 4 is good, pediatric cases are

more often mistriaged than adult cases (Travers et

al., 2006). The study evaluated both reliability and

validity of the ESI for children, enrolling 155 nurses

and 498 patients in the reliability evaluation and

1,173 patients in the validity evaluation across 7

hospitals in 3 states. The sites included urban, rural,

suburban, academic, and community hospitals and

two dedicated pediatric EDs. The researchers found

that nurses make more accurate ESI ratings for

trauma cases than medical cases (Katznelson et al.,

2006) and that certain types of pediatric patients are

harder to triage, including infants, psychiatric

patients, and those with fever, rashes, or respiratory

problems (Rosenau et al., 2006).

The Pediatric ESI Research Consortium’s

comprehensive review of the pediatric literature

included 15 emergency courses and pediatric

emergency text books, and the goal of the review

was to identify best practices and best evidence

relevant to ED triage of children (Hohenhaus et al.,

2008). The review noted both strengths and areas

for improvement in the existing literature. Strengths

included the use of case scenarios for teaching and

the existence of many courses that facilitate

education on pediatric assessment during

emergencies. Areas for improvement included a lack

of evidence-based normal pediatric vital sign

parameters; the need for a standardized,

interdisciplinary approach to assessment and history

taking; and the need for more pediatric triagespecific case scenarios for educational use.

41

Chapter 6. Use of the ESI for PediatricTriage
Pediatric Triage Assessment

Triage Assessment: What Is Different

for Pediatric Patients?

The goal of the triage nurse is to rapidly and

accurately assess an ill child in order to assign a

triage level to guide timely routing to the

appropriate emergency department area for

definitive evaluation and management. Triage is not

a comprehensive assessment of the pediatric patient.

The ESI version 4 requires that the triage nurse

follow the same algorithm on all patients, pediatric

and adult. While the algorithm is the same

regardless of age, the decision process in the

pediatric patient must take into account agedependent differences in development, anatomy,

and physiology.

The triage nurse needs a good sense of what

constitutes “normal” for children of all ages. This

knowledge will make it easier to recognize things

that should be concerning (e.g., the 6-month-old

who is not interested in his or her surroundings or

the 2-week-old who is difficult to arouse to feed).

The triage nurse must be comfortable interacting

with children across the age spectrum and must be

well versed in the anatomic and physiologic issues

that may put a child at increased risk, as well as

certain age-dependent “red flags” that should not be

overlooked. The importance of adequate education

in pediatrics prior to undertaking the triage of

pediatric patients cannot be overemphasized. The

following are key points that the triage nurse should

keep in mind when assessing a child:

1. Use a standardized approach to triage assessment

of the pediatric patient, such as the 6-step

approach described in the next section. Observe

skin color, respiratory pattern, and general

appearance. Infants and children cannot be

adequately evaluated through layers of clothing

or blankets.

2. Infants must be observed, auscultated, and

touched in order to get the required information.

Their caregivers are critical to their assessment.

Using a warm touch and a soft voice will help

with the assessment.

3. Infants over about 9 months of age and toddlers

often have a significant amount of “stranger

anxiety.” Approaching them in a nonthreatening manner, speaking quietly, getting

down to the child’s eye level, and allowing them

to have a trusted caregiver with them at all times,

will make the assessment easier. Allowing the

child to remain on the caregiver’s lap and

enlisting that person’s help in things like

removing clothing and attaching monitors can

help ease the child’s fears.

4. Elementary school age and older children can

usually be relied on to present their own chief

complaint. Some preschoolers may have the

verbal skills necessary to do so, but many do not

or are simply too shy or frightened. In these

cases, the chief complaint and other pertinent

information must be ascertained from the child’s

caregiver.

5. When assessing school-aged children, speak with

them and then include the caregiver. Explain

procedures immediately before doing them. Do

not negotiate.

6. Don’t mistake an adolescent’s size for maturity.

Physical assessment can proceed as for an adult,

remembering that they may be as afraid as a

smaller child and have many fears and

misconceptions. Pain response may be

exaggerated.

7. The signs of severe illness may be subtle and

easily overlooked in the neonate and young

infant. For example, poor feeding, irritability, or

hypothermia are all reasons to be concerned in

an otherwise well appearing neonate.

8. Cardiac output in the infant and small child is

heart-rate dependent—bradycardia can be as

dangerous if not more dangerous than

tachycardia.

9. Infants, toddlers, and preschoolers have a

relatively larger body surface area than their

adult counterparts. This puts them at increased

risk for both heat and fluid loss. This is

compounded in the neonate, who does not have

the fully developed ability to thermoregulate.

These patients should not be kept undressed any

longer than absolutely necessary and should

have coverings replaced after a specific area is

examined.

10.Hypotension is a late marker of shock in

prepubescent children. A hypotensive child is an

ESI level 1, requiring immediate life-saving

intervention.

11.Weights should be obtained on all pediatric

patients in triage or treatment area. The actual,

not estimated, weight (in kilograms) is important

42

Chapter 6. Use of the ESI for PediatricTriage
to the safe care of a child. Methods for

estimating a child’s weight may be used for

critically ill/injured children (e.g. length-based

tape). Weights should not be guessed by the

nurse, parent, or caregivers.

12.A hands-on approach to pediatric assessment

should accompany the use of technical

equipment. As you obtain a child’s vital signs,

assess skin color, temperature, and turgor. As you

auscultate the child’s chest with a stethoscope,

note the rate and quality of respirations, as well

as chest and abdominal movements.

13.Use appropriately sized equipment to measure

children’s vital signs.

Standardized Approach to Pediatric

Triage Assessment

It is helpful to think about pediatric assessment in a

standardized manner. A general approach to

pediatric triage is suggested here:

• Step 1. Appearance/work of

breathing/circulation--quick assessment

• Step 2.

Airway/breathing/circulation/disability/exposureenvironmental control (ABCDE)

• Step 3. Pertinent history

• Step 4. Vital signs

• Step 5. Fever?

• Step 6. Pain?

These steps are described below.

Step 1. Appearance, Work of Breathing,

Circulation--Quick Assessment. Most triage

nurses are comfortable with an “Airway, Breathing,

Circulation, and Disability” (ABCD) checklist

approach to help determine if a child is “sick” or

“not sick.” In each of the standardized national

pediatric emergency education courses, the ABCD

approach is preceded by the Pediatric Assessment

Triangle (PAT) (American Academy of Pediatrics,

2005). The PAT uses visual and auditory cues and is

performed at the first contact with a pediatric

patient. It can be completed in less than 60 seconds.

The PAT is an assessment tool, not a diagnostic tool

and assists the nurse with making quick life support

decisions using appearance, work of breathing, and

circulation to skin. A child’s appearance can be

assessed from across a room and includes tone,

interactiveness, consolability, look/gaze, and

speech/cry. A child’s work of breathing is

characterized by the nature of airway sounds,

positioning, retractions, and flaring. Circulation to

skin is assessed by observing for pallor, mottling, or

cyanosis. By combining the three parameters of the

PAT, the nurse can get a quick idea of the

physiological stability of a child and, in conjunction

with the chief complaint, make decisions regarding

the need for life support. Some patients may need to

be taken immediately to the treatment area to

address abnormalities found in the quick

assessment. For more stable patients, the nurse will

proceed to the next step in the assessment, ABCDE.

Step 2. Airway, Breathing, Circulation,

Disability, Exposure/Environmental Control

(ABCDE). Following the urgency decision made

with the PAT, a primary assessment using the

ABCDE checklist can then be performed (Emergency

Nurses Association, 2004). This assessment must be

done in order and includes assessing for airway

patency, respiratory rate and quality, heart rate, skin

temperature and capillary refill time, blood pressure

(where clinically appropriate, such as a child with

cardiac or renal disease), and an assessment for

disability or neurological status. A child’s

neurological status can be obtained by assessing

appearance, level of consciousness, and pupillary

reaction. Exposure involves undressing the patient

to assess for injury or illness, and addressing any

immediate environmental needs such as treating

fever. Exposure and environmental control may

happen at triage or in the treatment area, depending

on the patient’s condition and factors such as

treatment room availability. Any serious finding in

the ABCDE assessment indicates a need for

immediate treatment and may require deferral of

the next steps in the assessment.

Step 3. Pertinent History. Following performance

of the initial assessment of a child at triage, a

standardized history should be obtained (see

examples in Table 6-1). The history may be deferred

to the primary nurse if the triage nurse identifies the

need for any life-saving interventions or a high risk

situation.

Which method is chosen is not nearly as important

as using a consistent method to avoid missing

important information.

43

Chapter 6. Use of the ESI for PediatricTriage
Step 4. Vital Signs. There is a lack of rigorous

studies to support the various vital signs parameters

that are included in the major pediatric emergency

texts and courses such as Pediatric Advanced Life

Support (PALS), Advanced Pediatric Life Support

(APLS), Pediatric Education for Prehospital

Professionals (PEPP), and Emergency Nursing

Pediatric Course (ENPC) (AAP, 2004; AAP, 2005; AHA

2006; ENA, 2004; Hohenhaus et al., 2008). The

major courses and texts appear to represent

consensus recommendations for normal vital signs

parameters and include varying age groupings and

parameters. Version 4 of the ESI includes parameters

drawn from the literature (Wuerz et al., 2000).

The following are recommendations regarding the

use of blood pressure and oxygen saturation

measurements for ESI decisions (Keddington, 1998):

• Blood pressure measurement is not a critical

factor in assigning acuity, and its measurement

should be left to the judgment of the triage

nurse.

• Oxygen saturation should be measured in infants

and children with respiratory complaints or

symptoms of respiratory distress.

Pulse oximetry values may be interpreted differently

at high altitude; EDs in such settings may need to

develop local protocols to address this (Gamponia et

al., 1998).

It is essential that equipment used in pediatric

physical assessment is the correct size. Observations

have shown that nurses often use adult-sized

equipment for children, which may result in errors

in vital signs measurements (Hohenhaus, 2006).

Step 5. Fever. Unlike in adult patients,

decisionmaking with the febrile child must take into

account both the clinical picture and the child’s age.

Note D on the ESI version 4 addresses pediatric fever

considerations. These considerations are based on

published guidelines from emergency physicians

(American College of Emergency Physicians, 2003).

However, since those recommendations were

published, the heptavalent conjugate pneumococcal

vaccine has become a routine part of the infant

immunization series. With this in mind, many

physicians are changing their practice and not

routinely ordering blood work (including cultures)

on febrile children who do not appear toxic and

have completed this immunization series. Thus the

current Pediatric Fever Considerations in the ESI

version 4 reflect the fact that the fever criteria

continue to evolve. The guidelines for children with

fever (100.4°F or 38°C or greater) who are in the first

28 days of life are clear--these patients must be rated

ESI level 2 as they may have serious infections. The

ESI guidelines recommend that triage nurses

consider assigning ESI level 2 for infants 1-3 months

of age with fever, while taking into consideration

practices in their institution. Nurses may have to

adjust their fever considerations according to those

practices for 1- to 3-month-olds.

Other considerations include exposure to known

significantly sick contacts (e.g., diagnosed with

influenza, meningococcal meningitis) and

immunization status. An immunization history

should be ascertained at the time of triage. It may be

helpful to post a copy of the Recommended

Immunization Schedule for Persons Aged 0-6 Years

(Centers for Disease Control and Prevention, 2010)

44

Chapter 6. Use of the ESI for PediatricTriage

CIAMPEDS* SAMPLE+

C Chief complaint S Signs/symptoms

I Immunizations/isolation A Allergies

A Allergies M Medications

M Medications P Past medical problems

P Past health history L Last food or liquid

E Events preceding problem E Events leading to injury/illness

D Diet/elimination 

S Symptoms associated with problem

Table 6-1. Pediatric History Pneumonics

* AAP, 2004; ENA, 2004.
at triage. Febrile children over the age of 2 who have

not completed their primary immunization series

should be considered higher risk than their

immunized counterparts with similar clinical

presentations. The triage nurse should consider

making these patients at least an ESI level 3 if there

is no obvious source of fever.

Step 6. Pain. Section B on the ESI version 4 defines

severe pain/distress as determined either by clinical

observation or a patient rating of ≥7 on a 0-10 pain

scale. Pain assessment for children should be

conducted using a validated pediatric pain scale.

Pediatric patients who meet the ≥7 criterion should

be considered for triage as an ESI level 2. The triage

nurse is not required to assign these patients an ESI

level 2 rating and should use sound clinical

judgment in making the final decision. For example,

a child who reports his pain as an 8/10 but is awake,

alert, smiling, and in no apparent distress may not

warrant triage as a level 2. Neither does the young

child with a minor injury simply because they are

screaming loudly. There are several validated

pediatric pain scores. For example, the FLACC (Face,

Legs, Activity, Consolability) score for infants and

nonverbal children and the FACES score for those

who are not able to understand the 0-10 scale are

both validated, easy-to-use scoring systems (Bieri,

Reeve, Champion, Addicoat, & Ziegler, 1990; Keck,

Gerkensmeyer, Joyce, & Schade, 1996; Luffy &

Grove, 2003; Merkel, Voepel-Lewis, Shayevitz, &

Malviya, 1997).

Each institution should decide for itself which pain

scale(s) to use for pediatric patients. What is

important is that a validated pediatric pain scale be

available and used correctly and consistently by the

triage nurse. This may require additional education

in pain scales that is outside the scope of this

handbook but should be part of an institution’s inservice program.

Assessment of Rashes. Analysis of nurses’ ratings

of pediatric patients with the ESI has found that

triage nurses both under- and over-triage rash

patients (Travers et al., 2009). During this study,

nurses gave feedback that it is sometimes hard

to differentiate high-risk rashes (e.g.,

meningococcemia) from low-risk rashes (e.g.,

contact dermatitis). When triaging the patient with

a rash, the nurse should obtain a thorough history

and complete set of vital signs. Other associated

symptoms should be ascertained and the overall

appearance of the child should be taken into

account. The child should be undressed if necessary

to adequately visualize the rash. Rashes that should

raise an immediate “red flag” and warrant an ESI

level 2 include vesicular rashes in the neonate and

petechial and purpuric rashes in children of any age.

If a child has a petechial rash with altered mental

status, they should be rated as ESI level 1; they are at

risk of meningococcemia and may be in shock. They

will likely need significant IV fluid resuscitation and

antibiotics.

Infant Triage. For the purposes of ESI triage, an

“infant” is defined as any child who has not yet

reached his or her first birthday. This definition is

consistent with the ACEP definitions, as well as the

PALS guidelines regarding equipment size and

cardiopulmonary resuscitation (CPR) standards

(ACEP, 2003; AHA, 2006).

Of all the patients who present to the emergency

department, infants may be the most difficult for

the triage nurse to evaluate. These patients’ lack of

verbal skills, and often subtle signs of serious illness

can make an accurate assessment difficult. Parental

concerns about signs and symptoms, even those not

witnessed by the triage nurse, must be taken

seriously. Whether the report is of a physical sign

(e.g., fever) or an abnormal behavior (e.g.,

fussy/irritable), parents are the best judges of their

infant, and if they are concerned, they often have a

good reason to be.

When assessing an infant, the triage nurse must pay

close attention to the history offered by the parents

as this may be the only real clue to the problem.

The infant’s state should be assessed prior to

handling. Vital signs must be assessed using

appropriate-sized equipment and need to be part of

the triage process of any infant who does not

immediately fall into the ESI levels 1 or 2. Vital sign

abnormalities may be the only outward signs of a

serious illness. Infants must be unwrapped and

undressed for a hands-on assessment of perfusion

and respiratory effort, remembering that they can

rapidly lose body heat in a cool environment and

should be rewrapped as soon as possible.

Fever guidelines for infants are discussed above.

Specific practices for the evaluation of febrile older

infants may differ from institution to institution.

However, it is universally accepted that neonates

(<28 days of age) with a rectal temperature of 38C

(100.4F) or greater are considered high risk for a

serious bacterial infection and should be triaged

accordingly (at least at an ESI level 2). In the clinical

policy for children under age 3 with fever, the

American College of Emergency Physicians

45

Chapter 6. Use of the ESI for PediatricTriage
recommends measuring infants’ temperatures

rectally (ACEP, 2003). Infants with rectal

temperatures of 38C or higher are likely to need a

full sepsis workup including blood, urine, and

cerebrospinal fluid cultures) and parenteral

antibiotic administration.

Assigning ESI Levels for

Pediatric Patients

ESI Level 1

ESI level-1 patients are the highest acuity patients

that present to the ED. Because ESI level -1 patients

are clinically unstable, decisions on resources

needed during the ED stay are not considered. These

patients require a physician and a nurse at the

bedside to provide life-saving critical care

interventions. They cannot wait, even a brief time,

for initiation of treatment.

Research has found that the ESI level-1 rating is

under-utilized by nurses triaging critically ill

children, except for those children who are

intubated or in cardiac arrest (Travers et al., 2009).

In response to findings from an all-age study, the ESI

was modified in version 4 to classify any patient in

need of immediate, life-saving interventions as ESI

level 1; formerly, these patients were often thought

of as “sick level 2s” (Tanabe et al., 2005). Table 6-2

provides examples of ESI level-1 conditions. This is

not an exhaustive list.

46

Chapter 6. Use of the ESI for PediatricTriage

Respiratory arrest

Cardiopulmonary arrest

Major head trauma with hypoventilation

Active seizures

Unresponsiveness

Peticheal rash in a patient with altered mental status (regardless of vital signs)

Respiratory failure

• Hypoventilation

• Cyanosis

• Decreased muscle tone

• Decreased mental status

• Bradycardia (late finding, concerning for impending cardiopulmonary arrest)

Shock/sepsis with signs of hypoperfusion

• Tachycardia

• Tachypnea

• Alteration in pulses: diminished or bounding

• Alteration in capillary refill time >3-4 seconds

• Alteration in skin appearance: cool/mottled or flushed appearance

• Widened pulse pressure

• Hypotension (often a late finding in the prepubescent patient)

Anaphylactic reaction (onset in minutes to hours)

• Respiratory compromise (dyspnea, wheeze, stridor, hypoxemia)

• Reduced systolic blood pressure

• Hypoperfusion (eg, syncope, incontinence, hypotonia)

• Skin and/or mucosal involvement (hives, itch-flush, swollen lips, tongue or uvula

• Persistent gastrointestinal symptoms

Table 6-2. Examples of ESI Level-1 Conditions
ESI Level 2

As with assigning an ESI level-1 acuity, assigning an

ESI level-2 acuity is based on the clinical condition

of the patient, and it is not necessary to consider

resource utilization in the decision. ESI level-2

decisions are based on the history and assessment

findings indicative of sentinel symptom complexes

that signal a high-risk or potentially high-risk

situation. Table 6-3 provides examples of patient

problems that warrant ESI level-2 ratings. This is not

an exhaustive list.

Resource Considerations When

Using the ESI for Pediatrics

As with use of the ESI for adult patients, its use for

children includes resource prediction as a way of

differentiating the three lower acuity levels, ESI

levels 3 4, and 5. It is sometimes a challenge to

predict resource needs for pediatric patients. The

triage nurse may find it especially challenging to

differentiate pediatric patients predicted to need two

resources (ESI level 3), versus one resource (ESI level

4) or no resource (ESI level 5). One reason for this is

that some conditions require different numbers of

resources in children than in adults. Research has

shown that ESI level 5 is under-utilized for pediatric

patients (Travers et al., 2009). These issues will be

explored in this section.

Pediatric patients may occasionally warrant a

different ESI level than an adult for a comparable

problem. For example, adults with lacerations that

necessitate suturing are typically classified as ESI

level 4. However, some pediatric patients may

require sedation for a laceration repair, particularly if

they are below school age or appear to be especially

agitated or uncooperative. Sedation includes the

establishment of IV access, administration of IV

medications, and close monitoring; thus, all

sedation patients are classified as at least ESI level 3

based on their need for more than one resource.

Table 6-4 lists examples of children who are

candidates for sedation.

47

Chapter 6. Use of the ESI for PediatricTriage

Syncope

Immunocompromised patients with fever

Hemophilia patients with possible acute bleeds

• Joint pain or swelling

• History of fall or injury

• Vital signs and/or mental status outside of baseline

Febrile infant <28 days of age with fever ≥38.0°C rectal

Hypothermic infants <90 days of age with temperature <36.5°C rectal

Suicidality

Rule out meninigitis (headache/stiff neck/fever/lethargy/irritability)

Seizures--prolonged postictal period (altered level of consciousness)

Moderate to severe croup

Lower airway obstruction (moderate to severe)

• Bronchiolitis

• Reactive airway disease (asthma)

• Respiratory distress

– Tachypnea

– Tachycardia

– Increased effort (nasal flaring, retractions)

– Abnormal sounds (grunting)

– Altered mental status

Table 6-3. Examples of ESI Level-2 Conditions
It is important to remember that the ESI is not a

nursing workload measure. Rather, resources are

used in the ESI as a proxy for acuity. A child with a

small abrasion (ESI level 5) who gets the wound

cleansed and a tetanus shot is less acute than a

patient with a sprained ankle (ESI level 4) who gets

an x ray, ace wrap and crutch-walk instruction; and

this patient is less acute than a child with a complex

laceration (ESI level 3) who gets suturing and

sedation. While the tetanus injection, ace wrap and

crutch-walking instruction all require nursing time,

they are not considered ESI resources. The purpose

of the ESI resource assessment is to sort patients into

5 meaningful acuity categories, not to estimate the

nursing workload intensity. EDs are encouraged to

use appropriate workload measures to capture

nursing resource needs.

Table 6-5 lists patients who need no resources and

can be classified as ESI level 5.

Special Populations

Trauma

Trauma patients can be challenging to triage,

especially if they have suffered internal injuries

without visible external signs of injury. Pediatric

trauma patients may be difficult to assess due to

compensatory mechanisms that produce vital signs

with the appearance of stability. The nurse must be

proactive when providing care to the pediatric

trauma patient to prevent deterioration and rapid

de-compensation. Children who suffer traumatic

injuries must be assessed and assigned a triage level

based on the mechanism of injury and presenting

signs and symptoms, as opposed to basing the ESI

rating on the practices of individual triage nurses or

mode of arrival to the ED. For example, children

should not be assigned an ESI level based on their

arrival via Emergency Medical Services (EMS) or the

use of back boards and c-collars. Any patient with a

high risk mechanism of injury should be classified

as ESI level 2, unless their condition requires

immediate life-saving interventions that warrant

classification as ESI level 1. Vital signs and

estimation of resource needs are not needed for ESI

level-1 or level-2 determinations. The American

Academy of Pediatrics (AAP) has issued guidelines

that may be useful in the triage of children with

minor head injuries (AAP, 1999). Examples of

pediatric trauma patients and ESI ratings are

provided in Table 6-6.

Psychiatric

Psychiatric emergencies among children present a

unique challenge for the triage nurse, who will be

required to make a complex clinical decision as to

the degree of danger the patient may pose to

themselves or others. Patients at high risk may

exhibit a variety of symptoms including violent or

combative behavior, paranoia, hallucinations,

delusions, suicidal/homicidal ideation, acute

psychosis, anxiety, and agitation and should be

rated ESI level 2. The Mental Health Triage Scale can

be used in the assessment of the pediatric

psychiatric patient (Smart, Pollard, & Walpole,

1999). Any child presenting as confused,

disorganized, disoriented, delusional, or

hallucinating should be rated as an ESI level 2.

These altered mental states may be attributed to the

patient’s mental health or medical or neurological

complications (ENA, 2004). The amount of distress a

48

Chapter 6. Use of the ESI for PediatricTriage

Fracture/dislocation repair in ED

Complicated lacerations, such as:

Complex facial/intraoral lacerations

Lacerations across the vermillion border

Lacerations requiring a multilayered closure

Extremely dirty or contaminated wounds

CT/MRI procedures or image-guided procedures

(e.g. joint aspirations under bedside ultrasound,

fluoroscopy)

Lumbar punctures (except in infants)

Chest tube insertions

Table 6-4. Examples of SituationsThat May

Warrant Sedation in Pediatric Patients

Medication refills

Ear pain in healthy school-age children

Contusions and abrasions

URI symptoms with normal vital signs

2 year-old with runny nose, mild cough and

temp of 38°C (100.4°F), active and drinking

during triage

Poison ivy on extremities

Table 6-5. Examples of ESI Level 5
child appears to be in, or has reportedly been in, can

also classify them as an ESI level 2. The triage nurse

should be alert for any behaviors that may indicate

the patient is a high risk and needs treatment

immediately. A patient’s distress should not be

limited to physical symptoms but may include

situational triggers as well. Therefore, it is

important to be aware of the circumstances

underlying the current psychological event. In

addition to establishing the reason for the exhibited

behavior, it is important to capture the type,

severity, frequency, and focus (is the behavior

directed toward something or someone) of the

behavior. In some cases, it may be beneficial to

interview older children and adolescents alone.

They may be more likely to offer information on

sensitive subjects such as risky behaviors, abusive

relationships, and drug or alcohol use without the

presence of their parents.

Resources will determine whether the patient will

fall into ESI level 3, level 4, or level 5. Resources will

be somewhat different for the pediatric mental

health patient than for the pediatric medical patient

and are likely to include things such as psychiatric

and social work consults. Table 6-7 provides

examples of pediatric psychiatric patients.

49

Chapter 6. Use of the ESI for PediatricTriage

Patient Presentation Resources ESI Rationale

EMS arrives with a 7-year-old male Life-saving intervention, ESI level 1 Life threatening

who was hit by a car. Child is no need to assess for injury

somnolent, appears pale, non-labored number of resources

respirations.

14-year-old female is brought in by High risk injury, no need ESI level 2 High risk injury due

EMS after diving into the pool and to assess for number of to the mechanism.

hitting her head. She is awake, alert, resources

and moving all extremities. She is

currently immobilized on a back board

with c-collar in place. VS: BP 118/72,

HR 76, RR 14.

14-year-old male brought in by EMS More than one resource. ESI level 3 Fracture will need

who was tackled while playing reduction. He will

football. He has an obvious deformity need x rays, labs,

to his right lower leg. He has +2 pedal IV antibiotics and

pulses and his toes are warm and dry. pain medication

He is able to wiggle his toes. No head/

neck injuries reported. VS: 118/78,

HR 88, RR 18,T 98.2°F, Pain 6/10.

12-year-old female brought into the One resource. ESI level 4 Will require suturing

ED by mother. Claims she cut her

thumb while washing dishes.

She has a 2 cm superficial laceration

to her right thumb. VS: BP 110/70,

HR 72, RR 14,T 98.0°F.

Table 6-6. Examples of PediatricTrauma and ESI Levels
50

Chapter 6. Use of the ESI for PediatricTriage

Patient Presentation Resources ESI Rationale

17-year-old male, history of suicidality, Life saving intervention. ESI level 1 Life threatening

found unresponsive by parents.There No need to assess for situation—

are several bottles of liquor, and number of resources. unresponsive.

unidentified empty pill bottles next

to bed.

16-year-old male brought in by parents High-risk situation. No ESI level 2 High risk situation—

who report patient was out of control, No need to assess for danger to self and

screaming obscenities, and number of resources. others.

threatening to kill the family. He is

cooperative in triage and answers

your questions calmly.

15-year-old female presents to ED with More than one resource. ESI level 3 Will require labs, and

her boyfriend claiming, “I think I’m possibly more than

pregnant. When I told my mom she one specialty

threw me out of the house and told consult.

me never to come back. I have no

place to live, and now I might have a

baby.” VS: BP 126/85, HR 100, RR 16,

T 98.7°F.

10-year-old female presents to the ED One resource. ESI level 4 Will require a

with mother who states that she specialty consult.

received a call from her teacher

because the child has been disrupting

the class with sudden outbursts.

Mom has never witnessed this

behavior, but she does state that she

becomes very defiant when she

doesn’t get her own way. Currently,

the child is laughing and playing with

her little sister. VS: 98/72, HR 82,

RR 22,T 98.2°F.

13-year-old male walks into the ED No resources. ESI level 5 Will require a

with his mother on a Friday night. prescription filled.

Mom states, “I didn’t realize he was

out of his medications for his ADHD,

and I don’t want him to miss a day.”

The patient is cooperative and

pleasant. VS: BP 108/72, HR 78, RR 14,

T 98.6°F.

Table 6-7. Examples of Pediatric Psychiatric Patients and ESI Levels
Children with Co-Morbid Conditions

Research has found that children with co-morbid

conditions are both over-triaged and under-triaged

(Travers et al., 2009). Patients with chronic

conditions (e.g., spina bifida, seizures, metabolic

syndromes, short gut) may require more extensive

evaluation and workup than otherwise healthy

children with similar complaints. At the same time,

children should not be automatically triaged at a

higher level due to a co-morbid condition. A good

history and input from the child’s caregiver can help

greatly in this determination. For example, the child

with a known seizure disorder who presents with

breakthrough seizures needs to be triaged at a higher

level than the same child who presents for a

medication refill. The febrile 10-year-old with a VP

shunt is going to need more extensive evaluation

than the otherwise healthy and non-toxic appearing

10-year-old with an isolated fever. However, a child

with a sprained ankle likely does not need a higher

acuity level simply because the child has a history of

congenital heart disease.

Pediatric Patient Case Studies

In addition to this pediatric chapter of the ESI

Handbook, several sets of pediatric case studies are

available to support pediatric-specific ESI education

in locally-developed ESI educational programs. One

set was validated as part of a Health Resources and

Services (HRSA)-funded ESI study (Katznelson et al.,

2006) and is available from the HRSA website

(HRSA, 2010). This set includes new cases and others

adapted from the ESI Handbook (Gilboy et al.,

2005). In addition to this set of pediatric-only case

studies available through the HRSA website, many

pediatric case studies are included in chapter 9

(practice cases) and chapter 10 (competency cases)

of this handbook. There are also additional cases

available in Gilboy, Tanabe and Travers (2005).

Summary

Assessing the pediatric patient can be a daunting

task for both the novice and the experienced triage

nurse. Remembering some key developmental

differences between pediatric and adult patients can

help make the process significantly less stressful for

ill or injured children and their caregivers. Applying

the ESI algorithm consistently on patients of all

ages, while keeping in mind key anatomical and

physiological differences in the pediatric population,

can simplify the process for the triage nurse.

In order to most effectively triage pediatric patients,

the triage nurse must be experienced in caring for

the youngest patients. This chapter highlights

important factors to keep in mind when triaging the

pediatric patient, including the value of using a

standardized approach to assessment such as PAT,

keeping special populations in mind when

determining which patients are high risk, and the

importance of communication with the

accompanying caregiver.

This chapter was made possible by a grant (#

H34MC04371) through the Health Resources and

Services Administration, Maternal Child and Health

Bureau, Emergency Medical Services for Children (EMSC)

Program. The grant supported the work on this chapter

by the Pediatric ESI Research Consortium:

• University of North Carolina at Chapel Hill (Chapel

Hill, NC): Anna Waller (principal investigator)

Debbie Travers, Jessica Katznelson

• Wellspan Health System (York, PA): David Eitel,

Suanne McNiff

• Primary Children’s Medical Center (Salt Lake City,

UT): Nancy Mecham

• Lehigh Valley Health Network (Allentown, PA):

Alexander Rosenau, Valerie Rupp

• WakeMed Health and Hospitals (Raleigh, NC):

Douglas Trocinski.

• Hohenhaus and Associates, Inc (Wellsboro, PA):

Susan McDaniel Hohenhaus

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

51

Chapter 6. Use of the ESI for PediatricTriage
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of minor closed head injury in children. Pediatrics.

104(6):1407-1415.

American Academy of Pediatrics (2004). APLS: The

Pediatric Emergency Medicine Resource (4th ed.). Boston:

Jones and Bartlett.

American Academy of Pediatrics (2005). Pediatric Education

for Prehospital Professionals (2nd ed.). Sudbury, MA:

Jones and Bartlett.

American College of Emergency Physicians Clinical

Policies Committee (2003). Clinical policy for children

younger than three years presenting to the emergency

department with fever. Ann Emerg Med. 42(4):530-545.

American Heart Association (2006). Pediatric Advanced Life

Support ProviderManual. Dallas, TX: American Heart

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Baumann MR, Strout TD (2005). Evaluation of the

Emergency Severity Index (Version 3) triage algorithm

in pediatric patients. Acad Emerg Med. 12(3):219-224.

Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB

(1990). The Faces Pain Scale for the self-assessment of

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aged 0-18. MMWR Weekly. 58(51&52):1-4.

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Gamponia MJ, Babaali H, Gilman RH (1998). Reference

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Hohenhaus SM (2006). Someone watching over me:

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Hohenhaus SM, Travers D, Mecham N (2008). Pediatric

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Katznelson J, Hohenhaus S, Travers D, Agans R, Trcinski D,

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Keddington R (1998). A triage vital sign policy for a

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Luffy R, Grove SK (2003). Examining the validity,

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52

Chapter 6. Use of the ESI for PediatricTriage
Up to this point, an in-depth discussion has been

provided of the ESI algorithm and how to apply it

with individual patients. To help ensure successful

adoption of the Emergency Severity Index ESI) in an

emergency department (ED), a well-thought-out

implementation plan is critical. Change has become

constant, pervasive, and persistent in health care. It

is important to keep in mind that implementation

of any new system or process takes time, careful

planning, and a group of professionals dedicated to

a successful transition.

This chapter presents background information on

the change process in health care organizations and

a step-by-step guide for successful implementation

of the ESI. The implementation strategies

successfully used by members of the ESI research

team and others are presented.

The decision to switch from another triage acuity

rating system to ESI may be based on multiple

reasons. One reason may be the American College of

Emergency Physicians (ACEP) and the ENA joint

position statement on a standardized triage scale

and acuity categorization that supports the adoption

of a reliable, valid five-level triage scale such as ESI.

In many institutions, a particular event may be the

impetus for the change, such as a mistriage or a

sentinel event due to prolonged patient waiting

time. The clinical or administrative staff may express

concerns about patient safety. The nursing staff may

find that they are continuously re-triaging patients.

In crowded EDs with many urgent patients waiting

to be seen, nurses are forced to constantly

reprioritize these patients for the scarce ED beds.

The implementation of the ESI may be part of a

larger plan, but before transitioning to a new triage

acuity rating system, the implementation team

needs to consider all aspects of the “door to doctor”

process.

Revising the system requires understanding of the

planned change process. Planned change results

from a well-thought-out and conscious effort to

improve something. Kurt Lewin’s theory of planned

change is a frequently used approach in health care

organizations (Nelson, 2002). Lewin identified three

phases of change:

1. Unfreezing

2. Movement

3. Refreezing

These steps parallel the steps in the nursing process

that triage nurses follow. The first step in

implementing any change is to recognize that a

problem exists and that there is a clear need for

change. This unfreezing phase is often compared

to assessment, the first step of the nursing process.

During the assessment phase, data are gathered and

the problem or problems are identified. Both

informal and formal discussions may occur around

the problem and the need for change. In the ED,

this may occur at nursing and physician meetings or

during informal discussions in the clinical area. In

many cases, one individual, typically a nurse or

physician in a leadership role, drives the push for

change. This “champion” should take every

opportunity to discuss the problem and explain why

a change needs to occur. Hospital and department

leadership have to create a sense of urgency

regarding the change. Data that show staff that the

system they are using is not working can help

engender support for changing triage systems. Such

data may include mistriages per week, numbers of

patients who leave without being seen, and delays

in physician evaluation of high-risk patients.

As in the nursing process, during the movement

phase, those charged with carrying out the change

(the change agent or agents) identify, plan, and

implement suitable strategies. The last phase, the

refreezing phase, is similar to the evaluation and

reassessment phase of the nursing process. At this

stage, the champions of the new system need to

ensure that the change has been successfully

integrated into the day-to-day operations of the ED.

Once the decision is made to change to the ESI, a

multidisciplinary implementation team needs to be

identified. The implementation team becomes the

change agent. The implementation team leader is a

key player in the successful implementation of the

ESI and needs to have the respect of the department

as well as strong skills in leadership,

communication, problem solving, and decision

making.

Selection of the team members is paramount to the

timely success of lasting change. Membership must

include management, physicians with a

collaborative style, nursing staff with triage

expertise, the clinical educator or clinical nurse

specialist, and the triage committee if the

department has one. Staff in other disciplines, such

as registration and information systems, who will be

53

Chapter 7. Implementation of ESITriage
affected by the change, may also be asked to join

the team. These members may be invited to attend

meetings on an as-needed basis. The group should

consider asking one or more of the informal nursing

leaders to be staff nurse team members. This will

facilitate the informal leaders' buy-in of the change,

which will be helpful if staff begins to raise concerns

about the change to ESI.

It is important for the implementation team to meet

regularly. Department leadership needs to arrange

for staff to be available during meeting time. It is

well established that without adequate planning,

implementation will fail. Implementation is never a

single action but involves a well-designed

comprehensive plan, a stepwise process, and a

variety of strategies and interventions (Grol &

Grinshaw, 1999).

The implementation team must decide what needs

to be done, who will do it, and what strategies will

be used and develop a time line. Other teams have

found flow-charting or using a computer project

application helpful. A flow chart identifies the

critical tasks that need to occur and links them with

completion target dates. The team members can

regularly refer to the flow chart to see if they are

meeting their target dates.

At Brigham and Women's Hospital in Boston, MA,

the team brainstormed to identify who and what

would be affected by the change to ESI. The list

generated by this process included:

• Information systems

• The patient tracking system

• The physician record

• The nursing record

• Triage policies and procedures

• Triage orientation

Visiting other EDs that have already implemented

ESI can be very informative. Start by contacting

managers, educators, or clinical nurse specialists at

area EDs to identify EDs using ESI. Visiting a

department that has been using ESI for at least 6

months should be most beneficial. The leadership

team may share valuable information about their

own implementation experience, including issues

they encountered and strategies that worked well. It

is important to plan these visits to make sure that all

of the group's open issues are addressed. Prior to the

visit, make a list of questions and information the

team needs. Be sure to request copies of policies and

documentation forms. If team members have

questions that cannot be answered by the

publications, this book, or others who have

implemented ESI, they can contact the ESI Research

Team through AHRQ (see information in front cover

of this handbook).

Changing to ESI takes several months of planning,

and timing is important. Once all the tasks

associated with the change are identified and

timeframes established, the group can choose a

realistic implementation date. The team must

consider what is happening in the hospital and in

the ED and identify a time when the unit is able to

support the change and the educational activities.

The acuity system cannot be changed gradually. A

definite start date and time must be set and shared

with all staff affected by the change.

Policies and Procedures

All policies related to triage must be reviewed in

light of the change to ESI. Individual hospitals must

decide how the ESI will be incorporated into their

ED's existing triage policies and procedures. Many

policies may need to be rewritten. Examples of

policies and procedures that need to be addressed

include:

• Where are different types of patients seen within

the ED? This varies by hospital, depending on

the ED structure and patient flow.

• If non-urgent patients have been seen in the

urgent care or fast-track area, does that mean all

ESI levels 4 and 5 may be triaged to fast-track?

Can some ESI level-3 patients also go to the fast

track?

• Where will patients be seen who are triaged ESI

level 2 due to pain? For example, on a busy

afternoon in what part of the ED is the patient

with renal colic in severe pain seen? Are they

placed in the last open bed even if it is

monitored? In an ED with several different

sections, do they have to go to a specific section?

• Some EDS are using a licensed independent

provider in the triage area. The provider’s role is

to see and treat low acuity patients and discharge

them from triage. Is this a process your

department is considering? If a two-tier triage

process is being used, and the patient’s first

contact is with the greet nurse, does the greet

nurse assign ESI level for just ESI levels 1 and 2?

54

Chapter 7. Implementation of ESITriage
The ED leadership team will ultimately make these

policy decisions, but the implementation team

should identify these issues and make

recommendations.

The ESI research team is frequently asked if the ESI

system includes criteria for a time to reassessment

by triage level. The ESI system does not include

reassessment recommendations. This is a key

difference between ESI and other five-level triage

systems. The ESI triage research group has

purposefully not identified reassessment times but

has left that to individual departments to

incorporate into their triage policy. The group urges

caution; in this era of ED crowding it is very difficult

for busy triage nurses to reassess patients at set time

intervals when they are busy sorting incoming

patients. Falling short of the policy can become a

departmental liability. The ED tech can take and

document another set of vital signs, but the RN

must talk to the patient and evaluate the vital signs

for changes. Assessment is a nursing function that

cannot be delegated to non-licensed nursing

personnel (e.g., nursing assistants).

It would be unrealistic for the implementation team

to assume that all staff will embrace the change to

ESI. Resistance is expected. Major change can trigger

a wide range of emotional responses such as

enthusiasm, skepticism, stress, anxiety, anger, and a

sense of loss. The implementation team needs to be

prepared for these reactions and not personalize

them. The team should put into place strategies to

minimize or manage them. Change is never easy

and the implementation team needs to “stay the

course” and not give up. The team needs to openly

discuss the planned change, answer questions, and

gather support.

Planning ESI Education

Education for physicians, nurses, and support staff

is one of the critical tasks that the implementation

team needs to consider. ED leadership must commit

the resources to thoroughly prepare the ED staff to

use ESI. Several key concepts need to be understood

to maintain the reliability and validity of the

instrument. Some form of education about the ESI

should be provided to all staff who will use the ESI

information, including ED nurses, physicians, and

other providers; nursing assistants; and clerical staff.

While the triage nursing staff will need a full

orientation to the ESI, other staff will need less

education. The original ESI hospitals have found

that successful implementation of the ESI requires

every triage nurse to attend, at a minimum, a 2-4

hour education program. At University of North

Carolina Hospitals, clerical and nursing assistant

staff members received a memo describing the five

ESI categories and notice of the implementation

date.

The physician on the implementation team may

choose to handle physician education. The duration

of physician orientation to ESI will depend on how

familiar they are with the algorithm. At teaching

hospitals, the ED residency director needs to allocate

time for a member of the implementation team to

provide an orientation for the residents. It is helpful

to give residents copies of key ESI research articles

for review (see Chapter 1). With more hospitals

using physicians at triage, it is even more important

that physicians have a solid understanding of the

five levels of the ESI triage system.

The education program is best conducted in a

setting away from the ED that is free from the

distractions of the clinical area and conducive to

learning.

Implementation may be an opportunity for

collaboration. For example, two hospitals chose to

change to ESI at the same time and decided to pool

resources. They offered joint educational programs.

Two-to-four hours is a realistic timeframe for the

triage nurses' ESI educational program. The educator

or clinical nurse specialist should set the day and

time for education. Plans should include one or two

make-up classes for the triage nurses that are ill, are

on vacation, or are pulled from the class and back

into clinical duties due to staffing issues.

The implementation team must identify one or

several trainers for the orientation to ESI. It may not

be realistic to have an educator available to teach all

classes. Many groups use a train-the-trainer program,

which initially trains team nurses who feel

comfortable teaching and confident dealing with

questions and resistors in the group. An experienced

educator should be available during the initial

sessions to ensure accuracy of the information

provided and to assist the trainer if needed.

Experienced educators have found that reading the

research publications can be particularly helpful in

explaining why the change to ESI is so important.

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Chapter 7. Implementation of ESITriage
A number of low-cost training opportunities are

available for EDs to consider in implementing ESI:

• The ESI Interactive Web Based Training Course

• The ESI Training DVD “Everything You Need to

Know”

• The ESI Implementation Handbook is for

hospitals with staff with less curriculum

development experience

The ESI Interactive Web-Based

Training Course

The ESI Triage Research Team recognized that staff

attendance at a 2-4 hour program is often difficult

to organize. In addition, some hospitals have chosen

to conduct train-the- trainer programs and found

that there were inconsistencies in the information

presented by different trainers. As a solution, in

2009 the ESI Research Team developed an on-line

education program that is interactive, inexpensive,

and self-paced.

The program highlights some of the nuances of the

ESI that novices find challenging. This handbook

and segments of the ESI training DVD discussed

below have been incorporated, as well as numerous

learning activities that reinforce some of the key

concepts or critical decision points. Individuals have

30 days to complete the course after they register.

The advantage of this type of training is that a nurse

can take the course at his or her own pace and is

actively engaged by the content and review

exercises. On completion, the participants receive

the course post-test results and a completion

certificate.

The Web site also includes many resources and

much information about ESI. It is the only Web site

developed by the researchers and educators who

developed ESI and wrote this implementation

handbook. To learn more about the Web-based

course, go to www.esitriage.org and click on the

Web course.

The ESI Training DVD

Another training option is to use the Emergency

Severity Index, Version 4: Everything You Need To Know

DVD, produced by the Agency for Healthcare

Research and Quality (AHRQ). This product is free to

all EDs and can be ordered from AHRQ by phoning

800-358-9295 or sending an e-mail to

AHRQPubs@ahrq.hhs.gov.

The ESI training DVD was produced to help EDs

implement the ESI. The intent is to enable EDs to

implement ESI using a standardized training

program rather than requiring each department to

create its own program. The DVD has four sections

that can be used in several ways:

Section 1: The Introduction may help the ED

leadership make the decision to implement ESI.

Both physician and nursing leadership may learn

more about the value of ESI data.

Section 2: The Emergency Severity Index is a

step-by-step review of the algorithm and can be used

in several different ways depending on the

department's resources. Staff members can view this

section independently and then attend a group

inservice. The DVD can serve as the primary

educational tool with a member of the staff serving

as a resource and facilitator answering questions.

Educators may choose to develop their own

educational program and use the DVD as a guide.

The important point is that the DVD provides EDs

with standardized educational materials.

Section 3: Practice Cases can be used by

individuals or small groups to practice the

application of ESI. The facilitator can stop the DVD

after each patient scenario and ask participants to

assign the ESI level. When the DVD is restarted,

participants can listen to explanations of level

assignments. The facilitator can address the ED’s

specific policies and practices.

Section 4: Competency Cases can be used at the

end of a group educational program or individually.

Demonstration of competency using ESI is

important. Every triage nurse should have the

opportunity to demonstrate ability to accurately

assign a triage level.

Locally-Developed ESI Training

Many EDs develop their own educational programs

using the ESI Handbook and the training DVD, as

well as additional information relevant to triage at

the local ED.

A basic ESI training can take between 2-4 hours.

Many hospitals use this opportunity to review other

triage-related information, such as high-risk

situations or policy and procedure changes. The

following section provides a detailed description of a

2-hour training segment of ESI. It is advised that the

trainers review the entire ESI Handbook and training

DVD prior to developing their own content. This

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Chapter 7. Implementation of ESITriage
will help assure reliability and validity of the ESI

algorithm.

Section 1: Introduction. The introduction

explains why the department has chosen to adopt

ESI. The issues with the former triage acuity system

should be briefly explained along with how ESI will

address them and the advantages of ESI. The time

allocated for this section will depend on what

information has already been shared with staff. It is

important for the trainer to focus on what ESI will

do for the staff nurse and for ED administration.

A number of reasons can be cited to support a move

to ESI:

• Increases in local ED volume, change in

admission rate

• Desire to use a reliable and valid triage system

• Changes in ED patient population

– More trauma patients

– More psychiatric patients

– Changes within the hospital that have

affected the ED

– Beds closed

– Unit renovations

– Holding patients in the ED

– Increased length of ED stay for admitted

patients

• Nationwide trends

– Increase in the number of elderly

– Increase in the number of patients seeking

primary care in the ED

– Increase in the number of uninsured seeking

care in an ED

– Nursing shortage

At the end of the introduction, trainers should

discuss the issues with the current triage acuity

rating system that the ED may have already

identified. These may include mistriages. While it is

important to include specific examples of problems

the department has experienced with the current

triage system, it is also important that the trainer

not let this become a "gripe" session. The facts

should be presented and any comments or

questions can be addressed at the end of the

program.

If the staff is not convinced that a change in the

triage acuity rating system is necessary, they can

play the Triage Game before discussing the

importance of reliability and validity of triage

systems.

The Triage Game. The Triage Game is a way to

break the ice and illustrate the poor inter-rater

reliability of the three-level triage acuity rating

system. Each nurse in attendance is given a packet

consisting of red, yellow, and green colored cards.

The red card is labeled “emergent,” the yellow

“urgent,” and the green “non-urgent.” Three cases

are read to the group, and after each case

participants are asked to rate the patient acuity and

hold up the appropriate card. Each participant is

able to see how other members of the group rated

the patient. Resistance decreases as the group begins

to notice that participants rate the same patient

differently. The group begins to realize that with a

three-level system, there is always some level of

disagreement within the group.

Three cases that could be used for this game are

presented below:

Case 1. A 57-year-old woman presents with

epigastric pain 6/10, a smoker, her only medication

is for high cholesterol. She has been tired for the last

week and thinks she just needs a vacation. Her skin

is cool and clammy. Is this patient emergent, urgent,

or non-urgent? This case may generate some

interesting discussion. Chances are many of the

group will triage the patient as urgent. Some more

experienced staff may recognize that she is probably

having a cardiac event and will label her emergent.

Case 2. A 36-year-old female presents with left

lower quadrant abdominal pain 6/10, vaginal

spotting, last menstrual period 8 weeks ago, vital

signs within normal limits. Is this patient emergent,

urgent, or non-urgent? Is this patient pregnant?

Does she have an ectopic pregnancy? These are

questions the group may ask as they try to assign a

triage priority. Many participants will assign her to

the urgent category, while a few may think she is

emergent.

Case 3. A 10-day-old baby boy is brought to the ED

by the parents because he feels warm and is not

nursing well. Mom thinks he has the bug that her

other kids are getting over. His rectal temperature is

101°F. Is this patient emergent, urgent, or nonurgent? Some nurses may accurately say he is

emergent, recognizing that a temperature of 101°F

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Chapter 7. Implementation of ESITriage
in a 10-day old is concerning. Others will say he is

merely urgent because a temperature of 101 is not

that significant in light of the other kids having

been sick.

After the Triage Game, it is useful to highlight the

research on poor inter-rater and intra-rater reliability

of conventional three-level triage systems, which is

described in Chapter 1. At this point the group is

about 15-to-20 minutes into the presentation and

staff should be ready to hear about ESI. Participants

should have a copy of the front and back of the

algorithm (see the cards on the back cover of this

handbook). The trainer can now begin the

discussion.

Section 2: The ESI Algorithm. This section of

the presentation explains the algorithm in detail. It

is important to stress to course participants that ESI

was developed by a group of emergency nurses and

physicians and has been in use at a number of

hospitals since April 1999. Other important

background information to discuss includes the

following points about ESI:

• The program is research based.

• Consistent use of the ESI by all staff is more

likely when all triage nurses participate in a

standardized educational program.

• ESI allows for rapid sorting into one of five

categories.

Begin review of the algorithm with the conceptual

version so that the four major decision points can

be reviewed. Then begin a detailed description of

the algorithm itself. The instructor should walk

through each decision point slowly and not move

on to the next decision point until all questions and

concerns are addressed. This section will take from

40-to-65 minutes depending on the size of the

group and the experience of participants. For each

decision point, the trainer should review the

questions the triage nurse should be asking.

Decision point A: Does this patient require

immediate life-saving intervention? If the answer is

yes, the patient is assigned to ESI level 1. It is

imperative that the instructor spend time reviewing

the A notes on the back of the algorithm card. The

instructor should also include examples of ESI level1 patients and the reasons they fall into that triage

level. Experienced ED nurses have no problems

identifying this group of patients.

Decision point B: Is this a patient who shouldn't

wait? The trainer needs to discuss in detail the three

questions that are part of Decision Point B:

• Is this a high-risk situation?

• Is there new onset confusion, lethargy or

disorientation?

• Is this patient in severe pain or distress?

Is this a high-risk situation? Define the term

“high risk” and have the participants identify chief

complaints or diagnoses that are high risk.

Participants will usually mention aortic abdominal

aneurysm and ectopic pregnancy but the trainer

needs to encourage the staff to think about other

low volume, high-risk presentations. During this

discussion, knowledge deficits may become evident

and the instructor will need to provide additional

educational materials. For example, staff nurses may

disagree on the need for immediate evaluation of a

patient that presents with symptoms of central

retinal artery occlusion. This is a perfect opportunity

to explain why this is high-risk situation. A

discussion of high-risk situations also provides the

trainer with an opportunity to review triage red flags

in the elderly and in children.

To prepare for this section of the course, the

instructor may want to review the Emergency

Nursing Core Curriculum© (Emergency Nurses

Association, 2007) or other emergency nursing

textbooks and develop a list of high-risk patient

situations. These situations are outlined in Chapter

3 (Table 3-1). The instructor needs to stress that a

high-risk patient may be safe to wait up to 10

minutes while an open bed is found.

Is there new onset confusion, lethargy or

disorientation? This question also needs to be

reviewed using examples from various age groups

(see Table 3-1 and case studies in Chapters 9 and

10). The definition of “acute” change in level of

consciousness is important to clarify.

Is this patient in severe pain or distress? The

concept of severe pain or distress elicits many

opinions and questions from the audience. The

instructor should not engage in a debate about pain

scales and their use at triage. The discussion should

focus on the intent of this question to identify the

patient in extreme pain. It may be helpful to explain

that there are actually three components to severe

pain:

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Chapter 7. Implementation of ESITriage
• The patient's rating of pain is 7/10 or higher.

• The nurse's assessment, including chief

complaint, subjective and objective assessment,

past medical history, and current medications.

• Can the triage nurse perform any nursing

interventions that may decrease this patient's

pain? (Examples: ice, elevation, positioning, quiet

room, something to cover their eyes, and

medications.)

If the patient rates their pain as 7/10 or greater and

the triage RN feels this patient cannot wait and

needs IV analgesia, the patient will be assigned to

ESI level 2. Participants may have many questions

about this concept and the trainer needs to stress

that it is not just the patient's pain rating that

makes the patient an ESI level 2. This concept is

discussed in detail in chapter 3. Nurses may say they

feel uncomfortable documenting a patient's high

pain rating and then leaving the patient in the

waiting room. It is important for the instructor to

stress that the patient's rating is one piece of an

assessment and that the nurse should accurately

document what he or she is observing. For example:

“Rates pain as 10/10, skin warm and dry, laughing

with friend at triage,” or “Generalized abdominal

pain for 3 days, constant dull ache. Rates pain as

10/10.”

The instructor should describe several patients that

meet ESI level-2 criteria due to pain. Examples

include sickle-cell crisis, a cancer patient with

breakthrough pain, and renal colic. At the same

time the instructor needs to address patients who

probably will not be assigned to ESI level 2 due to

pain. Examples include toothache, eye pain, most

headaches, and extremity injuries. This is a great

opportunity to discuss nursing interventions at

triage to minimize or decrease a patient's pain. This

discussion may also prompt the recognition of

standing orders for analgesia at triage, (e.g.,

ibuprofen or opthane).

The next area to address is physiological or

psychological distress. Examples are often the best

method of explaining this concept. Examples of

physiological distress include urinary retention and

priapism. These patients are in acute distress and

require immediate intervention. Many psychiatric

emergencies fall under psychological distress.

Examples include: sexual assault, domestic violence,

paranoia, and manic behavior. The

suicidal/homicidal patient has already been assigned

to ESI level 2 because they are high risk. These

patients should be assigned to ESI level 2 even if

they come in every day stating they are going to

hurt themselves or someone else. This is an

excellent opportunity to review your ED psychiatric

policy.

After discussing the three questions under decision

point B, it is helpful to review all the level-2 criteria

together. Once again a list of examples is helpful.

Decision point C: How many different resources

will this patient consume? It is important to clarify

what is and what is not a resource. Reviewing the

resource table on the back of the algorithm card

usually generates questions and discussion. The

following discussion includes examples of typical

questions the trainer should be prepared to discuss.

Course participant: Why isn't an interpreter a

resource? We use them all the time.

Trainer: It is important for the nurse using ESI not

become overly focused on differentiation of what is

and what is not a resource. ESI is a triage acuity

rating system that evaluates how ill or injured a

patient is on presentation to the emergency

department. The need for an interpreter does not

change that. Inclusion of everything as a resource

will not allow differentiation of triage levels.

Course participant: I don't understand why

crutches aren't a resource. Fitting a patient correctly

and teaching crutch walking takes time.

Trainer: ESI assesses acuity on presentation to the

emergency department, not workload issues. If

crutch walking instructions counted as a resource,

all patients with sprains would now be triaged as ESI

Level 3; x ray and crutch walking. This would clearly

defeat the purpose of ESI.

Course participant: A patient who needs a blood

test and urine test will consume two resources.

Trainer: This is only one resource. For example, a

urinalysis and a urine culture is one resource:

laboratory study. A urinalysis and two blood tests

are one resource: laboratory study. A vaginal culture

and a blood test are one resource: laboratory study.

Course participant: Why isn't a pelvic exam a

resource? They take staff time.

Trainer: As we discussed, a physical exam is not a

resource. For the female patient with abdominal

pain, a pelvic exam is part of that physical exam.

Just like the patient with an eye complaint, a slit

lamp exam is part of the physical exam for that

chief complaint.

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Chapter 7. Implementation of ESITriage
Course participant: I don't understand why security

is not a resource. We use them all the time with our

psychiatric population.

Trainer: Security is used to monitor psychiatric

patients when they have been determined to be a

danger to themselves, others, or the environment or

when they are in acute distress. Because they are

high risk, these patients meet the criteria for ESI

level 2 as high risk. Remember, resources are only

looked at after the triage nurse has determined that

the patient does not meet the criteria for ESI level 1

or 2.

Once the group understands the concept of

resources, it is important to give multiple examples

of patients who would be assigned ESI level 4 and 5.

Before discussing ESI level 3, the trainer needs to

review decision point D.

Decision point D: What are the patient's vital

signs? It is important that participants understand

that the triage nurse should consider the patient’s

vital signs. The triage nurse uses her judgment to

determine whether the patient should be up-triaged

to ESI level 2 based on abnormal vital signs. It is

important to present examples of patients the triage

nurse should up-triage to ESI level 2, as well as

examples of ESI level-3 patients who do not require

up-triage based on abnormal vital signs.

At the end of this segment, the participants should

be quite comfortable with the type of patients that

fall into each ESI level. Reviewing practice cases will

reinforce use of the algorithm and answer many

questions.

Section 3: ESI Practice Cases. After a thorough

description of the ESI algorithm, patient scenarios

are used as a group teaching tool. Chapter 9 lists

many cases specifically written for practice and

intended to simulate an actual triage encounter. The

cases encompass all age groups and the complete

spectrum of acuity. In addition, these cases illustrate

most of the important points in the algorithm. The

instructor reads each case, and the participants are

asked to use the algorithm to assign an ESI level.

Each participant can be given an additional packet

of colored cards, such as those used in the Triage

Game, labeled ESI levels 1 through 5 and be asked

to hold up the appropriate card as each case study is

discussed. The advantage of using the cards is that

participants will begin to notice a higher degree of

agreement with ESI than they observed with the

three-level triage system.

Once everyone in the group has assigned an ESI

level, the trainer can proceed with a step-by-step

review of how the level was determined. The

research group found it helpful to instruct nurses to

always start with decision point A and work through

the algorithm. If the case moves to decision point C,

it is helpful to have the participants verbalize the

expected resources. Many misconceptions can be

cleared up with this strategy.

As previously discussed, staff may initially have

difficulty with what is and what is not a resource

and with determining the number of resources. This

is a perfect opportunity to re-emphasize the

definition of resources in the ESI triage method and

answer the "what about" questions.

Section 4: Competency Cases. One question

managers and educators frequently hear is, “How do

you know your staff is competent to perform

triage?” Chapter 10 was written with this question

in mind. The chapter includes two sets of cases for

each nurse to review and assign a triage acuity

rating using ESI.

Each nurse should complete the competency cases

individually and return them to the trainer to assess

for accuracy. The ED management and educational

staff of each hospital must define parameters for a

passing score prior to assessing staff competency. For

the staff nurse whose score falls below the

acceptable level, re-education is indicated and

competency should be re-assessed at a later date

with different cases. Paper case assessment of

competency only addresses the staff nurse's ability

to assign a triage acuity rating to paper cases. An

evaluation of each triage nurse performing triage

with real patients and using the ESI criteria should

be performed with a triage preceptor or other

designated expert.

Strategies to Assist With

Implementation

Strategies that the ESI triage research group have

found useful for successful ESI implementation

include the following:

• Wall posters, such as the one included in this

handbook, with the ESI algorithm hanging in

triage and clinical areas

• Pocket-sized laminated cards of the ESI algorithm

for every nurse

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Chapter 7. Implementation of ESITriage
• E-mails to remind staff of the upcoming change

• Computer help screens to explain the five ESI

levels during triage data entry

• Posters to address questions about ESI after

implementation

• Informal chart reviews conducted by the trainer,

clinical nurse specialist, or ESI champions

focusing on the finer points of the algorithm

Reinforcement is key to the successful

implementation of ESI. At Brigham and Women's

Hospital and the York Hospitals, the

implementation teams chose to have the algorithm

preprinted on progress notes. For 2 months the

triage nurse was required to use a progress note and

record the patient's chief complaint and circle the

assigned ESI level. The progress note served to make

the triage nurse look at the algorithm each time a

patient was triaged.

Questions and misinterpretation of the finer points

of the algorithm will always arise after

implementation and will need to be addressed with

re-education. After implementation of ESI at

Brigham and Women's Hospital, it was noted that

the staff were not consistently assigning an ESI level

1 to intoxicated and unresponsive patients. This

point was emphasized on a poster in the break room

to bring attention to the problem.

Implementation Day

The implementation team needs to be available

around the clock to support the triage staff, answer

questions, and review triage decisions. It is

important that mistriages be addressed immediately

in a non-threatening manner. Making staff aware

ahead of time that this will be taking place is less

threatening. Reinforcing the efforts of the staff and

being available will help ensure ESI is appropriately

integrated into the ED.

Post-Implementation

Following implementation, it is important that

triage nurses continue to be vigilant when assigning

triage acuity ratings. Many nurses may complain

that more patients are ESI level 2. Triage nurses

should be reminded not to deviate from the original

algorithm but instead to understand the value of ESI

as an operational tool. The staff should understand

that deviations from the algorithm will threaten the

reliability and predictive validity of the tool.

Staff efforts in making a smooth transition to ESI

should be recognized and rewarded. This could

include an article in the hospital newspaper or a

note of thanks to the staff from the ED leadership

team. Successful implementation of ESI requires a

dedicated team that recognizes the degree of change

and effort needed to change triage systems. The

team must be able to develop and carry out a

specific, simple, and realistic plan. The team leader

should have a clear vision, be able to clearly

articulate it, be committed to the ESI

implementation, and be able to energize the other

members of the team and the staff. The team needs

the support of the ED leadership and the resources

necessary to make this planned change. For this

change to be successful there must be broad-based

support beginning with the most senior levels of the

institution.

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

References

Emergency Nursing Core Curriculum Core 6th Edition

(2007). Des Plains: Mosby.

Grol R, Grinshaw J (1999). Evidence-based

implementation of evidence-based medicine. Joint

Commission Journal on Quality Improvement 25(10):503-

513.

Nelson R (2002). Major Theories Supporting Health Care

Informatics. In S. P. Englebardt and R. Nelson (Eds.),

Health care informatics: An interdisciplinary approach.

(3-27). St. Louis, MO: Mosby.

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Chapter 7. Implementation of ESITriage
To maintain reliability of the Emergency Severity

Index (ESI) in an individual institution, it is

important to evaluate how the system is being used.

A natural learning curve will occur and it can be

easy for nurses to fall back into maladaptive triage

habits, or become concerned about triaging “too

many level-2 patients” when the waiting room is

crowded. Additionally, new models of triage intake

are being used by EDs across the United States.

Physicians, nurse practitioners, and physician

assistants may play a role at triage. It is important

that anyone who performs the triage assessment and

is responsible for assigning a triage level upon

presentation be competent in ESI. Continuous

evaluation using standard quality improvement (QI)

methods will help ensure that reliability and validity

of the system is maintained by all.

In 2001, the IOM published the report, “Crossing

the Quality Chasm, A New Health System for the

21st Century,” which defined quality healthcare and

identified six aims to improve the overall quality of

healthcare (Institute of Medicine, 2001). The IOM

defined quality healthcare as, “The degree to which

health services for individuals and populations

increase the likelihood of desired health outcomes

and are consistent with current professional

knowledge.” The six aims of quality include

improving the safety, effectiveness, patientcenteredness, timeliness, efficiency and equity of the

healthcare system and are defined in Table 8-1

(Institute of Medicine, 2001). The triage process is

probably one of the highest risk areas in the ED and

attention to quality monitoring is important. All six

aims can be used to evaluate the triage process.

Emergency departments can structure their quality

improvement (QI) monitoring process around any

or all of the six IOM aims. Specific examples will be

discussed below.

It is also important to choose a system by which the

improvement can be readily assessed. When

choosing a method to evaluate the success or failure

of implementation, it is important to remember

why the triage process was changed. The following

reasons are frequently identified as driving forces to

change existing triage processes:

• Reduction in variation of assigned triage

categories and the ability for everyone to “speak

the same language” regarding triage categories

• Decreased risk of negative outcomes due to

mistriage, particularly while patients are waiting

• The ability to obtain more accurate data to use

for administrative purposes

• The need to move from a three-category to a

five-category triage system to better "sort" the

increasing number of ED patients

• A more accurate description of patient triage

levels and departmental case mix (Wuerz, Milne,

Eitel, Travers, & Gilboy, 2000)

The ultimate goal of ESI implementation is to

accurately capture patient acuity to optimize the

safety of patients in the waiting room by ensuring

that only patients stable to wait are selected to wait.

Patients should be “triaged” according to acuity of

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Chapter 8. Evaluation and Quality Improvement

IOM Aim Definition

Safety Avoiding injuries from care that is intended to help

Effectiveness Providing services based on evidence and avoiding interventions not

likely to benefit

Patient-Centeredness Respectful and responsive to individual patient preferences, needs,

values, in clinical decision making

Timeliness Reducing waits and sometimes harmful delays for those who receive

care

Efficiency Avoiding waste, in particular of equipment, supplies, ideas, energy

Equity Care that does not vary in quality due to personal characteristics (gender,

ethnicity, geographic location, or socio-economic status)

Table 8-1 The Six Institute of Medicine Aims
illness. When a reliable and valid triage system such

as ESI is used, the triage score can then be used as

administrative data to accurately describe

departmental case mix, beyond admission and

discharge status. With this in mind, it is important

that every patient be assigned a triage score on

arrival. The primary goal of conducting QI activities

of the ESI triage system is to maintain reliability and

validity of the system implementation. If triage

nurses are not assigning scores accurately, then the

data cannot be used for any purpose, either real

time or for other administrative purposes. With the

addition of new nurses or other providers at triage,

and natural trends over time, it is important to, at a

minimum, always monitor the accuracy of the triage

level. It is also important to clearly articulate to the

ED staff what is not a goal of ESI triage

implementation. For example, ESI triage alone

cannot decrease the ED length of stay or improve

customer satisfaction with the ED visit.

ESI Triage Quality Indicators

and Thresholds

In any QI plan, it is important to select meaningful

indicators to monitor. Donabedian’s trilogy of

structure, process, and outcome (Table 8.2) can be

used to select the type of indicator (Donabedian,

1992). All indicators can be organized around

Donabedian’s structure and the six IOM aims of

improving quality care: safety, effectiveness, patientcenteredness, timeliness, efficiency, and equity.

Selected examples are included in Tables 8.2 and 8.3.

The tables include indicators specific to monitoring

implementation of ESI and suggest other indicators

which can be used to evaluate other aspects of the

broader triage process.

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Chapter 8. Evaluation and Quality Improvement

Definition (Example)

Structure How care is organized (standing protocols which allow nurses to give

acetaminophen for fever at triage)

Process What is done by caregivers (proportion of patients with fever at triage who

receive acetaminophen at triage)

Outcome Results achieved (fever reduction within one hour after arrival)

Table 8-2. Donabedian’sTrilogy

Structure, Process,

IOM Aims Outcome Indicator Data Source/Method

Safety Structure Implementation of ESI Administrative process

(reliable and valid system)

Process Assignment of correct ESI Review of triage note

triage level (under and over by triage expert

triage levels)

Outcome Review of all negative Review by internal QI

outcomes or triage committee

Table 8.3 PossibleTriage Quality Improvement Indicators

continued
65

Chapter 8. Evaluation and Quality Improvement

Structure, Process,

IOM Aims Outcome Indicator Data Source/Method

Effectiveness Structure Implementation of nurse Administrative policy

initiated analgesic protocol at

triage

Process Proportion of patients with Medical record review

pain eligible for analgesics at

triage that received them

Outcome Decrease in patient reported Medical record review

pain score within 30 minutes

of arrival

PatientCenteredness Process Documentation of a Medical record and

subjective statement by the triage note

patient describing reason for

visit

Timeliness Process Time of arrival to time to Medical record review

physician evaluation

Efficiency Structure Staffing policy to allow Administrative policy

flexibility in RN staffing

pattern to meet the demands

of changing influx of patients

at triage

Process Increased RN’s float to triage Staffing pattern log

during increased influx and reviews

move to other patient care

areas when triage demand

is low

Length of stay per ESI triage Medical record and

level triage note

Admission rates per ESI Medical record and

triage level triage note

Review of all ESI level 4 and Medical record and

5 cases admitted to the triage note

hospital

Equity Process All patients eligible for Medical record and

analgesics at triage according triage note

to the protocol receive them,

regardless of gender or race

Table 8.3 PossibleTriage Quality Improvement Indicators (Continued)
While selecting QIs to review is critical, it is also

important to recognize specific indicators that are

not appropriate to review. For example, the actual

number of resources that were used in providing

care to the patient is NOT an appropriate quality

indicator to monitor. Resources are incorporated in

the ESI algorithm only to help the triage nurse to

differentiate among the large proportion of patients

that are not critically ill. Monitoring the number of

resources used "on the back end" may further

increase the triage nurses' focus on counting

resources, which is not the most important

component of the algorithm. However, knowledge

of the standard of care will serve to increase

accuracy in assessing the resources used for various

presentations, allowing for accurate triage

assignment.

In addition to selecting useful QIs, it is also

important that the ED management team select a

realistic threshold to meet for each indicator. All

indicators do not need to have the same threshold.

For example, when reviewing accuracy of triage

categorization, a realistic goal must be determined.

Should the triage category be correct 100 percent, 90

percent, or 80 percent of the time? Frequently a

threshold of 90 percent is selected. However, the

goals and circumstances of each department may be

unique and should be considered when selecting

each indicator and threshold. For example, the ED

management team might stipulate that, when in

doubt about a patient's triage rating, nurses err on

the side of over-triage. While this approach might

result in some patients being mistriaged as more

acute than they actually are, it is preferable to

risking an adverse event because the patient was

triaged to a less urgent category. In this ED, the

triage accuracy threshold might be 80 percent, with

a goal to keep the mistriage rate at 20 percent.

Finally, it is also important to determine how many

triage indicators should be monitored on an

ongoing basis. It is reasonable to select one or more

indicators. The number of indicators to be

monitored will be determined by available staff

resources and the relationship of ESI indicators to

other QIs that are routinely monitored. It is also

possible to focus on monitoring one aspect of triage

for a period of time and then switch to another

indicator when improvement occurs in the

previously monitored indicator. Various levels of

indicators could also be measured, e.g., shift-level or

a day-of-week level of evaluation.

Accuracy of triage acuity level should probably be

monitored on a continuous basis to evaluate new

triage nurses as well as monitor for trends which

may identify the need for re-education on a

particular aspect of triage. These data can be

reported as the proportion of correctly assigned

triage levels. In addition, a more formal evaluation

of inter-rater reliability can be periodically

conducted by having a proportion (example, 20%)

of randomly selected nurses from all shifts assign

triage levels to pre-selected paper cases It is

recommended that at least 10 paper cases are used

for this type of evaluation. This evaluation will

measure how often the triage nurses in an

individual department would assign triage levels the

same, or would “agree”. This can be a valuable

exercise to conduct on a regular basis (e.g. after key

changes in departmental processes) if resources are

available. It may also be appropriate to evaluate

triage acuity accuracy more often in a department

with higher nurse turnover.

ESI Triage Data Collection

The method of collecting QI data for ESI triage

indicators can be incorporated into the data

collection process for other ED QIs or data can be

collected as a separate process. The method of data

collection will depend on the indicator selected, the

availability of triage experts, and logistic issues such

as accessibility to electronic versus paper ED records.

For example, if “accuracy of triage category” is

selected as a triage QI, a triage expert is needed to

review the triage categories.

Accuracy of the triage category assigned is a critical

indicator and should be monitored when ESI is first

implemented. If it is determined that the institution

wishes to measure ED length of stay or wait times to

see the physician for each ESI triage category, it is

preferable to have access to electronic information

to successfully monitor this indicator. Without

electronic sources, these data are cumbersome to

track and manual calculations most likely result in

error. It is also advisable to monitor medians instead

of means when evaluating any indicator that is a

time measure (e.g. time to physician assessment).

When calculating means, the resultant values are

typically very skewed, and are therefore not an

accurate measure. Standardized time interval

nomenclature is starting to appear in the literature

however, it is important to reiterate that ESI does

not stipulate times to care. Finally, when monitoring

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Chapter 8. Evaluation and Quality Improvement
QIs, it is important to determine how many charts

must be reviewed for each indicator and how

frequently the indicator should be reviewed

(monthly, quarterly, etc.). Selection of the

appropriate number of charts for each indicator will

depend on the particular indicator. If wait times for

each category are reviewed, data will be most

accurate when a large percentage of cases, preferably

all, are reviewed.

Routine evaluation of the accuracy of ESI should

reflect an appropriate number of randomly selected

charts. Cases from different nurses and each shift

and day of the week should be reviewed. Ten

percent of all cases is often selected as an

appropriate number of cases to review. In a busy ED,

this is often an unrealistic number. It is important

for each institution to consider the number of

review staff, their backgrounds, and their

availability. It is also prudent to evaluate ESI rating

accuracy for individual cases where there was a nearmiss or an adverse event related to the triage

process.

When determining the frequency of triage audits,

the institution should consider other departmental

QI activities and try to integrate the review of triage

indicators into the same process and schedule.

It is also very helpful to involve the triage nurses in

data collection. Peer reviews are a useful way to raise

awareness about triage accuracy.

Sharing Results and Making

Improvements

Often, 95 percent of the time and attention to QI

and process improvement activities is given to the

monitoring stage of the process, and little attention

is paid to evaluating the data and determining

process improvements. The “numbers”" are often

posted somewhere and little is done to actually

improve the outcomes. The most important

component of QI is sharing the data and discussing

ways to improve the results. Positive systems

outcome in triage improvement depends on

measuring, analyzing data, and then educating the

staff. All staff should be aware of the triage QI, the

current overall incidence in which the threshold is

met, and the actual goal. For example, if the

accuracy of the triage category is being monitored

and continues to be reported as 60 percent,

intervention is necessary.

Examples of ESI Triage Indicators

The emergency departments described below have

implemented ESI and a QI program. They have

provided examples of how they incorporate triage

indicators into their QI plan.

Hospital 1. At hospital 1, the accuracy of triage

nurses' ESI triage ratings is assessed on a continuous

basis and reported quarterly as one indicator of the

overall ED QI plan. This indicator has been

monitored since ESI was implemented and

continues to be the only triage indicator monitored

to date. Each week, three different nurses randomly

select five charts to review with the ED clinical

nurse specialist (CNS). The assessment team reviews

many different general documentation indicators,

including the accuracy of the ESI triage category.

The CNS is the designated triage expert and

discusses each case with the staff nurse as she

reviews the records. When there is a disagreement,

cases are reported as mistriages for the QI report.

The assessment team collects and retypes all

mistriages as an educational tool that includes an

explanation of the correct triage category. These

cases are compiled in a handout and distributed to

all staff nurses monthly. The assessment team

reviews sixty charts monthly.

Hospital 1 has noted several distinct advantages of

the triage accuracy review:

• All ED staff nurses are aware of the QI indicators;

case examples provide individual nurses with the

opportunity to reflect on their own practice with

similar case scenarios. Staff nurses have the

opportunity to discuss each case with the CNS to

obtain additional insight.

• All nurses benefit from the discussion when the

cases are distributed as a teaching tool.

Hospital 1, like many other EDs, also has excellent

information technology resources that facilitate

quality monitoring of clinical information. The

triage acuity is part of the electronic medical record.

It is possible to track time to physician evaluation

for each triage category. This can be powerful

administrative data. This data is far more powerful

when describing overall ED acuity than using

hospital admission data to describe overall ED

acuity.

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Chapter 8. Evaluation and Quality Improvement
Hospital 2. At hospital 2, several triage indicators

are reviewed on a regular basis. The ESI rating

assigned by the nurse at triage and time data are

recorded in the hospital's computer information

system during the ED visit. The electronic

information is compiled for monthly QI

monitoring. Time data are reported by ESI triage

level, including the following:

• Total ED length of stay

• Time from triage to placement in the ED bed

• Time from triage to being seen by the ED

physician

• Time from placement in the ED bed to discharge

The time data are used for many purposes, such as

monitoring for operational problems that lead to

increased length of stay. The time data prove useful

in addressing issues related to specific patient

populations at hospital 2's ED. For example, the

time data were tracked for psychiatric patients and

subsequently a new policy regarding psychiatric

consults was developed. The policy stipulates

response times for the crisis team to see ED

psychiatry patients and is based on ESI triage level.

Information about the number of patients triaged to

the various areas of the ED (medical urgent care,

minor trauma, pediatrics, acute) is also reported by

ESI triage level on a monthly basis. These data are

used to make operational decisions, such as the time

of day that medical urgent care and minor trauma

services are offered.

The accuracy of triage nurses’ ESI ratings is reviewed

as part of the QI program at hospital 2. The initial

review was conducted during the first few months

after implementation of the ESI. The nurse educator

reviews a random sample of ED charts on a regular

basis to assess the accuracy of the triage nurses’ ESI

ratings. Individual nurses receive feedback and

trends are reported to the entire nursing staff.

Accuracy of triage ratings are also reviewed as an

indicator at hospital 2, through a monthly peer

chart review process. Each nurse selects two random

ED charts per month and reviews many aspects of

nurses’ documentation, including the ESI triage

rating. The review is forwarded to nursing leadership

for followup with individual nurses. Any important

trend identified is communicated to the entire staff.

Another QI effort at hospital 2 is the review of all

ESI level-3 patients triaged to the medical urgent

care (fast track) area. The nurse manager receives a

monthly report, compiled with electronic data from

the hospital computer system, of all ESI level-3

patients triaged to medical urgent care and all ESI

level-4 and level-5 patients triaged to the ED.

Though the department has a guideline that ESI

level-4 and level-5 adult patients are primarily

triaged to medical urgent care or minor trauma, and

ESI levels-1, -2, and -3 adult patients are primarily

triaged to the acute ED, the triage nurse is allowed

discretion in triaging these patients. The ongoing

review of the ESI level-3 patients sent to medical

urgent care allows the leadership team to review the

accuracy of the nurses' triage decisions.

Hospital 3. At hospital 3 the manager assigns

experts to review triage categories. The manager and

clinical coordinators review charts identified by

peers as potential mistriages. The expert group

reviews the chart and discusses it with the triage

nurse. The team of experts spot check charts

frequently. If a trend is noticed, the expert group

will post the case so that all staff can learn from it.

Hospital 4. At hospital 4, the manager created a

log after initiation of the ESI triage system. The

triage nurse logged the patient name, triage nurse

name, triage level and rationale and resources for

each patient triaged. The management team

reviewed each chart for triage category accuracy

either while the patient was in the department or

the next day. The management did this for the first

2 weeks and again in 3 months. The purpose of this

monitoring activity was to assess the triage nurses’

understanding of resource definitions.

Hospital 5. Hospital 5's strategic plan called for the

hospital to increase the number of trauma and

stroke patients they would accept from outlying

hospitals. Most of these patients were emergencydepartment-to-emergency-department transfers.

Many of these patients arrived intubated and others

were intubated on arrival. The staff felt that the

acuity of the ED patient population was rising

quickly. Nursing leadership chose to look at case

mix data (the number of patients in each ESI

category) for 1 year and was able to make

adjustments to staffing to cover increases in patient

acuity. This is an excellent example of why it is so

important that every patient, including traumas and

cardiac arrest patients, receive an accurate triage

category. This allows each hospital to benchmark

their case mix data with other institutions. These

patients are clearly not “triaged” at “triage,” but

they represent an important group of patients seen

in the ED. If the primary nurse does not assign a

triage category to these patients, the ED case mix

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Chapter 8. Evaluation and Quality Improvement
data will significantly under-represent the higher

acuity of the department.

It is important for the emergency department

nursing leadership to implement a QI plan. The

plan should generate meaningful data that can be

shared with the ED staff on a regular basis. Issues

with individual triage nurses must be promptly

identified and education provided. Larger trends

also must be identified rapidly and accompanied by

an appropriate response including communication

with senior level leadership to plan for change. The

members of the ESI research team are repeatedly

asked about quality assurance and our suggestion is

to keep it simple, relevant, and meaningful.

Note: Appendix A of this handbook includes

frequently asked questions and post-test

assessment questions for Chapters 2 through

8. These sections can be incorporated into a

locally-developed ESI training course.

References

Donabedian A (1992). Quality assurance: Structure,

process and outcomes. Nursing Standard. 11(Suppl

QA):4-5.

Institute of Medicine (2001). Crossing the quality chasm: A

new health system for the 21st century. Washington, DC:

National Academies Press.

Wuerz R., Milne LW, Eitel D R, Travers D, Gilboy N (2000).

Reliability and validity of a new five-level triage

instrument. Academic Emergency Medicine. 7(3):236-242.

69

Chapter 8. Evaluation and Quality Improvement
The cases in this chapter are provided to give a

nurse the opportunity to practice categorizing

patients using the Emergency Severity Index (ESI).

Please read each case and, based on the information

provided, assign a triage acuity rating using ESI.

Answers to and discussions of these cases are

presented at the end of the chapter.

Practice Cases

1. “I was taking my contacts out last night, and I

think I scratched my cornea,” reports a 27-yearold- female. “I’m wearing these sunglasses

because the light really bothers my eyes.” Her

right eye is red and tearing. She rates her pain

as 6/10. Vital signs are within normal limits.

2. EMS presents to the ED with an 18-year-old

female with a suspected medication overdose.

Her college roommates found her lethargic and

“not acting right,” so they called 911. The

patient has a history of depression. On exam,

you notice multiple superficial lacerations to

both wrists. Her respiratory rate is 10, and her

SpO2 on room air is 86 percent.

3. EMS arrived with an unresponsive 19-year-old

male with a single self-inflicted gunshot wound

to the head. Prior to intubation, his Glasgow

Coma Scale score was 3.

4. “I ran out of my blood pressure medicine, and

my doctor is on vacation. Can someone here

write me a prescription?” requests a 56-year-old

male with a history of HTN. Vital signs: BP

128/84, HR 76, RR 16, T 97 ̊F.

5. A 41-year-old male involved in a bicycle

accident walks into the emergency department

with his right arm in a sling. He tells you that

he fell off his bike and landed on his right arm.

His is complaining of pain in the wrist area and

has a 2-centimeter laceration on his left elbow.

“My helmet saved me,” he tells you.

6. A 32-year-old female presents to the emergency

department complaining of shortness of breath

for several hours. No past medical history,

+smoker. Vital signs: RR 32, HR 96, BP 126/80,

SpO2 93% on room air, T 98.6 ̊F. No allergies,

current medications include vitamins and birth

control pills.

7. “I just turned my back for a minute,” cried the

mother of a 4-year-old. The child was pulled

out of the family pool by a neighbor who

immediately administered mouth-to-mouth

resuscitation. The child is now breathing

spontaneously but continues to be

unresponsive. On arrival in the ED, vital signs

were: HR 126, RR 28, BP 80/64, SpO2 96% on a

non-rebreather.

8. A normal healthy 7-year-old walks into the

emergency department accompanied by his

father, who reports that his son woke up

complaining of a stomach ache. “He refused to

walk downstairs and is not interested in eating

or playing.” The child vomits at triage. Vital

signs: T 100.4 ̊F, RR 22, HR 88, BP 84/60,

SpO2100%. Pain 6/10.

9. A 6-year-old male tells you that he was running

across the playground and fell. He presents

with a 3-centimeter laceration over his right

knee. Healthy, no medications and no allergies,

immunizations are up to date.

10. “I slipped on the ice, and I hurt my wrist,”

reports a 58-year-old female with a history of

migraines. There is no obvious deformity. Vital

signs are within normal limits, and she rates

her pain as 5/10.

11. A 4-year-old female is transported to the ED

following a fall off the jungle gym at a

preschool. A fall of 4 feet. A witness reports

that the child hit her head and was

unconscious for a couple of minutes. On arrival

you notice that the child is crying and asking

for her mother. Her left arm is splinted. Vital

signs: HR 162, RR 38.

12. A 60-year-old man requests to see a doctor

because his right foot hurts. On exam the great

toe and foot skin is red, warm, swollen, and

tender to touch. He denies injury. past medical

history includes type 2 diabetes, and psoriasis.

Vital signs: T 99.4 ̊F, RR 18, HR 82, BP 146/70,

SpO2 99%.

13. A 52-year-old female requests to see a doctor for

a possible urinary tract infection (UTI). She is

complaining of dysuria and frequency. She

denies abdominal pain or vaginal discharge. No

allergies, takes vitamins, and has no significant

past medical history. Vital signs: T 97.4 ̊F, HR

78, RR 14, BP 142/70.

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Chapter 9. Practice Cases
14. “I called my pediatrician, and she told me to

bring him in because of his fever,” reports the

mother of a 2-week-old. Vital signs: T 101 ̊F, HR

154, RR 42, SpO2 100%. Uncomplicated,

vaginal delivery. The baby is acting

appropriately.

15. “My right breast is so sore, my nipples are

cracked, and now I have a fever. Do you think I

will have to stop nursing my baby?” asks a

tearful 34-year-old female. She is 3 months post

partum and has recently returned to work parttime. Vital signs: T 102.8 ̊F, HR 90, RR 18, BP

108/60, pain 5/10. No past medical history,

taking multivitamins, and is allergic to

penicillin.

16. Paramedics arrive with a 16-year-old

unrestrained driver who hit a tree while

traveling at approximately 45 miles per hour.

The passenger side of the car had significant

damage. The driver was moaning but moving

all extremities when help arrived. His initial

vital signs were BP 74/50, HR 132, RR 36, SPO2

99%, T 98.6 ̊F.

17. EMS arrives with a 45-year-old woman with

asthma who has had a cold for week. She

started wheezing a few days ago and then

developed a cough and a fever of 103. Vital

signs: T 101.6 ̊F, HR 92, RR 24, BP 148/86, SpO2

97%.

18. “I have an awful toothache right here,” a 38-

year-old male tells you as he points to his right

lower jaw. “I lost my dental insurance, so I

haven’t seen a dentist for a couple of years.” No

obvious swelling is noted. Vital signs are within

normal limits. Pain 9/10.

19. “I think I have food poisoning,” reports an

otherwise healthy 33-year-old female. “I have

been vomiting all night, and now I have

diarrhea.” The patient admits to abdominal

cramping that she rates as 5/10. She denies

fever or chills. Vital signs: T 96.8 ̊F, HR 96, RR

16, BP 116/74.

20. “My migraine started early this morning, and I

can’t get it under control. I just keep vomiting.

Can I lie down somewhere?” asks a 37-year-old

female. Past medical history migraines, no

allergies. Pain 6/10, T 98 ̊F, RR 20, HR 102, BP

118/62, SpO2 98%.

21. “I cut my finger trying to slice a bagel,” reports

a 28-year-old healthy male. A 2-centimeter

laceration is noted on the left first finger.

Bleeding is controlled. Vital signs are within

normal limits. His last tetanus immunization

was 10 years ago.

22. “The smoke was so bad; I just couldn’t

breathe.” reports a 26-year-old female who

entered her burning apartment building to try

to rescue her cat. She is hoarse and

complaining of a sore throat and a cough. You

notice that she is working hard at breathing.

History of asthma; uses inhalers when needed.

No known drug allergies. Vital signs: T 98 ̊F, RR

40, HR 114, BP 108/74.

23. “I’m 7 weeks pregnant, and every time I try to

eat something, I throw up,” reports a 27-yearold female. “My doctor sent me to the

emergency department because he thinks I am

getting dehydrated. T 97 ̊F, RR 18, HR 104, BP

104/68, SpO2 99%. Pain 0/10. Lips are dry and

cracked.

24. “I have this aching pain in my left leg,” reports

an obese 52-year-old female. “The whole ride

home, it just ached and ached.” The patient

tells you that she has been sitting in a car for

the last 2 days. “We drove my daughter to

college, and I thought it was the heat getting to

me.” She denies any other complaints. Vital

signs: BP 148/90, HR 86, RR 16, T 98 ̊F.

25. EMS arrives with an 87-year-old male who fell

and hit his head. He is awake, alert, and

oriented and remembers the fall. He has a past

medical history of atrial fibrillation and is on

multiple medications, including warfarin. His

vital signs are within normal limits.

26. “I have this rash in my groin area,” reports a

20-year-old healthy male. “I think it’s jock rot,

but I can’t get rid of it.” Using over the counter

spray, No known drug allergies. Vital Signs: T

98 ̊F, HR 58, RR 16, BP 112/70.

27. EMS arrives with a 17-year-old restrained driver

involved in a high-speed motor vehicle crash.

The patient is immobilized on a backboard and

is complaining of abdominal pain. He has

multiple lacerations on his left arm. Vital signs

prior to arrival: BP 102/60; HR 86, RR 28, SpO2

96%.

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Chapter 9. Practice Cases
28. “I just need another prescription for pain

medication. I was here 10 days ago and ran

out,” a 27-year-old male tells you. “I hurt my

back at work, and it’s still bothering me.”

Denies numbness, tingling, or bladder or bowel

issues. Vital signs are within normal limits. Pain

10+/10.

29. EMS arrives with a 32-year-old female who fell

off a stepladder while cleaning her first-floor

gutters. She has an obvious open fracture of her

right lower leg. She has +2 pedal pulse. Her toes

are warm, and she is able to wiggle them.

Denies past medical history medications, or

allergies. Vital signs are within normal limits for

her age.

30. The medical helicopter is en route to your

facility with a 16-year-old male who was

downhill skiing and hit a tree. Bystanders

report that he lost control and hit his head. He

was intubated at the scene and remains

unresponsive.

31. A healthy middle-aged man presents to the

emergency department with his left hand

wrapped in a bloody cloth. “I was using my

table saw, and my hand slipped. I think I lost of

couple of fingertips.” No past medical history,

no med or allergies. Vital signs are within

normal limits. Pain 6/10.

32. A 27-year-old female wants to be checked by a

doctor. She has been experiencing low

abdominal pain (6/10) for about 4 days. This

morning, she began spotting. She denies

nausea, vomiting, diarrhea, or urinary

symptoms. Her last menstrual period was 7

weeks ago. past medical history: previous

ectopic pregnancy. Vital signs: T.98 ̊F, HR 66, RR

14, BP 106/68.

33. “My right leg is swollen, and my calf hurts,”

reports a 47-year-old morbidly obese female

sitting in a motorized scooter. The patient

denies chest pain or shortness of breath, but

admits to a history of type 2 diabetes and HTN.

Vital signs: T 98 ̊F, RR 24, HR 78, BP 158/82,

SpO2 98%. Pain 6/10.

34. “I think my son has swimmer’s ear. He spends

half the day in the pool with his friends, so I

am not surprised,” the mother of a 10-year-old

boy tells you. The child has no complaints

except painful, itchy ears. Vital signs: T 97 ̊F,

HR 88, RR 18, BP 100/68.

35. EMS presents with a 54-year-old female with

chronic renal failure who did not go to dialysis

yesterday because she was feeling too weak. She

tells you to look in her medical record for a list

of her current medications and past medical

history. Her vital signs are all within normal

limits.

36. A 68-year-old female presents to the ED with

her right arm in a sling. She was walking out to

the mailbox and slipped on the ice. “I put my

arm out to break my fall. I was lucky I didn’t

hit my head.” Right arm with good circulation,

sensation, and movement, obvious deformity

noted. past medical history: arthritis,

medications, ibuprofen, No known drug

allergies. Vital signs within normal limits. She

rates her pain as 6/10.

37. “I just don’t feel right,” reports a 21-year-old

female who presented in the ED complaining of

a rapid heart rate. “I can barely catch my

breath, and I have this funny pressure feeling in

my chest.” HR is 178 and regular, RR 32, BP

82/60. Her skin is cool and diaphoretic.

38. Concerned parents arrive in the ED with their

4-day-old baby girl who is sleeping peacefully

in the mother’s arms. “I went to change her

diaper,” reports the father, “and I noticed a

little blood on it. Is something wrong with our

daughter?” The mother tells you that the baby

is nursing well and weighed 7 lbs., 2 oz. at

birth.

39. “I was using my chainsaw without safety

goggles, and I think I got some sawdust in my

left eye. It hurts and it just won’t stop tearing,”

reports a healthy 36-year-old male. Vital signs

are within normal limits.

40. “It hurts so much when I urinate,” reports an

otherwise healthy 25-year-old. She denies fever,

chills, abdominal pain, or vaginal discharge.

Vital signs: T 98.2 ̊F, HR 66, RR 14, BP 114/60.

41. “I was smoking a cigarette and had this

coughing fit, and now I feel short of breath,”

reports a tall, thin 19-year-old man. No past

medical history, No meds or allergies, Vital

signs: T 98 ̊F, HR 102, RR 36, BP 128/76, SpO2

92%. Pain 0/10.

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Chapter 9. Practice Cases
42. A 26-year-old female is transported by EMS to

the ED because she experienced the sudden

onset of a severe headache that began after she

moved her bowels. She is 28 weeks pregnant.

Her husband tells you that she is healthy, takes

only prenatal vitamins, and has no allergies.

On arrival in the ED, the patient is moaning

and does not respond to voice. Emergency

medical technicians (EMTs) tell you that she

vomited about 5 minutes ago.

43. “I think I’m having a stroke,” reports an

anxious 40-year-old female. “I looked in the

mirror this morning, and the corner of my

mouth is drooping and I can’t close my left eye.

You have to help me, please.” No past medical

history, no meds. Vital signs all within normal

limits.

44. An 88-year-old female is brought to the ED by

EMS. This morning, she had an episode of

slurred speech and weakness of her left arm

that lasted about 45 minutes. She has a history

of a previous stroke, and she takes an aspirin

every day. She is alert and oriented with clear

speech and equal hand grasps.

45. “It is like I have my period. I went to the

bathroom, and I am bleeding. This is my first

pregnancy, and I am scared. Do you think

everything is OK?” asks a 26-year-old healthy

female. Vital signs: BP 110/80, HR 72, RR 18,

SpO2 99%, T 98.6 ̊F. She describes the pain as

crampy, but rates it as “1” out of 10.

46. A 42-year-old male presents to triage with a

chief complaint of “something in his right

eye.” He was cutting tree limbs and thinks

something went into his eye. No past medical

history, no allergies, no medications. On exam,

his right eye is reddened and tearing. Pain is

4/10.

47. “Our pediatrician told us to bring the baby to

the emergency department to see a surgeon and

have some tests. Every time I feed him, he

vomits and it just comes flying out,” reports the

mother of a healthy appearing 3–week-old.

“None of my other kids did this.” Normal

vaginal delivery. Vital signs are within normal

limits.

48. “I suddenly started bleeding and passing clots

the size of oranges,” reports a pale 34-year-old

who is 10 days post partum. “I never did this

with my other two pregnancies. Can I lie down

before I pass out?” Vital signs: BP 86/40, HR

132, RR 22, SpO2 98%.

49. “I have had a cold for a few days, and today I

started wheezing. When this happens, I just

need one of those breathing treatments,”

reports a 39-year-old female with a history of

asthma. T 98 ̊F, RR 22, HR 88, BP 130/80, SpO2

99%, No meds, no allergies.

50. “I was seen in the ED last night for my

fractured wrist. The bone doctor put this cast

on and told me to come back if I had any

problems. As you can see, my hand is really

swollen and the cast is cutting into my fingers.

The pain is just unbearable.” Circulation,

sensation, and movement are decreased.

51. A 58-year-old male collapsed while shoveling

snow. Bystander CPR was started immediately;

he was defibrillated once by the paramedics

with the return of a perfusing rhythm. The

hypothermic cardiac arrest protocol was

initiated prehospital, and he presents with cold

normal saline infusing.

52. “My doctor told me to come to the ED. I had a

gastric bypass 3 weeks ago and have been doing

fine, but today I started vomiting and having

this belly pain.” The patient, an obese 33-yearold female, rates her pain as 6/10. Vital signs:

BP 126/70, HR 76, RR 14, T 98 ̊F.

53. “I had a baby 5 weeks ago, and I am just

exhausted. I have seen my doctor twice, and he

told me I wasn’t anemic. I climb the stairs, and

I am so short of breath when I get to the top

that I have to sit down, and now my ankles are

swollen. What do you think is wrong with

me?” asks a 23-year-old obese female.

54. “I am so embarrassed!” An 18-year-old tells you

that she had unprotected sex last night. “My

friend told me to come to the hospital because

there is a pill I can take to prevent pregnancy.”

The patient is healthy, takes no medications,

and has no allergies. Vital signs: T 97 ̊F, HR 78,

RR 16, BP 118/80.

55. A 76-year-old male requests to see a doctor

because his toenails are hard. Upon further

questioning, the triage nurse ascertains that the

patient is unable to cut his own toenails. He

denies any breaks in the skin or signs of

infection. He has a history of chronic

obstructive pulmonary disease and uses several

metered-dose inhalers. His vital signs are

normal for his age.

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Chapter 9. Practice Cases
56 EMS arrives with a 42-year-old male who called

911 because of dizziness and nausea every time

he tries to move. The patient states, “I feel okay

when I lie perfectly still, but if I start to sit up,

turn over, or move my head, the room starts to

spin and I have to throw up.” No past medical

history. Vital signs: T 97.2 ̊F, RR 16, HR 90, BP

130/82, SpO2 99%. Pain 0/10.

57. This patient is the restrained driver of an SUV

involved in a high-speed, multicar accident.

Her only complaint is right thigh pain. She has

a laceration on her left hand and an abrasion

on her left knee. Vital signs: BP 110/74, HR 72,

RR 16, no medications, no allergies, no past

medical history.

58. “My wife called 911 because my internal

defibrillator gave me a shock this morning

when I was eating breakfast. Really scared me! I

saw my doctor a few days ago, and he changed

some of my medications. Could that be why

that happened?” The patient has a significant

cardiac history and reports taking multiple

medications, including amiodarone. Vital signs:

T 98.5 ̊F, RR 20, HR 90, BP 120/80.

59. “Nurse, I have this pressure in my chest that

started about an hour ago. I was shoveling that

wet snow, and I may have overdone it,” reports

an obese 52-year-old male. He tells you his pain

is 10 out of 10 and that he is nauseous and

short of breath. His skin is cool and clammy.

Vital signs: BP 86/50, HR 52 and irregular.

60. “My sister has metastatic breast cancer, and her

doctor suggested that I bring her in today to

have more fluid drained off her lungs.” The

fluid buildup is making it harder for her to

breathe. The patient is a cachectic 42-year-old

female on multiple medications. Vital signs:

T 98.6 ̊F, RR 34, SpO2 95%, HR 92, BP 114/80.

61. A 58-year-old male presents to the emergency

department complaining of left lower-quadrant

abdominal pain for 3 days. He denies nausea,

vomiting, or diarrhea. No change in appetite.

past medical history HTN. Vital signs: T 100 ̊F,

RR 18, HR 80, BP 140/72, SpO2 98%. Pain 5/10.

62. “I think he has another ear infection,” the

mother of an otherwise healthy 2-year-old tells

you. “He’s pulling on his right ear.” The child

has a tympanic temperature of 100.2 ̊F and is

trying to grab your stethoscope. He has a

history of frequent ear infections and is

currently taking no medication. He has a

normal appetite and urine output, according to

the mother.

63. “My son needs a physical for camp,” an

anxious mother tells you. “I called the clinic,

but they can’t see him for 2 weeks and camp

starts on Monday.” Her son, a healthy 9-yearold, will be attending a summer day camp.

64. “Last night I had sex, and we used a condom

but it broke. I just don’t want to get pregnant,”

a teary 18-year-old female tells you. Vital signs

are within normal limits.

65. “I have a fever and a sore throat. I have finals

this week, and I am scared this is strep,” reports

a 19-year-old college student. She is sitting at

triage drinking bottled water. No past medical

history, medications: birth control pills, no

allergies to medications. Vital signs: T 100.6 ̊F,

HR 88, RR 18, BP 112/76.

66. “This 84-year-old male passed out in the

bathroom,” reports the local paramedics.

“When we arrived he was in a third-degree

heart block with a rate in the 20s and a blood

pressure in the 60s. We began externally pacing

him at a rate of 60 with an MA in the 50s. He is

now alert, oriented, and asking to see his wife.”

67. A 16-year-old male wearing a swimsuit walks

into the ED. He explains that he dove into a

pool, and his face struck the bottom. You

notice an abrasion on his forehead and nose as

he tells you that he needs to see a doctor

because of tingling in both hands.

68. A-25-year-old female presented to the

emergency department because of moderate

lower abdominal pain with a fever and chills.

Two days ago, the patient had a therapeutic

abortion at a local clinic. The patient reports

minimal vaginal bleeding, Vital signs: T 100.8 ̊F,

RR 20, HR 92, BP 118/80, SpO2 99%. Pain 5/10.

69. EMS radios in that they are in route with a 17-

year-old with a single gunshot wound to the

left chest. On scene the patient was alert,

oriented and had a BP of 82/palp. Two largebore IVs were immediately inserted. Two

minutes prior to arrival in the ED, the patient’s

HR was 130 and BP was 78/palp.

70. “I was at a family reunion, and we were playing

baseball. One of my nephews hit the ball so

hard, and I tried to catch it, missed, and it hit

me right in the eye. My vision is fine. It just

hurts,” reports a 34-year-old healthy female.

Vital signs are within normal limits. There are

no obvious signs of trauma to the globe, only

redness and swelling in the periorbital area. The

patient denies loss of consciousness.

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Chapter 9. Practice Cases
71. A 76-year-old male is brought to the ED

because of severe abdominal pain. He tells you,

“It feels like someone is ripping me apart.” The

pain began about 30 minutes prior to

admission, and he rates the intensity as 20/10.

He has HTN, for which he takes a diuretic. No

allergies. The patient is sitting in a wheelchair

moaning in pain. His skin is cool and

diaphoretic. Vital signs: HR 122, BP 88/68, RR

24, SPO2 94%.

72. The patient states that she is 6 weeks post

laparoscopic gastric bypass. Two days ago, she

began to have abdominal pain with nausea and

vomiting of pureed food. She reports a decrease

in her fluid intake and not being able to take

her supplements because of vomiting. Vital

signs: T 97.8 ̊F, RR 20, HR 90, BP 110/70, SpO2

99%. Pain 4/10.

73. A 26-year-old female walks into the triage room

and tells you she needs to go into detox again.

She has been clean for 18 months but started

using heroin again 2 weeks ago when her

boyfriend broke up with her. She had called

several detox centers but was having no luck

finding a bed. She denies suicidal or homicidal

ideation. She is calm and cooperative.

74. “My throat is on fire,” reports a 19-year-old

female. It started a couple of days ago, and it

just keeps getting worse. Now I can barely

swallow, and my friends say my voice is

different. I looked in the mirror, and I have this

big swelling on one side of my throat.” No past

medical history , no meds, no allergies. Vital

signs: T 101.6 ̊F, RR24, HR 92, BP 122/80, SpO2

100% on room air.

75. “My doctor told me to come to the ED. He

thinks my hand is infected,” a 76-year-old

female with arthritis, chronic renal failure, and

diabetes tells you. She has an open area on the

palm of her hand that is red, tender, and

swollen. She hands you a list of her

medications and reports that she has no

allergies. She is afebrile. Vital signs: HR 72, RR

16, BP 102/60.

76. Police escort a disheveled 23-year-old

handcuffed male into the triage area. The police

report that the patient had been standing in

the middle of traffic on the local highway

screaming about the end of the world. The

patient claims that he had been sent from Mars

as the savior of the world. He refuses to answer

questions or allow you to take vital signs.

77. “My dentist can’t see me until Monday, and my

tooth is killing me. Can’t you give me

something for the pain?” a healthy 38-year-old

male asks the triage nurse. He tells you the pain

started yesterday, and he rates his pain as

10/10. No obvious facial swelling is noted.

Allergic to penicillin. Vital signs: T 99.8 ̊F, HR

78, RR 16, BP 128/74.

78. “I have been on antibiotics for 5 days for

mastitis. I am continuing to nurse my baby, but

I still have pain and tenderness in my right

breast. Now there is this new reddened area,” a

34-year-old new mother tells you. The patient

reports having a fever, chills, and just feeling

run down. T 102.2 ̊F, RR 20, HR 990, BP 122/80,

SpO2 98%. Pain 6/10.

79. A young male walks into triage and tells you

that he has been shot. As he rolls up the left leg

of his shorts, you notice two wounds. He tells

you that he heard three shots. He is alert and

responding appropriately to questions. Initial

Vital signs: T 98.2 ̊ F, HR 78, RR 16, BP 118/80.

80. An 82-year-old resident of a local assisted living

facility called 911 because of excruciating

generalized abdominal pain and vomiting that

started a few hours ago. The woman is moaning

in pain but is still able to tell you that she had

a heart attack 6 years ago. Vital signs: T 98 ̊F, RR

28, HR 102, BP 146/80, SpO2 98%. Pain 10/10.

81. “I should have paid more attention to what I

was doing,” states a 37-year-old carpenter who

presents to the ED with a 3-centimeter

laceration to his right thumb. The thumb is

wrapped in a clean rag. “I know I need a

tetanus shot,” he tells you. BP 142/76, RR 16,

T 98.6 ̊F.

82. “My son woke me up about 3 hours ago

complaining of a right earache. I gave him

some acetaminophen but it didn’t help,” the 4-

year-old’s mother tells you. No fever, other vital

signs within normal limits for age.

83. “How long am I going to have to wait before I

see a doctor?” asks a 27-year-old female with a

migraine. The patient is well known to you and

your department. She rates her pain as 20/10

and tells you that she has been like this for 2

days. She vomited twice this morning. past

medical history: migraines, no allergies,

medications include Fioricet.

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Chapter 9. Practice Cases
84. EMS arrives with a 75-year-old male with a selfinflicted 6-centimeter laceration to his neck.

Bleeding is currently controlled. With tears in

his eyes, the patient tells you that his wife of 56

years died last week. Health, No known drug

allergies, baby ASA per day, BP 136/82, HR 74,

RR 18, SpO2, 98% RA.

85. “My mother is just not acting herself,” reports

the daughter of a 72-year-old female. She is

sleeping more than usual and complains that it

hurts to pee.” Vital signs: T 100.8 ̊F, HR 98, RR

22, BP 122/80. The patient responds to verbal

stimuli but is disoriented to time and place.

86. EMS arrives in the ED with a 57-year-old female

with multiple sclerosis. She is bedridden, and

her family provides care in the home. The

family called 911 because her Foley catheter

came out this morning. No other complaints.

Vital signs are within normal range, currently

on antibiotics for a UTI.

87. “I got my belly button pierced a month ago

and now it hurts so bad,” reports a 19-year-old

healthy college student who is accompanied by

her roommate. They are chatting about plans

for the evening. The area is red, tender, and

swollen, and pus is oozing from around the

site. Vital signs: T 100 ̊F, HR 74, RR 18, BP

102/70, SpO2 100%. Pain 8/10.

88. “Why the hell don’t you just leave me alone?”

yells a 73-year-old disheveled male who was

brought to the ED by EMS. He was found

sitting on the curb drinking a bottle of vodka

with blood oozing from a 4-centimeter

forehead laceration. He is oriented to person,

place, and time and has a Glasgow Coma Scale

score of 14.

89. “This is so embarrassing,” reports a 42-year-old

male. “We were having incredible sex, and I

heard a crack. Next thing you know, my penis

was flaccid, and I noticed some bruising.” The

pain is “unbelievable,” 20/10. No meds, No

known drug allergies.

90. “I have this infection in my cuticle,” reports a

healthy 26-year-old female. “It started hurting 2

days ago, and today I noticed the pus.” The

patient has a small paronychia on her right

second finger. No known drug allergies.

T 98.8 ̊F, RR 14, HR 62, BP 108/70.

91. A 20-year-old male presents to the ED after

being tackled while playing football. He has an

obvious dislocation of his left shoulder and

complains of 10/10, severe pain. Neurovascular

status is intact, and vital signs are within

normal limits.

92. A 72-year-old female with obvious chronic

obstructive pulmonary disease and increased

work of breathing is wheeled into triage.

Between breaths, she tells you that she “is

having a hard time breathing and has had a

fever since yesterday.” The SpO2 monitor is

alarming and displaying a saturation of 79

percent.

93. A 17-year-old handcuffed male walks into the

ED accompanied by the police. The parents

called 911 because their son was out of control:

verbally and physically acting out and

threatening to kill the family. He is cooperative

at triage and answers your questions

appropriately. He has no past medical history or

allergies and is currently taking no medications.

Vital signs are within normal limits.

94. “I think I need a tetanus shot,” a 29-year-old

female tells you. “I stepped on a rusty nail this

morning, and I know I haven’t had one for

years.” No past medical history, No known drug

allergies, no medications.

95. A 63-year-old cachectic male is brought in from

the local nursing home because his feeding

tube fell out again. The patient is usually

unresponsive. He has been in the nursing home

since he suffered a massive stroke about 4 years

ago.

96. A 28-year-old male presents to the ED

requesting to be checked. He has a severe

shellfish allergy and mistakenly ate a dip that

contained shrimp. He immediately felt his

throat start to close, so he used his EpiPen. He

tells you that he feels okay. No wheezes or rash

noted. Vital signs: BP 136/84, HR 108, RR 20,

SpO2 97%, T 97 ̊F.

97. You are trying to triage an 18-month-old whose

mother brought him in for vomiting. The

toddler is very active and trying to get off his

mother’s lap. To distract him, the mother hands

him a bottle of juice, which he immediately

begins sucking on. The child looks well

hydrated and is afebrile.

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Chapter 9. Practice Cases
98. “He was running after his brother, fell, and cut

his lip on the corner of the coffee table. There

was blood everywhere,” recalls the mother of a

healthy 19-month-old. “He’ll never stay still for

the doctor.” You notice that the baby has a 2-

centimeter lip laceration that extends through

the vermilion border. Vital signs are within

normal limits for age.

99. A 44-year-old female is retching continuously

into a large basin as her son wheels her into

the triage area. Her son tells you that his

diabetic mother has been vomiting for the past

5 hours, and now it is “just this yellow stuff.”

“She hasn’t eaten or taken her insulin,” he tells

you. No known drug allergies. Vital signs: BP

148/70, P 126, RR 24.

100. EMS arrives with a 76-year-old male found on

the bathroom floor. The family called 911

when they heard a loud crash in the bathroom.

The patient was found in his underwear, and

the toilet bowl was filled with maroon-colored

stool. Vital signs on arrival: BP 70/palp, HR

128, RR 40. His family tells you he has a

history of atrial fibrillation and takes a “little

blue pill to thin his blood.”

Practice Cases Answers and

Discussion

1. ESI level 5: No resources. This patient will

need an eye exam and will be discharged to

home with prescriptions and an appointment

to follow up with an ophthalmologist.

2. ESI level 1: Requires immediate

lifesaving intervention. The patient’s

respiratory rate, oxygen saturation, and

inability to protect her own airway indicate the

need for immediate endotracheal intubation.

3. ESI level 1: Requires immediate

lifesaving intervention. The patient is

unresponsive and will require immediate

lifesaving interventions to maintain airway,

breathing, circulation, and neuro status;

specifically, the patient will require immediate

confirmation of endotracheal tube placement.

4. ESI level 5: No resources. The patient needs

a prescription refill and has no other medical

complaints. His blood pressure is controlled

with his current medication. If at triage his

blood pressure was 188/124 and he complained

of a headache,, then he would meet the criteria

for a high-risk situation and be assigned to ESI

level 2. If this patient’s BP was elevated and the

patient had no complaints, he or she would

remain an ESI level 5. The blood pressure would

be repeated and would most likely not be

treated in the ED or treated with PO

medications.

5. ESI level 3: Two or more resources. At a

minimum, this patient will require an x ray of

his right arm and suturing of his left elbow

laceration.

6. ESI level 2: High risk. This 32-year-old

female with new-onset shortness of breath is on

birth control pills. She is a smoker and is

exhibiting signs and symptoms of respiratory

distress (SpO2 and respiratory rate.) Based on

history and signs and symptoms, a pulmonary

embolus, as well as other potential causes for

her respiratory distress, must be ruled out.

7. ESI level 1: Unresponsive. This 4-year-old

continues to be unresponsive. The patient will

require immediate lifesaving interventions to

address airway, breathing, and circulation.

8. ESI level 3: Two or more resources. At a

minimum, this child will need a workup for his

abdominal pain, which will include labs and a

CT or ultrasound – two resources.

9. ESI level 4: One resource. The laceration

will need to be sutured – one resource.

10. ESI level 4: One resource. This patient needs

an x ray to rule out a fracture. A splint is not a

resource.

11 ESI level 2: High-risk situation. This 4-

year-old had a witnessed fall with loss of

consciousness and presents to the ED with a

change in level of consciousness. She needs to

be rapidly evaluated and closely monitored.

12. ESI level 3: Two or more resources. This

patient has a significant medical history, and

based on his presentation, he will require two

or more resources, which could include labs

and IV antibiotics.

13. ESI level 4: One resource. She will need one

resource – lab, which will include a urinalysis

and urine culture. She most likely has a UTI

that will be treated with oral medications.

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Chapter 9. Practice Cases
14. ESI level 2: High risk. A temperature higher

than 100.4 ̊F (38.0 ̊C) in an infant less than 28

days old is considered high risk no matter how

good the infant looks. Infants in this age range

are at a high risk for bacteremia.

15. ESI level 3: Two or more resources. At a

minimum, she will require labs and IV

antibiotics.

16. ESI level 1: Requires immediate

lifesaving intervention. The patient is

presenting with signs of shock – hypotension,

tachycardia, and tachypnea. Based on the

mechanism of injury and presenting vital signs,

this patient requires immediate lifesaving

interventions, including aggressive fluid

resuscitation.

17. ESI level 3: Two or more resources. This

history sounds more like pneumonia. Because

the patient is not in acute respiratory distress,

he or she doesn’t meet ESI level-2 criteria. This

patient will require labs, a chest x ray, and

perhaps IV antibiotics.

18. ESI level 5: No resources. This patient will

require a physical exam. He has no signs and

symptoms of an abscess or cellulitis, so he will

be referred to a dentist for treatment. In the

emergency department, he may be given

medications by mouth. On arrival he rates his

pain as 9/10, but because he does not meet the

criteria for ESI level 2, he would not be given

the last open bed.

19. ESI level 3: Two or more resources. Lab

studies, IV fluid, and an IV antiemetic are three

of the resources this patient will require. The

patient is not high risk or in severe pain or

distress.

20. ESI level 3: Two or more resources. A

patient with a known history of migraines with

vomiting will require pain medication, an

antiemetic, and fluid replacement. The pain is

not severe, 6/10. This patient is not high risk.

21. ESI level 4: One resource. This patient will

require a laceration repair. A tetanus booster is

not a resource.

22. ESI level 1: Requires immediate

lifesaving intervention. From the history

and presentation, this patient appears to have a

significant airway injury and will require

immediate intubation. Her respiratory rate is

40, and she is in respiratory distress.

23. ESI level 3: Two or more resources. Lab

studies, IV fluid, and an IV antiemetic are three

of the resources this patient will require. She is

showing signs of dehydration.

24. ESI level 3: Two or more resources. At a

minimum, she will require labs and

noninvasive vascular studies of her lower leg.

She should be placed in a wheelchair with her

leg elevated and instructed not to walk until

the doctor has seen her.

25. ESI level 2: High risk. Patients taking

warfarin who fall are at high risk of internal

bleeding. Although the patients’ vital signs are

within normal limits and he shows no signs of

a head injury, he needs a prompt evaluation

and a head CT.

26. ESI level 5: No resources. Following a

physical exam, this patient will be sent home

with prescriptions and appropriate discharge

instructions.

27. ESI level 2: High-risk situation. The

mechanism of injury is significant, and this

patient has the potential for serious injuries. He

needs to be evaluated by the trauma team and

should be considered high risk. If his BP was

70/palp and his HR was 128, he would be an

ESI level 1; requires immediate life-saving

intervention.

28. ESI level 5: No resources. No resources are

required. Following a physical exam, this

patient will be sent home with appropriate

discharge instructions and a prescription if

indicated.

29. ESI level 3: Two or more resources. An

obvious open fracture will necessitate this

patient going to the operating room. At a

minimum, she will need the following

resources: x ray, lab, IV antibiotics, and IV pain

medication.

30. ESI level 1: Requires immediate

lifesaving interventions. Prehospital

intubation is one of the criteria for ESI level 1.

This patient has sustained a major head injury

and will require an immediate trauma team

evaluation.

31. ESI level 3: Two or more resources. Based

on the patient’s presentation, he will require a

minimum IV pain medication and laceration

repairs. In addition he may need an x ray and

IV antibiotics.

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Chapter 9. Practice Cases
32. ESI level 3: Two or more resources. Based

on her history, this patient will require two or

more resources – lab and an ultrasound. She

may in fact be pregnant. Ectopic pregnancy is

on the differential diagnosis list, but this

patient is currently hemodynamically stable,

and her pain is generalized across her lower

abdomen.

33. ESI level 3: Two or more resources. This

patient is at high risk for a deep vein

thrombosis. For diagnostic purposes, she will

require two resources: labs and a Doppler

ultrasound. If a deep vein thrombosis is

confirmed, she will require additional resources

– remember, ESI level 3 is two or more

resources. If this patient were short of breath or

had chest pain, they would meet ESI level-2

criteria.

34. ESI level 5: No resources. This child needs a

physical exam. Even if eardrops are

administered in the emergency department,

this does not count as a resource. The family

will be sent home with instructions and a

prescription.

35. ESI level 2: High risk. A complaint of

weakness can be due to a variety of conditions,

such as anemia or infection. A dialysis patient

who misses a treatment is at high risk for

hyperkalemia or other fluid and electrolyte

problems. This is a patient who cannot wait to

be seen and should be given your last open

bed.

36. ESI level 3: Two or more resources. It

looks like this patient has a displaced fracture

and will need to have a closed reduction prior

to casting or splinting. At a minimum, she

needs x rays and an orthopedic consult. Her

vital signs are stable, so there is no need to uptriage her to an ESI level 2. Her pain is currently

6/10. If she rated her pain as 9/10 and she is

tearful, would you up-triage her to an lESI level

2? Probably not, given the many nursing

interventions you could initiate to decrease her

pain, such as ice, elevation, and appropriate

immobilization.

37. ESI level 1: Requires immediate

lifesaving interventions. The patient is

hypotensive with a heart rate of 178. She is

showing signs of being unstable – shortness of

breath and chest pressure. This patient requires

immediate lifesaving interventions, which may

include medications and cardioversion.

38. ESI level 5: No resources. The parents of this

4-day-old need to be reassured that a spot of

blood on their baby girl’s diaper is not

uncommon. The baby is nursing and looks

healthy.

39. ESI level 4: One resource. This patient will

require eye irrigation. Eye drops are not a

resource. A slit lamp exam is part of the

physical exam of this patient.

40. ESI level 4: One resource. This patient will

require one resource – lab. A urinalysis and

urine culture will be sent, and depending on

your institution, a urine pregnancy test. One or

all of these tests count as one resource.

41. ESI level 2: High risk. This young, healthy

male has an elevated respiratory rate and a low

oxygen saturation. The patient’s history and

signs and symptoms are suggestive of a

spontaneous pneumothorax. He needs to be

rapidly evaluated and closely monitored.

42. ESI level 1: Requires immediate

lifesaving intervention. From the history, it

sounds like this patient has suffered some type

of head bleed. She is currently unresponsive to

voice and could be showing signs of increased

intracranial pressure. She may not be able to

protect her own airway and may need to be

emergently intubated.

43. ESI level 2: High risk. Facial droop is one of

the classic signs of a stroke. This patient needs

to be evaluated by the stroke team and have a

head CT within minutes of arrival in the ED.

Many nurses want to make all stroke alerts an

ESI level 1. This patient does not meet level 1

criteria as she does not require immediate

lifesaving interventions. The triage nurse needs

to facilitate moving this patient into the

treatment area and initiate the stroke alert

process.

44. ESI level 2: High-risk situation. The

patient’s history indicates that she may have

had a transient ischemic attack this morning.

The patient is high risk, and it would not be

safe for her to sit in the waiting room for an

extended period of time.

45. ESI level 3: Two or more resources. Based

on her history, this patient will require two or

more resources – labs, an ultrasound. On the

differential diagnosis list is a spontaneous

abortion. Currently, she is hemodynamically

stable and has minimal cramping or pain.

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Chapter 9. Practice Cases
46. ESI level 4: One resource. The only resource

this patient will require is irrigation of his eyes.

A slit lamp exam is not considered a resource

but is part of the physical exam.

47. ESI level 3: Two or more resources. A 3-

week-old with projectile vomiting is highly

suspicious for pyloric stenosis. The infant will

need, at minimum, labs to rule out electrolyte

abnormalities, an ultrasound, and a surgery

consult.

48. ESI level 1: Requires immediate

lifesaving intervention. This patient is

presenting with signs and symptoms of a post

partum hemorrhage. She tells you she is going

to pass out, and her vital signs reflect her fluid

volume deficit. The patient needs immediate IV

access and aggressive fluid resuscitation.

49. ESI level 4: One resource. This patient will

need a hand-held nebulizer treatment for her

wheezing. No labs or x ray should be necessary

because the patient does not have a fever.

50. ESI level 2: High-risk situation. The recent

application of a cast along with swelling of the

hand and unbearable pain justifies an ESI level2 acuity level. He may have compartment

syndrome.

51. ESI level 1: Requires immediate

lifesaving intervention. Studies have shown

that lowering brain temperature post cardiac

arrest decreases ischemic damage. This patient

requires immediate lifesaving interventions to

airway, breathing, circulation, and neurologic

outcome. Even though the patient converted to

a stable rhythm, the nurse should anticipate

that additional lifesaving interventions might

be necessary.

52. ESI level 3: Two or more resources. She

will need two or more resources – laboratory

tests, IV fluid, medication for her nausea, and

probably a CT of her abdomen. This patient

will be in your emergency department an

extended period of time being evaluated. If her

pain was 10/10 and she was tachycardic, the

patient would meet the ESI level-2 criteria.

53. ESI level 2: High risk. This patient is

describing more than just the fatigue or

anemia. This patient could be describing the

classic symptoms of a low-volume but high-risk

situation – peripartum cardiomyopathy, a form

of cardiomyopathy that occurs in the last

month of pregnancy and up to 5 months postpartum. There is a decrease in the left

ventricular ejection fraction which causes

congestive heart failure.

54. ESI level 5: No resources. This patient will

need a bedside pregnancy test before receiving

medication. She may be an ESI level 4, if your

institution routinely sends pregnancy tests to

the lab.

55. ESI level 5: No resources. This elderly

gentleman has such brittle toenails that he is

no longer able to clip them himself. He requires

a brief exam and an outpatient referral to a

podiatrist.

56. ESI level 3: Two or more resources. Based

on the history, this patient may have acute

labyrinthitis and will require two or more

resources – IV fluids and an IV antiemetic.

57. ESI level 2: High-risk situation. Based on

mechanism of injury, this patient will need

rapid evaluation by the trauma team.

58. ESI level 2: High risk. This patient is not

someone who should sit in your waiting room.

He does not meet the criteria for ESI level 1, but

he meets the criteria for ESI level 2. The

patient’s internal defibrillator fired for some

reason and needs to be evaluated.

59. ESI level 1: Requires immediate

lifesaving intervention. The history

combined with the signs and symptoms

indicate that this patient is probably having an

MI. The “pressure” started after shoveling wet

snow, and now he is nauseous and short of

breath, and his skin is cool and clammy. He

needs immediate IV access, the administration

of medications, and external pacing pads in

place.

60. ESI level 2: High risk. Breast cancer can

metastasize to the lungs and can cause a pleural

effusion. The collection of fluid in the pleural

space leads to increasing respiratory distress as

evidenced by the increased respiratory rate and

work of breathing.

61. ESI level 3: Two or more resources.

Abdominal pain in a 58-year-old male will

require two or more resources. At a minimum,

he will need labs and an abdominal CT.

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Chapter 9. Practice Cases
62. ESI level 5: No resources. This child has had

previous ear infections and is presenting today

with the same type of symptoms. He is not ill

appearing, and his vital signs are within normal

limits. The child requires a physical exam and

should be discharged with a prescription.

63. ESI level 5: No resources. Because the

mother could not get an appointment with a

primary care physician, she brought her son to

the emergency department for a routine

physical exam. He will be examined and

discharged.

64. ESI level 5: No resources. This patient will

need a bedside pregnancy test prior to receiving

medication. She may be an ESI level 4 if your

institution routinely sends pregnancy tests to

the lab.

65. ESI level 4: One resource. In most EDs, this

patient will have a rapid strep screen sent to the

lab; one resource. She is able to drink fluids and

will be able to swallow pills if indicated.

66. ESI level 1: Requires immediate

lifesaving intervention. The patient is in

third-degree heart block and requires external

pacing to preserve airway, breathing, and

circulation.

67. ESI level 2: High risk. Because of the

mechanism of injury and his complaints of

tingling in both hands, this patient should be

assigned ESI level 2. He has a cervical spine

injury until proven otherwise. He is not an ESI

level 1 in that he does not require immediate

lifesaving interventions to prevent death. At

triage, he needs to be appropriately

immobilized.

68. ESI level 3: Two or more resources. Based

on the history, this patient will require at a

minimum labs and IV antibiotics. In addition

she may need a gyn consult and IV pain

medication.

69. ESI level 1: Requires immediate

lifesaving interventions. The trauma team

needs to be in the trauma room and ready to

aggressively manage this 17-year-old with a

single gunshot wound to the left chest. He will

require airway management, fluid resuscitation

and, depending on the injury, a chest tube or

rapid transport to the operating room.

70. ESI level 4: One resource. The history is

suggestive of an orbital fracture. The patient

will require one resource – an x ray. She will

need a visual acuity check and eye evaluation,

but these are not ESI resources.

71. ESI level 1: Requires immediate

lifesaving intervention. The patient is

presenting with signs of shock--hypotensive,

tachycardic, with decreased peripheral

perfusion. He has a history of HTN and is

presenting with signs and symptoms that could

be attributed to a dissecting aortic abdominal

aneurysm. He needs immediate IV access,

aggressive fluid resuscitation, and perhaps

blood prior to surgery.

72. ESI level 3: Two or more resources.

Abdominal pain and vomiting post gastric

bypass needs to be evaluated. This patient

needs labs, IV, antiemetics, and a CT.

73. ESI level 4: One resource. This patient is

seeking help finding a detoxification program

that will help her. She is not a danger to herself

or others. The social worker or psychiatric

counselor should be consulted to assist her.

Once a placement has been found, she can be

discharged from the emergency department

and can get herself to the outpatient program.

If your social worker or psychiatric counselor

requires a urine toxicology or other lab work,

the patient will require two or more resources

and then meet ESI level-3 criteria.

74. ESI level 2: High risk. Voice changes, fever,

difficulty swallowing, and swelling on one side

of the throat can be signs of a peritonsilar

abscess. The patient needs to be monitored

closely for increasing airway compromise and

respiratory distress.

75. ESI level 3: Two or more resources. This

patient has a complex medical history and

presented with an infected hand. At a

minimum she will need labs, an IV, and IV

antibiotics to address her presenting complaint.

Her vital signs are normal, so there is no reason

to up-triage her to ESI level 2.

76. ESI level 2: High risk. This patient is

experiencing delusions and may have a past

medical history of schizophrenia or other

mental illness, or he may be under the

influence of drugs. Regardless, the major

concern is patient and staff safety. He needs to

be taken to a safe, secure area and monitored

closely.

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Chapter 9. Practice Cases
77. ESI level 5. No resources. No resources

should be necessary. He will require a physical

exam, but without signs of an abscess or

cellulitis, this patient will be referred to a

dentist. In the ED, he may be given oral

medications and prescriptions for antibiotics

and/or pain medication. He is not an ESI level

2, even though he rates his pain as 10/10.

Based on the triage assessment, he would not

be given the last open bed.

78. ESI level 3: Two or more resources. This

patient probably has been on antibiotics for 5

days for mastitis and now presents to the ED

due to fever, chills, and feeling rundown. She

will require labs, IV antibiotics, a lactation

consult if available, and perhaps admission.

79. ESI level 2: High-risk situation. This

patient has two obvious wounds, but until he is

thoroughly examined in the trauma room, you

can’t rule out the possibility that he has

another gunshot wound. The wounds on his

thigh look non-life-threatening, but a bullet

could have nicked a blood vessel or other

structure; therefore, he meets ESI level-2

criteria. His vital signs are within normal limits,

so he does not meet ESI level-1 criteria.

80. ESI level 2: High risk and severe pain

and distress. Abdominal pain in the elderly

can be indicative of a serious medical

condition, and a pain score of 10/10 is

significant. The triage nurse needs to keep in

mind that due to the normal changes of aging,

the elderly patient may present very differently

than a younger patient and is more likely to

present with vague symptoms.

81. ESI level 4: One resource. This patient will

require a laceration repair. A tetanus booster is

not a resource.

82. ESI level 5: No resources. Following a

physical exam, this 4-year-old will be sent

home with appropriate discharge instructions

and perhaps a prescription.

83. ESI level 3: Two or more resources. At a

minimum, this patient will require an IV with

fluid, IV pain medication, and an antiemetic.

Although she rates her pain as 20/10, she

should not be assigned to ESI level 2. She has

had the pain for 2 days, and the triage nurse

can’t justify giving the last open bed to this

patient. The triage nurse will need to address

this patient’s concerns about wait time.

84. ESI level 2: High-risk. This 75-year-old male

tried to kill himself by cutting his throat.

Because of the anatomy of the neck, this type

of laceration has the potential to cause airway,

breathing, and/or circulation problems. At the

same time, he is suicidal, and the ED needs to

ensure that he does not leave or attempt to

harm himself further.

85. ESI level 2: New onset confusion,

lethargy, or disorientation. The daughter

reports that her mother has a change in level of

consciousness. The reason for her change in

mental status may be a UTI that has advanced

to bacteremia. She has an acute change in

mental status and is therefore high risk.

86. ESI level 4: One resource. The patient was

brought to the emergency department for a

new Foley catheter – one resource. There are no

other changes in her condition, and she is

already on antibiotics for a UTI, so no further

evaluation is needed.

87. ESI level 3: Two or more resources. Based

on the history, this patient may have a cellulitis

from the navel piercing. At a minimum she will

require labs and IV antibiotics.

88. ESI level 2: High-risk situation. The

history of events is unclear. How did the 73-

year-old gentleman get the laceration on his

forehead? Did he fall? Get hit? Because of his

age, presentation, and presence of alcohol, he is

at risk for a number of complications.

89. ESI level 2: High risk. This patient may be

describing a penile fracture, a medical

emergency. It is most often caused by blunt

trauma to an erect penis. This patient needs to

be evaluated promptly.

90. ESI level 4: One resource. This young

woman needs an incision and drainage of her

paronychia. She will require no other resources.

91. ESI level 2: Severe pain and distress. The

triage nurse is unable to manage his pain at

triage other than applying a sling and ice. He

will require IV opioids to reduce his pain and

relocate his shoulder.

92. ESI level 1: Requires immediate

lifesaving intervention. Immediate

aggressive airway management is what this

patient requires. Her saturation is very low, and

she appears to be tiring. The triage nurse does

not need the other vital signs in order to decide

that this patient needs immediate care.

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Chapter 9. Practice Cases
93. ESI level 2: High-risk situation. Homicidal

ideation is a clear high-risk situation. This

patient needs to be placed in a safe, secure

environment, even though he is calm and

cooperative at triage.

94. ESI level 5: No resources. A tetanus

immunization does not count as a resource.

The patient will be seen by a physician or

midlevel provider and receive a tetanus

immunization and discharge instructions. This

patient will require no resources.

95. ESI level 4: One resource. This patient will

be sent back to the nursing home after the

feeding tube is reinserted. There is no acute

change in his medical condition that warrants

any further evaluation. He is unresponsive, but

that is the patient’s baseline mental status so

he is not an ESI level 1.

96. ESI level 2: High-risk situation for

allergic reaction. The patient has used his

EpiPen but still requires additional medications

and close monitoring.

97. ESI level 5: No resources. A physical exam

and providing the mother with reassurance

and education is what this 18-month-old will

require. His activity level is appropriate, and he

is taking fluids by mouth.

98. ESI level 3: Two or more resources. A

laceration through the vermilion border

requires the physician to line up the edges

exactly. Misalignment can be noticeable. A

healthy 19-month-old will probably not

cooperate. In most settings, he will require

conscious sedation, which counts as two

resources. The toddler’s vital signs are within

normal limits for his age, so there is no reason

to up-triage to ESI level 2.

99. ESI level 2: High risk. A 44-year-old diabetic

with continuous vomiting is at risk for diabetic

ketoacidosis. The patient’s vital signs are a

concern, as her heart rate and respiratory rate

are both elevated. It is not safe for this patient

to wait for an extended period of time in the

waiting room.

100. ESI level 1: Requires immediate

lifesaving intervention. This 76-year-old

patient is in hemorrhagic shock from his GI

bleed. His blood pressure is 70, his heart rate is

128, and his respiratory rate is 40, all

indicating an attempt to compensate for his

blood loss. This patient needs immediate IV

access and the administration of fluid, blood,

and medications.

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Chapter 9. Practice Cases
This chapter can be used to assess competency. Two

sets of 25 case studies have been included. The cases

are divided into two sets to allow flexibility in ESI

competency evaluation. For example, Set A can be

used for initial assessment and Set B can be used for

remedial or follow-up assessment. Both sets contain

realistic patient scenarios that a triage nurse would

encounter in any emergency department. Please

read each case and, based on the information

provided, assign a triage acuity rating using ESI.

Answers to all cases follow after Set B.

Set A Competency Cases

1. I think I picked up a bug overseas,” reports a

34-year-old male who presented in the

emergency department complaining of frequent

watery stools and abdominal cramping. “I think

I am getting dehydrated.” T 98°F, RR 22, HR

112, BP 120/80, SpO2 100%. His lips are dry

and cracked.

2. “I think he broke it,” reports the mother of a 9-

year-old boy. “He was climbing a tree and fell

about 5 feet, landing on his arm. I am a nurse,

so I put on a splint and applied ice. He has a

good pulse.” The arm is obviously deformed.

Vital signs: T 98°F, RR 26, HR 90, SpO2 99%.

Pain 5/10.

3. “I don’t know what’s wrong with my baby girl,”

cries a young mother. She reports that her 2-

week-old baby is not acting right and is not

interested in eating. As you begin to undress

the baby, you notice that she is listless and her

skin is mottled.

4. “My pain medications are not working

anymore. Last night I couldn’t sleep because

the pain was so bad,” reports a 47-year-old

female with metastatic ovarian cancer. “My

husband called my oncologist, and he told me

to come to the emergency department.” The

patient rates her pain as 9/10. Vital signs are

within normal limits.

5. A 48-year-old male tells you that he has a

history of kidney stones and thinks he has

another one. He has right costovertebral angle

pain that radiates around to the front and into

his groin. He is nauseous but tells you he took a

pain pill, and right now he has minimal pain.

He denies vomiting. T 98°F, RR 16, HR 80, BP

136/74, SpO2 100%. Pain 3/10.

6. “After my pediatrician saw my son’s rash, he

said I had to bring him to the emergency

department immediately. He has this rash on

his face and chest that started today. He has

little pinpoint purplish spots he called

petechiae. My son is a healthy kid who has had

a cold for a couple of days and a cough. My

pediatrician said he had to be sure nothing bad

is going on. What do you think?”

7. “Her grandfather pulled her by the wrist up and

over a big puddle. Next thing you know, she is

crying and refusing to move her left arm,” the

mother of a healthy 3–year-old tells you. Vital

signs are within normal limits.

8. A 46-year-old asthmatic in significant

respiratory distress presents via ambulance. The

paramedics report that the patient began

wheezing earlier in the day and had been using

her inhaler with no relief. On her last

admission for asthma, she was intubated. Vital

signs: RR 44, SpO2 93% on room air, HR 98, BP

154/60. The patient is able to answer your

questions about allergies and medications.

9. A 56-year-old male with a recent diagnosis of

late-stage non-Hodgkin’s lymphoma was

brought to the ED from the oncology clinic. He

told his oncologist that he had facial and

bilateral arm swelling and increasing shortness

of breath. The patient also reports that his

symptoms are worse if he lies down. Vital signs:

BP 146/92, HR 122, RR 38, SpO2 98% on room

air, temperature normal.

10. EMS arrives with a 28-year-old male who was

stabbed in the left side of his neck during an

altercation. You notice a large hematoma

around the wound, and the patient is moaning

he can’t breathe. HR 110, RR 36, SpO2 89%.

11. An 11-year-old presents to triage with his

mother, who reports that her son has had a

cough and runny nose for a week. The child is

running around the waiting room and asking

his mother for a snack. Vital signs are within

normal limits.

12. “I don’t know what is wrong with my son,”

reports the worried mother of a normally

healthy eight-year-old male. “He’s losing weight

and acting so cranky. Last night he was up to

the bathroom every hour, and he can’t seem to

get enough to drink.” The child is alert and

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Chapter 10. Competency Cases
oriented and answers your questions

appropriately. Vital signs: T 98.6°F, RR 30, HR

98, BP 92/78, SpO2 98%.

13. “He has had diarrhea for 2 days, and he just

started throwing up this morning. This has

been going around the family, and he seems to

have it the worst. He has been drinking before

today, but now he doesn’t want anything to

drink,” reports the mother of a 19-month-old.

The toddler is awake and alert but quiet in the

mother’s arms, and you notice his lips are dry

and cracked. Vital signs: T 99°F, RR 30, HR 130,

SpO2 100%.

14. EMS arrives with an 87-year-old male who

slipped on the ice and injured his right hip. His

right leg is shortened and externally rotated.

The patient’s only complaint is hip pain. He

rates his pain as 5/10, and his vital signs are

within normal limits.

15. “My baby is having a hard time drinking his

bottle,” reports the young mother of a 3–

month-old. The baby is alert and looking

around. You notice a large amount of dried

mucus around both nares. T 98°F, RR 40,

HR 132, SpO2 99%.

16. A 72-year-old female is brought in by

ambulance from the nearby nursing home.

They report that she has become increasingly

confused over the last 24 hours. She is usually

awake, alert, and oriented and takes care of her

own activities of daily living. At triage she has a

temperature of 99.6°F, HR 86, RR 28, BP 136/72,

SpO2 94% on room air.

17. Melissa, a 4-year-old with a ventriculoperitoneal shunt (drains excess cerebrospinal

fluid), is brought to the ED by her parents. The

mother tells you that she is concerned that the

shunt may be blocked because Melissa is not

acting right. The child is sleepy but responds to

verbal stimuli. When asked what was wrong,

she tells you that her head hurts and she is

going to throw up. T 98.6°F, RR 22, HR 120,

SpO2 99% on room air, BP 94/76.

18. The overhead page announces the arrival of the

Code STEMI. Paramedics arrive with a 62-yearold male with a history of a myocardial

infarction 4 years ago who is complaining of

chest pressure that started an hour ago. The

field EKG shows anterior lateral ischemic

changes. Currently, the patient’s heart rate is

106, RR 28, BP 72/53, SpO2 is 95% on a nonrebreather mask. His skin is cool and clammy.

19. “I had a knee replacement 3 months ago. Now

look at it!” states a 64-year-old male. The knee

is red, swollen and tender to touch. Vital signs:

T 99°F, RR 20, HR 74, BP 164/74, SpO2 97%.

Pain 6/10.

20. “This is so embarrassing,” reports a 29-year-old

male. “For the last 12 hours, I have had this

thing stuck in my rectum. I have tried and tried

to get it out with no success. Can someone help

me?” The patient denies abdominal pain or

tenderness. Vital signs are within normal limits.

Pain 4/10.

21. EMS arrives with a 67-year-old female who lives

alone. The patient called 911 because she was

too sick to get herself to the doctor. The patient

has had a fever and cough for 3 days. She

reports coughing up thick green phlegm and is

concerned that she has pneumonia. She denies

shortness of breath. Past medical history HTN,

T 102°F, RR 28, HR 86, BP 140/72, SpO2 94%.

22. EMS arrives with a 14-year-old male who was

snowboarding at a nearby ski area, lost control,

and ran into a tree. The patient was wearing a

ski helmet, is currently aware, alert, and

oriented and is complaining of left upperquadrant pain and left thigh pain. His left

femur appears to be broken. BP 112/80, HR 86,

RR 14, SpO2 98%, and temperature is normal.

23. “I woke up this morning, and there was a bat

flying around our bedroom. Scared me half to

death, and now I am so worried about rabies,”

an anxious 48-year-old female tells you. “My

husband opened the window, and the bat flew

out.” Past medical history of ovarian cysts, no

med or allergies, vital signs are within normal

limits.

24. The family of a 74-year-old male called 911

when he developed severe mid-abdominal pain.

“My husband is not a complainer,” reports his

wife. “The only medication he takes is for high

blood pressure.” On arrival in the ED, the

patient’s HR is 140, RR 28, SpO2 94%, BP

72/56.

25. “I woke up this morning, and my eyes are all

red and crusty,” reports a 29-year-old

kindergarten teacher. “I think I got it from the

kids at school,” she tells you. She denies pain or

other visual disturbances. Her vital signs are

within normal limits.

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Chapter 10. Competency Cases
Set B Competency Cases

1. “Without the helmet, I would have been really

hurt,” reports a 19-year-old healthy male who

was involved in a bicycle accident. He lost

control of his bike when he hit a pothole. He

has a 2-centimeter laceration on his arm and

pain over his left clavicle. Vital signs: T 97.4°F,

RR 18, HR 62, BP 122/70, SpO2 100%. Pain 6/10.

2. When asked why she came to the emergency

department, the 18-year-old college student

begins to cry. She tells the triage nurse that she

was sexually assaulted last night at an offcampus party.

3. “I have this skin rash in my crotch. It looks like

jock rot. Probably got it from not washing my

gym clothes,” reports a 19-year-old healthy

male. No abnormal vital signs.

4. “The doctor told me to come back this morning

and have my boil checked. He lanced it

yesterday and packed some stuff in it. He said

he just want to make sure it is healing OK,”

reports a 54-year-old diabetic male. The patient

goes on to tell you that he feels so much better.

T 98°F, RR 16, HR 64, BP 142/78, SpO2 98%.

Pain 2/10.

5. A 16-year-old high school hockey player

collapsed on the ice after being hit in the

anterior chest by the puck. The coaching staff

began CPR almost immediately, and he was

defibrillated three times with a return of

spontaneous circulation. He arrives in the

emergency department intubated.

6. “I have been wheezing for a few days, and

today I woke up with a fever. My rescue inhaler

doesn’t seem to be helping,” reports a 43-yearold female with a past history of asthma. Vital

signs: T 101.4°F, RR 26, HR 90, BP 138/70, SpO2

95%.

7. “This sounds really strange. A bug flew into my

right ear while I was gardening. I tried to get it

out by using a Q-tip. I just don’t know what

else to do, but this buzzing noise is driving me

crazy,” a 55-year-old female tells you. No

previous medical history and vital signs are

within normal limits.

8. “This morning, I stepped on a rusty nail, and it

went right through my shoe into my foot. I

washed it really well. I read on the Internet that

I need a tetanus shot.” No previous medical

history, and vital signs are within normal

limits.

9. “I was having breakfast with my wife, and all of

a sudden I couldn’t see out of my right eye. It

lasted about 5 minutes. I’m just scared because

I’ve never had anything like this happen

before,” reports a 56-year-old male with a

history of HTN and high cholesterol.

10. “I was walking down the street and twisted my

ankle as I stepped off the curb. I don’t think it’s

broken, but it hurts so much,” report a 43-yearold female with a history of colitis. Vital signs:

T 98°F, HR 72, RR 18, BP 134/80, SpO2 100%.

Pain 8/10.

11. A 16-year-old female is brought to the

emergency department by her mother, who

reports that her daughter took more than 30

acetaminophen tablets about 30 minutes before

admission. The tearful girl tells you that her

boyfriend broke up with her this morning. No

previous medical history, and no allergies or

medications. Vital signs within normal limits.

12. “My colitis is acting up,” report a 26-year-old

female. “It started with an increased number of

stools, and now I am cramping a lot. My

gastroenterologist told me to come to the

emergency department to be evaluated.” No

other past medical history. T 97°F, RR 18,

HR 68, BP 112/76, SpO2 100%. Pain 6/10.

13. “I was so disappointed about not making the

varsity soccer team that I punched a wall,”

reports a 15-year-old healthy male. His hand is

swollen and tender to touch. Vital signs: T 97°F,

RR 16, HR 58, BP 106/80, SpO2 100%. Pain

5/10.

14. A 46-year-old female with a history of sickle cell

disease presents to the emergency department

because of a crisis. She has pain in her lower

legs that began 8 hours ago, and the pain

medication she is taking is not working.

Currently, she rates her pain as 8/10. She has

no other medical problems, and her current

medications include folate and vicodin. Vital

signs are all within normal limits.

15. “I take a blood thinner because I have had clots

in my legs,” reports a 54-year-old black male.

“They told me that medicine would prevent

them, but today I have pain and swelling in my

lower leg. It started out just being sore, but now

I can hardly walk on it.” Denies any other

complaints. Vital signs within normal limits.

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Chapter 10. Competency Cases
16. A 65-year-old female is brought in by

ambulance from the local nursing home for

replacement of her PEG tube. The information

from the nursing home states that she had a

massive stroke 3 years ago and is now aphasic.

Her condition is unchanged, and she is a do

not resuscitate/do not intubate. Vital signs

within normal limits.

17. A 26-year-old female presents to the ED because

she can’t get an appointment with her

therapist. She went home for the holidays, and

the visit brought back many issues from her

childhood. She is unable to sleep and has been

drinking more than usual. She admits to

thinking about hurting herself but has no plan.

History of previous suicide attempts. Vital signs

within normal limits.

18. “I am here on business for a week, and I forgot

to pack my blood pressure medication. I

haven’t taken it for 2 days. Do you think one of

the doctors will write me a prescription?” asks a

58-year-old male. BP 154/88, HR 64, RR 18, T

98°F, SpO2 99%.

19. “I fell running for the bus,” reports a 42-yearold female. “Nothing hurts, I just have road

burn on both my knees, and I think I need a

tetanus booster.” Vital signs within normal

limits.

20. EMS radios in that they are in route with a 21-

year-old with a single gunshot wound to the

left chest. Vital signs are BP 78/palp, HR 148,

RR 36, SpO2 96% on a non-rebreather.

21. A 51-year-old presents to triage with redness

and swelling of his right hand. He reports being

scratched by his cat yesterday. Past medial

history gastroesophageal reflux disease. Vital

signs: BP 121/71, HR 118, RR 18, T 101.8°F,

SpO2 98%. Pain 5/10.

22. EMS arrives with a 52-year-old female overdose.

The patient took eight 75 mg tabs of wellbutrin

2 hours ago because her husband left her for

another woman, and now she wants to die. She

is awake, alert, and oriented.

23. The local police arrive with a 48-year-old male

who was arrested last night for public

intoxication. He spent the night in jail, and this

morning he is restless and has tremors. The

patient usually drinks a case of beer a day and

has not had a drink since 7 p.m. Vital signs: BP

172/124, HR 122, RR 18, T 98.6°F, SpO2 97%

Pain 0/10.

24. A healthy 10-year-old male is brought to the

emergency department by his mother, who

reports that her son has not moved his bowels

for a week. He is complaining of 7/10

generalized abdominal pain, nausea, and lack of

appetite. Vital signs: BP 107/66, HR 75, RR 20,

T 98.6°F, SpO2 99%.

25. EMS arrives with a 22-year-old woman with

asthma who began wheezing earlier this

morning. She is sitting upright on the

ambulance stretcher leaning forward with an

albuterol nebulizer underway. The patient is

diaphoretic, working hard at breathing and

unable to answer your questions. EMS tells you

that they think she is tiring out. Her respiratory

rate is 48, SpO2 is 94%, and she has a prior

history of intubations.

Set A Competency Cases—

Answers

1. ESI level 3: Two or more resources. From

the patient’s history, he will require labs and IV

fluid replacement—two resources.

2. ESI level 3: Two or more resources. It

looks as though this patient has a displaced

fracture and will need a closed reduction prior

to casting or splinting. At a minimum, he needs

x rays and an orthopedic consult. This patient

may also require procedural sedation. However,

there are already two or more resources, so it is

not necessary to be overly concerned about

counting resources beyond two.

3. ESI level 1: Requires immediate

lifesaving intervention; possible aggressive

fluid resuscitation.

4. ESI level 2: Severe pain or distress. This

patient needs aggressive pain management with

IV medications. There is nothing the triage

nurse can do to decrease the patient’s pain

level. The answer to “Would you give your last

open bed to this patient?” should be yes.

5. ESI level 3: Two or more resources. The

patient is presenting with signs and symptoms

of another kidney stone. At a minimum, he will

need a urinalysis and CT scan. If his pain

increases, he may need IV pain medication. At

a minimum, two resources are required. If the

pain level was 7/10 or greater and the triage

nurse could not manage the pain at triage, the

patient could meet level-2 criteria.

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Chapter 10. Competency Cases
6. ESI level 2: High risk. Rashes are difficult to

triage, but the presence of petechiae is always a

high-risk situation. Even if the patient looks

good, it is important to recognize that petechia

can be a symptom of a life-threatening

infection, meningococcemia.

7. ESI level 4 or 5: This case is an example of

variations in practice around the country. Many

emergency departments would examine the

child and then attempt to reduce the

dislocation of the radial head without an x ray.

Others may x ray the child’s arm, which is

considered one ESI resource. Relocation is not

considered a resource.

8. ESI level 2: High-risk. An asthmatic with a

prior history of intubation is a high-risk

situation. This patient is in respiratory distress

as evidenced, by her respiratory rate, oxygen

saturation, and work of breathing. She does not

meet the criteria for ESI level 1, requires

immediate lifesaving intervention.

9. ESI level 2: High risk. This patient is

demonstrating respiratory distress with his

increased respiratory rate and decreased oxygen

saturation. Symptoms are caused by

compression of the superior vena cava from the

tumor. It is difficult for blood to return to the

heart, causing edema of the face and arms.

10. ESI level 1: Requires immediate

lifesaving intervention. Depending on the

exact location penetrating neck trauma can

cause significant injury to underlying

structures. Based on the presenting vital signs,

immediate actions to address airway, breathing,

and circulation are required. Intubation might

be necessary due to the large neck hematoma,

which may expand.

11. ESI level 5: No resources. This healthysounding 11-year-old will be examined by a

physician and then discharged home with

appropriate instructions and a prescription if

indicated.

12. ESI level 2: High risk. This patient has an

elevated respiratory rate and heart rate. The

symptoms of polydipsia and polyuria are two

classic signs of diabetic ketoacisosis.

13. ESI level 3: Two or more resources. This

19-month-old is dehydrated and will require a

minimum of two resources: labs and IV fluids.

In addition the physician may order an IV

antiemetic.

14. ESI level 3: Two or more resources. This

patient probably has a fractured hip and will

need an x ray, IV pain medication, and an

orthopedic consult. If the reason for a fall in

the elderly is unclear, the patient should be

assigned ESI level 2 to rule out a cardiac or

neurological event.

15. ESI level 5: No resources. Following a

physical exam, this baby will be discharged to

home. Prior to leaving, the mother needs to be

taught techniques to keep the baby’s nares clear

of mucus.

16. ESI level 2: High risk. An elderly patient

with increasing confusion and a fever needs to

be evaluated for an infection. UTIs and

pneumonia need to be ruled out. This patient

may be septic and requires rapid evaluation and

treatment.

17. ESI level 2: New-onset confusion,

lethargy, or disorientation. The mother of

this 4-year-old knows her child and has

probably been through this situation before. A

child with a ventriculo-peritoneal shunt with a

change in level of consciousness and a

headache is thought to have a blocked shunt

until proven otherwise and may be

experiencing increased intracranial pressure.

18. ESI level 1: Requires immediate

lifesaving intervention. This patient is

experiencing another cardiac event that

requires immediate treatment. His vital signs

and skin perfusion are suggestive of cardiogenic

shock, and the patient may require fluid

resuscitation or vasopressors to treat

hypotension.

19. ESI level 3: Two or more resources. The

patient is presenting with signs and symptoms

of an infection. At a minimum, he will require

labs, an x ray, an orthopedic consult, and IV

antibiotics.

20. ESI level 3: Two or more resources. An x

ray is needed to confirm placement in rectum.

Then IV sedation and analgesia may be used to

enable the physician to remove the foreign

body in the ED, or he may be admitted for

surgery. In this situation, two or more resources

are required.

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Chapter 10. Competency Cases
21. ESI level 3: Two or more resources. This

elderly patient may have pneumonia. Labs and

a chest x ray are required, in addition to IV

antibiotics. If vital signs are outside the

accepted parameters, they may be considered

high risk and meet ESI level-2 criteria.

22. ESI level 2: High risk. The mechanism of

injury represents a high-risk situation. His left

upper-quadrant pain could be due to a splenic

rupture or injury. He may also have a fractured

femur, another source of volume loss. This

patient’s vital signs are stable, so there is no

need for immediate lifesaving intervention, but

he is at risk for hemorrhagic shock due to

volume loss.

23. ESI level 4: One resource. It is unknown

whether the patient was bitten by the bat

because they were sleeping, so postexposure

prophylaxis will be initiated. One resource—an

intramuscular medication.

24. ESI level 1: The patient is presenting with

signs of shock, hypotension tachycardia, and

tachypnea. He has a history of HTN and is

presenting with signs and symptoms that could

be suggestive of a dissecting aortic abdominal

aneurysm. On arrival in the emergency

department, he will require immediate

lifesaving interventions such as immediate IV

access, aggressive fluid resuscitation, and

perhaps blood prior to surgery.

25. ESI level 5: No resources. Following a

physical exam, this patient will be discharged

to home with a prescription and appropriate

discharge instructions. No resources are

required.

Set B Competency Cases—

Answers

1. ESI level 3: Two or more resources. Based

on the mechanism of injury, this patient will

require an x ray of his clavicle and suturing of

his arm laceration. In addition, he may need a

tetanus booster, but that does not count as a

resource. If the mechanism of injury was

higher, the patient could meet ESI level-2

criteria, high risk. The patient’s pain rating is

8/10, but the triage nurse can intervene by

applying a sling and providing ice to decrease

the pain and swelling.

2. ESI level 2: Severe pain or distress. This

patient needs to be taken to a safe, quiet room

within the emergency department. Her medical,

emotional, and legal needs must be addressed

in a timely manner.

3. ESI level 5: No resources. Following a

physical exam, this young man will be

discharged to home with a prescription and

appropriate discharge instructions.

4. ESI level 5: No resources. This patient was

instructed to come back to the emergency

department for a wound check. He will be

examined and discharged to home. No

resources are required. A point-of-care finger

stick glucose is indicated, but this is not a

resource. If the patient came back with a fever

or increasing pain and redness, then his ESI

level would reflect the additional resources he

would require.

5. ESI level 1: Requires immediate

lifesaving interventions. From the history,

it sounds like the hockey player experienced a

disruption in the electrical activity in his heart

due to the blow to the chest from the hockey

puck. He will require immediate lifesaving

interventions to address airway, breathing, and

circulation. This patient is intubated, which

meets criteria for lifesaving interventions.

6. ESI level 3: Two or more resources. This

patient has a history of asthma that is not

responding to her rescue inhaler. In addition,

she has a fever. At a minimum, she will need

two resources: hand-held nebulizer treatments

and a chest x ray.

7. ESI level 4: One resource. This patient will

need an ear irrigation to flush it out.

8. ESI level 5: No resources. This patient will

require a physical exam then a tetanus booster,

which is not considered a resource.

9. ESI level 2: High risk. This patient is

exhibiting signs of central retinal artery

occlusion, which represents an acute threat to

loss of vision. Rapid evaluation is necessary.

10. ESI level 4: One resource. To rule out a

fracture, this patient will require an x ray, one

resource. The application of a splint and crutch

walking instructions are not counted as

resources. This patient does not meet the

criteria for ESI level 2 for pain because nursing

can immediately initiate interventions to

address her pain.

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Chapter 10. Competency Cases
11. ESI level 2: High risk. An overdose is a clear

high-risk situation. This patient needs to be

seen immediately, and interventions to prevent

liver damage must be initiated. At the same

time she needs to be placed in a safe, secure

environment and monitored closely to prevent

harm to herself.

12. ESI level 3: Two or more resources. The

patient is presenting with a colitis flare. She will

need labs and possibly an IV and a CT of the

abdomen, especially in light of her presentation

with normal vital signs. Two resources.

13. ESI level 4: One resource. This young man

presents with a mechanism of injury suggestive

of a boxer’s fracture. An x ray is indicated to

rule out a fracture,—one resource.

14. ESI level 2: High risk. Sickle cell disease

requires immediate medical attention because

of the severity of the patient’s pain, which is

caused by the sickle cells occluding small and

sometimes large blood vessels. Rapid analgesic

management will help prevent the crisis from

progressing to the point where hospitalization

will be unavoidable.

15. ESI level 3: Two or more resources. This

patient will need lab tests and lower-extremity

vascular studies to rule out a deep vein

thrombosis.

16. ESI level 3: Two or more resources. This

patient will need to be seen by surgery or GI

and her PEG tube reinserted—two resources.

17. ESI level 2: High-risk situation. This

patient is a danger to herself and needs to be

placed in a safe environment with a constant

observer.

18. ESI level 5: No resources. The patient will

need a history and physical exam and then will

be discharged to home with a prescription. An

oral dose of his blood pressure medication does

not count as a resource.

19. ESI level 5: No resources. A tetanus booster

is not a resource, and neither is cleaning and

dressing abrasions.

20. ESI level 1: Requires immediate

lifesaving intervention. The trauma team

needs to be in the trauma room and ready to

aggressively manage this 21-year-old with a

single gunshot wound to the left chest. He will

require airway management, fluid resuscitation

and, depending on the injury, a chest tube or

rapid transport to the operating room.

21. ESI level 3: Two or more resources. This

patient probably has a cellulitis of the hand and

will require labs and IV antibiotics. Starting a

saline lock is not a resource, but IV antibiotics

are a resource.

22. ESI level 2: High-risk situation. An

overdose is a high-risk situation, and wellbutrin

overdoses are prone to seizures, hallucinations,

and irregular heart rhythms. This patient is

suicidal and also needs to be monitored closely

for safety.

23. ESI level 2: High-risk situation. This 48-

year-old male is probably showing signs of

alcohol withdrawal, a high-risk situation. He is

restless, tremulous and tachycardic. In addition

he is hypertensive. He is not safe to wait in the

waiting room, and should be given your last

open bed.

24. ESI level 3: Two or more resources.

Abdominal pain, loss of appetite, and nausea in

a 10-year-old who has not had a bowel

movement in several days is probably due to

constipation. He will need two or more

resources—labs, maybe an x ray, maybe a

surgery consult, maybe an enema—but at least

two resources.

25. ESI level 1: Requires immediate

lifesaving intervention. This young

asthmatic is tiring out and will need immediate

lifesaving intervention that will require at a

minimum a nurse and physician at the bedside

immediately. The decision may be to continue

the respiratory treatments and try IV steroids,

IV magnesium, and heliox immediately. She

may also require rapid sequence intubation.

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Chapter 10. Competency Cases
This chapter can be used in locally-developed ESI

educational programs, or on an as-needed basis to

address frequently-asked questions (FAQ) about

triaging with the ESI. In addition to these FAQs,

additional case studies are provided. The case studies

illustrate how the concepts discussed in the FAQs

are applied to actual triage situations.

Chapter 2

Frequently Asked Questions

1. Do I have to upgrade the adult patient's

triage level if the heart rate is greater

than 100?

No, but it is a factor to consider when assigning

the ESI level.

2. Do I have to upgrade the patient's triage

level if the pain rating is 7/10 or greater?

No. Again, this is one factor to consider when

assigning the ESI level

3. If the patient is chronically confused,

should the patient then automatically be

categorized as ESI level 2?

No, an ESI level 2 is assigned to patients with an

acute change in mental status.

4. When do I need to measure vital signs?

For any patient who meets ESI level-3 criteria.

While local emergency departments may have

protocols regarding when and by whom vital

signs are obtained, the triage nurse determines

whether or not they may be useful in

determining the ESI level for an individual

patient.

Post-Test Questions and Answers

Questions

Assign an ESI level to each of these patients.

Level Patient

1. _________ A 62-year-old with CPR in progress.

2. _________ A 53-year-old with 30% body

surface area burn.

3. _________ A 22-year-old who needs a work

note.

4 _________ A 12-year-old with an earache.

5. _________ A 45-year-old involved in high speed

motor vehicle collision, BP 120/60

HR 72, RR. 18.

6. _________ An unresponsive 14-year-old. EMS

tells you he and his friends had been

“doing shots.”

Answers

1. ESI level 1

2. ESI level 2

3. ESI level 5

4. ESI level 5

5. ESI level 2

6. ESI level 1

Chapter 3

Frequently Asked Questions

1. Do I have to assign the ESI triage

category of 2 for the 25-year-old female

patient who rates her pain as 10/10 and

is eating potato chips?

No. With stable vital signs and no other factors

that would meet high-risk criteria, this patient

should be assigned ESI level 3. She will most

likely need labs and either x rays, an IV, or pain

medications, i.e., two or more resources. You

would not use your last open bed for her.

2. Does an 80-year-old female who is

chronically confused need to be triaged

as ESI level 2?

No. The criteria for ESI level 2 are new onset of

confusion, lethargy, or disorientation.

3. Shouldn't the patient with active chest

pain be rated an ESI level 1?

Not all patients with chest pain meet ESI level-1

criteria. If they are unresponsive, pulseless,

apneic or not breathing, or require immediate

life-saving intervention, they then meet level-1

criteria. A chest pain patient that is pale,

diaphoretic, hypotensive, or bradycardic will

A–1

Appendix A. Frequently Asked Questions and

Post-Test Materials for Chapters 2-8
require immediate IV access to improve their

hemodynamic status is level 1. Stable patients

with active chest pain usually meet high-risk

criteria and should be categorized ESI level 2;

immediate placement should be facilitated.

Post-Test Questions and Answers

Questions

Read each case and determine whether the patient

meets the criteria for ESI level 2. Justify your

decision.

1. A 40-year-old male presents to triage with

vague, midsternal chest discomfort, occurring

intermittently for one month. This morning, he

reports a similar episode, which has now

resolved. Currently complains of mild nausea,

but feels pretty good. Medical history: Smoker.

He is alert, with skin warm and dry, does not

appear to be in any distress.

2. A 22-year-old female on college break presents

to the triage desk complaining of sudden onset

of feeling very sick, severe sore throat, and

feeling “feverish.” She is dyspneic and drooling

at triage, and her skin is hot to touch.

3. A 68-year-old male brought in by his wife for

sudden onset of left arm weakness, slurred

speech, and difficulty walking. Symptoms

began 2 hours prior to arrival. Past medical

history: Atrial fibrillation. Meds: Lanoxin. The

patient is awake, oriented, mildly short of

breath. Speech is slurred; right-sided facial

droop is present. Left upper-extremity weakness

noted with 2/5 muscle strength.

4. A 60-year-old male complains of sudden loss of

vision in the left eye that morning. Patient

denies pain or discomfort. Past medical history:

CAD, HTN. The patient is slightly anxious but

no distress.

5. A 22-year-old female with 10/10 abdominal

pain for two days. Denies nausea, vomiting,

diarrhea, or urinary frequency. Her heart rate is

84 and she is eating ice cream.

6. A 70-year-old female with her right arm in a

cast is brought to triage by her daughter. The

daughter states that her mother fell yesterday

and fractured her arm. The patient is

complaining of pain. Daughter states, “They

put this cast on yesterday, but I think it's too

tight.” Daughter reports her mother has been

very restless at home and thinks her mother is

in pain. Patient has a history of Alzheimer's

disease. The patient is confused and mumbling

(at baseline per daughter); face flushed. She is

unable to provide verbal description of her

complaints. Her right upper extremity is in a

short arm cast; digits appear tense, swollen and

ecchymotic. Nail beds are pale; capillary refill

delayed. Patient is not wearing a sling.

7. An 8-month-old presents with fever, cough,

and vomiting. The baby has vomited twice this

morning; no diarrhea. Mom states the baby is

usually healthy but has “not been eating well

lately.” Doesn't own a thermometer, but knows

the baby is “hot”" and gave acetaminophen two

hours prior to arrival. The baby is wrapped in a

blanket, eyes open, appears listless, skin hot

and moist, sunken fontanel. Respirations are

regular and not labored.

8. A 34-year-old male presents to triage with right

lower quadrant pain, 5/10, all day. Pain is

associated with loss of appetite, nausea and

vomiting. Past medical history: None. The

patient appears in moderate discomfort, skin

warm and dry, guarding abdomen.

9. A 28-year-old male arrives with friends with a

chief complaint of a scalp laceration. Patient

states he was struck in the head with a baseball

bat one hour prior to arrival. Friends state he

“passed out for a couple of minutes.” Patient

complains of headache, neck pain, mild nausea,

and emesis x 1. Patient looks pale, but is

otherwise alert and oriented to person, place,

and time. There is a 5-cm laceration to the

scalp near his left ear with bleeding controlled.

10. A 28-year-old male presents with a chief

complaint of tearing and irritation to the right

eye. He is a construction worker and was

drilling concrete. He states “I feel like there is

something in my eye” and reports ”irrigated

the eye several times but it doesn't feel any

better.” Patient appears in no severe distress;

however, he is continually rubbing his eye.

Right eye appears red, irritated, with excessive

tearing.

11. A 40-year-old male is brought in by his son. He

is unable to ambulate due to foot and back

pain. Patient states he fell approximately 10

feet off of a ladder and is complaining of foot

and back pain. States he landed on both feet

and had immediate foot and back pain. Denies

A–2

Appendix A. Frequently Asked Questions
loss of consciousness/neck pain. No other signs

of trauma noted. The patient appears pale,

slightly diaphoretic, and in mild distress. He

rates his pain 6/10. Patient is sitting upright in

a wheelchair.

12. A 12-year-old female is brought to triage by her

mother who states her daughter has been weak

and vomiting for three days. The child states

she "feels thirsty all the time and her head

hurts." Vomited once today. Denies fever,

abdominal pain, or diarrhea. No significant past

medical history. The child is awake, lethargic,

and slumped in the chair. Color is pale, skin

warm and dry.

13. A 40-year-old male presents to triage with a

gradual increase in shortness of breath over the

past two days associated with chest pain. Past

medical history: colon cancer. He is in

moderate respiratory distress, skin warm and

dry.

14. A 60-year-old male presents with complaint of

dark stools for one month with vague

abdominal pain. Past medical history: None.

Pulse is tachycardic at a rate of 140 and he has

a blood pressure of 80 palpable. His skin is pale

and diaphoretic.

15. EMS arrives with a 25-year-old female with the

sudden onset of significant vaginal bleeding,

with 9/10 abdominal pain. The patient is 7

months pregnant. BP 92/pal, HR 130.

Answers

1. ESI level 2. This patient is high-risk, due to

history of angina for 1 month. The patient

complained of symptoms of acute coronary

syndrome earlier in the morning. Smoking is a

significant risk factor; however, the patient

presentation is concerning enough to be

considered high risk. These are symptoms

significant for a potential cardiac ischemic

event. Acute myocardial infarction is frequently

accompanied or preceded by waxing and

waning symptoms. An immediate

electrocardiogram is necessary.

2. ESI level 2. This patient is at high risk for

epiglottitis. This is a life-threatening condition

characterized by edema of the vocal cords.

Onset is rapid, with a high temp (usually

>101.3° F/38.5° C), lethargy, anorexia, sore

throat. Patients do not have a harsh cough

associated with croup, often assume the tripod

position, and also have mouth drooling, an

ominous sign, and may demonstrate an

exhausted facial expression. Epiglottitis is more

common in children, but may occur in adults;

usually age 20 to 40. These patients are at high

risk for airway obstruction and need rapid

access of an airway (preferably in the operating

room).

3. ESI level 2. This patient is presenting with

signs of an acute stroke and requires immediate

evaluation. If he meets criteria for thrombolytic

therapy, he may still be in the time window of

less than three hours, but every minute counts

with this patient. He is a very high-priority ESI

level-2 patient.

4. ESI level 2. High risk for central retinal artery

occlusion caused by an embolus. This is one of

the few true ocular emergencies and can occur

in patients with risk factors of coronary artery

disease, hypertension, or embolus. Without

rapid intervention, irreversible loss of vision

can occur in 60 to 90 minutes.

5. ESI level 3. Since she is able to eat ice cream,

you would not give your last open bed for this

patient. She will probably require at least two

resources.

6. ESI level 2. High risk for compartment

syndrome. Despite the patient being a poor

historian, the triage nurse should be able to

identify some of the signs of threatened

compartment syndrome: Pain, pallor,

pulselessness, paresthesia, and paralysis. The

patient requires immediate life-saving

intervention: Cutting of the cast and further

evaluation for potential compartment

syndrome.

7. ESI level 2. High risk for sepsis or severe

dehydration. If the baby was alert and active

with good eye contact, similar complaints, and

a fever of 100.4° F or greater, the ESI category

would be 3. The temperature is not needed to

make the assessment that the baby is high risk.

The presence of lethargy and a sunken fontanel

are indications of severe dehydration.

8. Initially ESI level 3. However, the patient

could be upgraded to ESI level 2 if vital signs

were abnormal, i.e., heart rate greater than 100.

Signs of acute appendicitis include mild-tosevere right lower quadrant pain with loss of

appetite, nausea, vomiting, low-grade fever,

muscle rigidity, and left lower quadrant

A–3

Appendix A. Frequently Asked Questions
pressure that intensifies the right lower

quadrant pain. The presence of all these

symptoms and tachycardia would indicate a

high risk for a surgical emergency.

9. ESI level 2. High risk for epidural hematoma.

This is a great example of the importance of

understanding mechanism of injury. This man

was struck with a baseball bat to the head with

enough force to cause a witnessed loss of

consciousness. Patients with epidural

hematomas have a classic transient loss of

consciousness before they rapidly deteriorate.

Even though this patient looks good now and is

alert and oriented at present, he must be

immediately placed for further evaluation.

10. ESI level 2. High risk for severe alkaline burn.

Concrete is an alkaline substance and continues

to burn and penetrate the cornea causing severe

burns. Alkaline burns are more severe than

burns with acid substances and require

irrigation with very large amounts of fluids.

11. ESI level 2. High risk for lumbar and

calcaneus fractures. Again, mechanism of injury

is very important to evaluate. Although he is

not unresponsive or lethargic, he needs rapid

evaluation and treatment.

12. ESI level 2. Lethargy and high risk for severe

dehydration from probably diabetic

ketoacidosis (DKA). It is not normal for a 12-

year-old to be slumped over in a chair. Her

history of being thirsty and lethargic suggest a

strong suspicion for DKA. She needs rapid

evaluation and rehydration.

13. ESI level 2. High risk for a variety of

complications associated with cancer, i.e.,

pleural effusion, congestive heart failure,

further malignancy, and pulmonary embolus. A

history of cancer can help identify high-risk

status.

14. ESI level 1. Patient is placed in ESI level 1

after consideration of heart rate, skin condition

and blood pressure. Tachycardia and

hypotension indicate blood loss. The patient

needs immediate hemodynamic support.

15. ESI level 1. She is at high risk for abruptio

placentae, and needs an immediate cesarean

section to save the fetus. Abruption occurs

when the placenta separates from its normal

site of implantation. Primary causes include

hypertension, trauma, illegal drug use, and

short umbilical cord. Bleeding may be dark red

or absent when hidden behind the placenta.

Abruption is usually associated with pain of

varying intensity.

Chapter 4

Frequently Asked Questions

1. Why isn't crutch-walking instruction a

resource?

Though crutch-walking instruction may

consume a fair amount of the ED staff

members’ time, it is often provided to patients

who have simple ankle sprains. These patients

are typically classified as ESI level 4 (ankle x ray

= one resource). The patients are clearly less

acute and less resource intensive than more

complex patients like those with tibia/fibula

fractures who are usually ESI level 3 (leg films,

orthopedic consult, cast/splint, IV pain

medications = two or more resources). A better

way to reflect the ED staff's efforts for crutchwalking instruction is with a nursing resource

intensity measure.

2. Why isn't a splint a resource?

The application of simple, pre-formed splints

(such as splints for ankle sprains) is not

considered a resource. In contrast, the creation

and application of splints by ED staff, such as

thumb spica splints for thumb fractures, does

constitute a resource. A helpful way to

differentiate patients with extremity trauma is

as follows: patients with likely fractures should

be rated ESI level 3 (two or more resources:

x ray, pain medications, creation and

application of splints/casts); whereas patients

more likely to have simple sprains can be rated

as ESI level 4.

3. Why isn't a saline or heparin lock a

resource?

Generally speaking, insertion of a heparin lock

doesn't consume a large amount of ED staff

time. However, many patients who have

heparin locks inserted also have at least two

other resources (e.g., laboratory tests,

intravenous medications) and are therefore

classified as ESI level 3 anyway.

A–4

Appendix A. Frequently Asked Questions
4. Are all moderate sedation patients ESI

level 3 or higher?

Yes, moderate sedation is considered a complex

procedure (two resources) and is generally

performed with patients who also have

laboratory tests or x rays, and other procedures

such as fracture reduction or dilation and

curettage.

5. Which of the following are considered

resources: eye irrigation, nebulized

medication administration, and blood

transfusions?

All three are considered resources for the

purposes of ESI triage ratings. The resources

tend to be used for more acute patients, require

significant ED staff time, and likely lead to

longer length of stay for patients.

6. Are all asthmatics ESI level 4 because

they will require a nebulized

medication?

No. Stable asthmatics who only require

nebulized medications are assigned ESI level 4.

However, some asthmatics are in severe

respiratory distress and meet ESI level-2 criteria.

Others are somewhere in between and will

require intravenous steroids or an x ray in

addition to nebulized treatments and would be

assigned ESI level 3. Finally, asthmatics who

require only a prescription refill of their inhaler

are assigned ESI level 5. They do not require

any resources.

Post-Test Questions and Answers

Questions

Read the following statements and provide the

correct answer.

1. A magnetic resonance imaging (MRI) procedure

is considered a resource in the ESI triage system.

(T/F)

2. A psychiatry consult is considered a resource in

the ESI triage system.

(T/F)

3. Cardiac monitoring is considered a resource in

the ESI triage system.

(T/F)

4. How many ESI resources will this patient need?

A healthy 25-year-old construction worker

presents with back pain. The triage nurse

predicts he will need a lumbar spine x ray, oral

pain medication administered in the ED, and a

prescription to take home.

(0, 1, 2 or more)

5. It is necessary to take vital signs to determine

the number of ESI resources an adult ED patient

will need.

(T/F)

6. The triage nurse must have enough experience

to be certain about the resources needed for

each patient in order to accurately assign an ESI

triage level.

(T/F)

7. A 30-year-old sexually active female patient

with vaginal bleeding and cramping, doesn't

use birth control, and is dizzy and pale. In

determining this patient's ESI triage level, does

it matter if the local ED does urine pregnancy

tests at the point of care versus sending a

specimen to the laboratory?

(Y/N)

How many resources will this patient require?

(0, 1, 2 or more)

8. How many ESI resources will this patient need?

A healthy 40-year-old man presents to triage at

2:00 a.m. with a complaint of a toothache for

two days, no fever, and no history of chronic

medical conditions.

(0, 1, 2 or more, irrelevant)

9. How many ESI resources will this patient need?

A 22-year-old female involved in a high-speed

rollover motor vehicle collision and thrown

from the vehicle, presents intubated, no

response to pain, and hypotensive.

(0, 1, 2 or more, irrelevant)

10. How many ESI resources will this patient need?

A 60-year-old healthy male who everted his

ankle on the golf course presents with moderate

swelling and pain upon palpation of the lateral

malleolus.

(0, 1, 2 or more, irrelevant)

11. Is it considered an ESI resource if a patient

requires a constant observer to prevent a fall?

(Y/N)

A–5

Appendix A. Frequently Asked Questions
Answers

1. True. The MRI will make use of personnel

outside the ED (MRI staff) and increase the

patient's ED length of stay.

2. True. The consult involves personnel outside

the ED (psychiatry team) and increases the

patient's ED length of stay.

3. False. Monitoring is part of the routine care

provided by ED staff. However, most patients

who receive monitoring also need at least two

other ED resources (electrocardiogram, blood

tests, x rays), and may therefore be classified as

ESI level 3.

4. One ESI resource. The x ray is considered a

resource since it utilizes personnel outside the

ED. The oral pain medication and take-home

prescription are not considered resources since

they are quick interventions performed by ED

personnel.

5. False. While vital signs are helpful in up-triage

of level-3 patients to level 2, they are not

necessary for differentiating patients needing

one, two, or more than two resources.

6. False. The ESI is based upon the experienced

ED triage nurse's prediction, or estimation, of

the number and type of resources each patient

will need in the ED. The purpose of resource

prediction isn't to order tests or make an

accurate diagnosis, but to quickly sort patients

into distinct categories using acuity and

expected resources as a guide.

7. No, it doesn't matter. The patient will need

at least two resources, and be classified as a

level 3 whether the pregnancy test is done in

the ED (not a resource) or in the laboratory (a

resource). The predicted resources will include:

Complete blood count, intravenous fluids,

ultrasound, and possibly a gynecology consult

and intravenous medications if it is determined

that she is aborting a pregnancy and the

cervical os is open.

8. No resources. This patient will likely have a

brief exam (not a resource) and receive a

prescription for pain medication (not a

resource) by the provider, and therefore is an

ESI level-5 patient.

9. Irrelevant. The patient is an ESI level 1 based

on being intubated and unresponsive. The

nurse does not need to make a determination

of the number of resources in order to make the

triage classification.

10. One resource. The patient will need an ankle

x ray (one resource), and may get an ace wrap

or ankle splint (not a resource) and crutches

(not a resource). Simple ankle sprains are

generally classified as ESI level 4. However, if

the patient was in severe pain that required

pain medication by injection, or if he had a

deformity that might need a cast, orthopedic

consult and/or surgery, then he would need

two or more resources and be classified as an

ESI level 3.

11. Yes. A constant observer at the bedside is

considered a resource. However, if a patient is

ESI level 2 or high risk because they are a

danger to themselves or others, it is not

necessary to predict the number of resources

they will require in the ED.

Chapter 5

Frequently Asked Questions

1. Why aren't vital signs required to triage

ESI level-1 and level-2 patients?

Vital signs are not necessary to rate patients as

life threatening (ESI level 1) or high-risk (ESI

level 2). Since ESI level-1 and level-2 patients

are critical, they require the medical team to

respond quickly. Simultaneous actions can

occur and vital signs can be collected as part of

the initial assessment in the main acute area of

the emergency department. There is one

situation in which vital signs are taken for

level-1 or level-2 patients. If the life-threatening

situation is not initially obvious, the triage

nurse may recognize it only when vital signs

are taken. For example, a young healthy patient

with warm dry skin who complains of feeling

dizzy may not initially meet the level-1 or level2 criteria, until the heart rate is obtained and

found to be 166.

2. Why aren't vital signs required for ESI

level-4 and level-5 patients?

Vital signs are not necessary to rate patients as

low or no resource (ESI level 4 or 5). Also, the

pain, anxiety, and discomfort associated with

an emergency department visit often alter a

patient's vital signs. Vital signs may quickly

return to normal once the initial assessment is

A–6

Appendix A. Frequently Asked Questions
addressed. However, a nurse may choose to

assess vital signs if signs of deranged symptoms

exist (e.g., changes in skin color, mentation,

dizziness, sweating). If there is no physical sign

indicating a need for vital signs, the patient can

be taken in the main emergency department or

express care room.

3. Why are vital signs done on ESI level-3

patients?

Vital signs can aid in differentiating patients

needing multiple resources as either stable (ESI

level 3) or potentially unstable or high-risk (ESI

level 2). On occasion, ESI level-3 patients may

actually have unstable vital signs while

appearing stable. Vital signs for ESI level-3

patients provide a safety check. In general, ESI

level-3 patients are more complicated and

many are admitted to the hospital. Since these

patients are not appropriate for the fast-track

area, they are sometimes asked to wait for more

definitive care. These patients present a unique

challenge to the triaging process and caregivers

find it necessary to rely on vital signs to

confirm that an appropriate ESI level has been

assigned.

4. Why are temperatures always done for

pediatric patients less than 36 months?

Temperature is useful in differentiating pediatric

patients that are low or no resource (ESI level 4

or 5) from those that will consume multiple

resources. An abnormal temperature in the less

than 3-month-old may indicate bacteremia,

and place the child in a high-risk category.

5. Why does the literature present

conflicting information on the value of

vital signs during the triage process?

There is no definitive research on the utility of

vital signs for emergency department triage.

Many factors influence the accuracy of vital

sign data. Vital signs are a somewhat operatordependent component of a patient's

assessment. In some cases, vital signs may be

affected by many factors such as chronic drug

therapy (e.g., beta-blockers). Vital signs may

also be used to fulfill part of the public health

obligation assumed by emergency departments.

And, lastly, vital signs help segment young

pediatric patients into various categories.

6. Does The Joint Commission require vital

signs to be done during triage?

The Joint Commission does not specifically

state a standard for obtaining vital signs. The

organization does assert that physiologic

parameters should be assessed as determined by

patient condition.

7. Should vital sign criteria be strict in the

danger zone vital sign box?

In common usage, when the danger zone vital

sign criteria are exceeded, up-triage is

"considered" rather than automatic. The

experienced triage nurse is called on to use

good clinical judgment in rating the patient's

ESI level. The nurse incorporates information

about the vital signs, history, medications, and

clinical presentation of the patient in that

decisionmaking process. Research is still needed

to determine the predictive value of vital signs

at triage, and to determine absolute cutoffs for

up-triage.

8. What if ESI level-4 or -5 patients have

danger zone vital signs?

Though it is not required to take vital signs in

order to assign ESI 4 or 5 levels, many patients

may have vitals assessed at triage if that is part

of the particular ED's operational process. Per

the ESI triage algorithm, the triage nurse does

not have to take the vital signs into account in

determining that the patient meets ESI level-5

(no resources) or ESI level-4 (one resource)

criteria. However, in practice, the prudent nurse

will use good clinical judgment and take the

vital sign information into account in rating

the ESI level. If the patient requests only a

prescription refill and has no acute complaints,

but has a heart rate of 104 after walking up the

hill to the ED, the nurse might still rate the

patient as an ESI level 5. But if the patient

requests a prescription refill and has a heart rate

of 148 and irregular, the nurse should rate the

patient as ESI level 2. The triage nurse must also

consider the following dilemma: an elevated

blood pressure in an ESI level-4 or 5 patient. If

the patient is asymptomatic related to the

blood pressure, the triage level should not

change. Most likely, an elevated BP in the

asymptomatic patient will not be treated in the

ED. However, it may be important to refer the

patient to a primary care physician for BP

follow-up and long-term diagnosis and

treatment.

A–7

Appendix A. Frequently Asked Questions
Post-Test Questions and Answers

Questions

Rate the ESI level for each of the following patients.

1. 3-week-old male

Vital signs:

Temperature: 100.8° F (38.2° C)

Heart rate: 160

Respiratory rate: 48

Oxygen saturation: 96%

Narrative:

Poor feeding

Less active than usual

Sleeping most of the day

2. 22-month-old, fever, pulling ears,

immunizations up to date, history of frequent

ear infections

Vital signs:

Temperature: 102° F (39° C)

Heart rate: 128

Respiratory rate: 28

Oxygen saturation: 97%

Narrative:

Awoke screaming

Pulling at ears

Runny nose this week

Alert, tired, flushed, falling asleep now

Calm in mom's arms, cries with exam

3. 6-year-old with cough

Vital signs:

Temperature: 104.4° F (40.2° C)

Heart rate: 140

Respiratory rate: 30

Oxygen saturation: 91%

Narrative:

Cough with fever for two days

Chills

Short of breath with exertion

Green phlegm

Sleeping a lot

4. 94-year-old male, abdominal pain

Vital signs:

Temperature: 98.9° F (37.2° C)

Heart rate: 100

Blood pressure: 130/80

Oxygen saturation: 93%

Narrative:

Vomiting

Epigastric pain

Looks sick

5. 61-year-old female, referred with asthma

Vital signs:

Temperature: 99.1° F (37.3° C)

Heart rate: 112

Respiratory rate: 28

Blood pressure: 157/94

Oxygen saturation: 91%

Peak expiratory flow rate = 200

Narrative:

Asthma exacerbation with dry cough

Steroid dependent

Multiple hospitalizations

Never intubated

6. 9-year-old male, head trauma

Narrative:

Collided with another player at lacrosse game

Loss of consciousness for “about 5 minutes,”

witnessed by coach

Now awake with headache and nausea

Answers

1. ESI level 2. An infant less than 28 days with a

temperature greater than 38.0° C (100.4° F) is

considered high risk regardless of how good

they look. With a child between 3 and 36

months with a fever greater than 39.0° C

(102.2° F), the triage nurse should consider

assigning ESI level 3, if there is no obvious

source for a fever or the child has incomplete

immunizations.

2. ESI level 5. A child under 36 months of age

requires vital signs. This child has a history of

frequent ear infections, is up to date on

immunizations and presents with signs of

another ear infection. This child meets the

criteria for ESI level 5 (exam, PO medication

administration and discharge to home). Danger

zone vitals not exceeded. If the child was

underimmunized or there was no obvious

source of infection, the child would be assigned

to ESI level 3.

3. ESI level 2. The clinical picture indicates high

probability of tests that equal two or more

resources (ESI level 3). Danger zone vital signs

exceeded (SpO2 = 91%, Respiratory rate = 30),

making the patient an ESI level 2.

4. ESI level 2. The clinical picture mandates ESI

level 3 with expected utilization of x ray, blood

work, and specialist consultation resources.

Danger zone vital signs not exceeded. If an

experienced triage nurse reported this patient as

looking in imminent danger of deterioration,

the patient may be upgraded to an ESI level 2.

A–8

Appendix A. Frequently Asked Questions
A 94-year-old ill-appearing patient presenting

with epigastric pain, vomiting, and probable

dehydration should be considered a high-risk

ESI level-2 patient. If this patient did not look

toxic, an ESI level 3 might be an appropriate

starting point in the decision algorithm.

5. ESI level 2. The clinical picture mandates ESI

level 3 with expected utilization of x ray, blood

work, and specialist consultation resources.

Respiratory rate and heart rate danger zone vital

signs are exceeded, so patient is up-triaged to

ESI level 2.

6. ESI level 2. This patient is assigned an ESI

level 2 due to the high-risk information

provided in the scenario. Vital signs are not

necessary, and patient should be immediately

taken to treatment area for rapid assessment.

Chapter 6

Frequently Asked Questions

1. How do you rate the ESI level for

children with rashes, since some rashes

are of great concern while others are less

serious?

In triaging patients with rashes (as with other

conditions), the most important action by the

triage nurse is to perform a quick assessment of

the patient’s appearance, work of breathing and

circulation. These will give the nurse

information about the physiological stability of

the child and facilitate assessment of their need

for life support or their high risk status. If the

child with a rash does not meet level 1 or 2

criteria, then the history becomes an important

factor in determining the ESI level. Key

information in the history of patients with a

rash includes the presence of a fever, exposure

to tick bites, or exposure to plants that might

indicate contact dermatitis.

2. Why isn’t the placement of a saline lock

a resource for pediatric patients? It is a

much more intensive procedure in

children, especially infants and small

children who need to be immobilized

for the procedure.

While the placement of a saline lock in a young

child is a more involved procedure than in

adults, in the ESI system resources are proxies

for acuity and are not used to monitor nursing

resource intensity. Children in need of saline

locks are likely going to need other

interventions such as laboratory studies and

medications or fluid, and thus qualify for ESI

level 3 based on these additional resource

needs. In the unusual case of a child needing a

prophylactic saline lock but no other resources,

the child is likely to be of lower acuity and thus

not likely to be a level-3 patient.

3. Since resource prediction is a major part

of the ESI, have you considered changing

the ESI for pediatrics to reflect the fact

that resources for children are different

than adults?

We actually studied this in the course of the

pediatric ESI study (Travers et al., 2009). The

study results did not support this. The use of

resources in the differentiation of ESI level 3, 4

and 5 is a proxy for acuity, not a staff workload

index. Children who require fewer resources

tend to be less acute than those who require

more resources, even though some resources

(e.g., placing a splint) may be more timeconsuming in children than adults.

4. Are you going to create a separate

pediatric version of the ESI?

No. Again, we studied this in the course of the

pediatric ESI study (Travers et al., 2009) but the

results did not support the creation of a

separate ESI for children. An additional

consideration is the increased complexity that

would be introduced for triage nurses if they

had to use 2 different algorithms, one for

children and one for adults. The ESI version 4

does include vital signs criteria for all ages,

including 3 categories for ages from birth to 8

years, so it is an all-age triage tool.

Post-test Questions and Answers

Questions

Rate the ESI level for each patient.

Level Patient

1. _________ A 14-year-old with rash on feet, was

exposed to poison ivy 3 days ago.

Ambulatory, with stable vital signs.

2. _________ A 3-month-old with petechial and

purpuric lesions all over. Vital signs:

respiratory rate 60, heart rate 196,

oxygen saturation 90%, temperature

39°C rectal.

A–9

Appendix A. Frequently Asked Questions
3. _________ A 5-year-old with rash on neck and

face, with swelling and moist lesions

around the eyes and cheeks. Vital

signs: respiratory rate 20, heart rate

100, oxygen saturation 99%,

temperature 37°C. Respirations nonlabored. Was treated by her

pediatrician yesterday for poison ivy

on the neck, but the rash is worse

and spreading today. Mom states

child not eating or drinking well

today and was up most of the night

crying with itching and pain.

4. _________ A 10-year-old patient presents with

facial swelling after eating a cookie

at school. Fine red rash all over. Has

a history of peanut allergies.

Wheezing heard upon auscultation.

Vital signs: respiratory rate 16, heart

rate 76, oxygen saturation 97%,

temperature 36.7°C.

5. _________ An 8-year-old healthy child with a

fever of 38.7°C at home arrives at

triage with complaints of a sore

throat and a fine red sandpaper rash

across chest. Sibling at home had a

positive strep culture at the

pediatrician a few days ago.

Respirations are non-labored. Vital

signs are stable.

Answers

1. ESI level 5. This patient has a rash but is able

to ambulate and has no abnormalities in

appearance, work of breathing or circulation.

During his ED visit he will receive an exam and

perhaps a prescription, but no ESI resources.

2. ESI level 1. The baby has the classic signs of

meningococcemia with abnormalities in

appearance, work of breathing and circulation.

She needs immediate life-saving interventions.

3. ESI level 3. Unlike the first patient with

poison ivy, this patient will likely need

additional interventions including possible

intravenous hydration and medications to

reduce swelling.

4. ESI level 2. Though this patient has stable

vital signs, she is at high risk of respiratory

compromise given her history and wheezing.

She is a high risk patient and should be

promptly taken to the treatment area for

monitoring and treatment.

5. ESI level 4. This is a healthy patient with

stable vital signs and a family member with a

positive strep culture. One resource would be a

strep culture.

Chapter 7

Post-Test Questions and Answers

Questions

1. Identify the three phases of change described

by Lewin.

2. The ESI algorithm is so simple; why do the

nurses need two hours of education to learn to

use it?

3. As the nurse manager of a low-volume

emergency department, do I still need an

implementation team?

Answers

1. Unfreezing, movement, and refreezing.

2. Yes, the algorithm looks simple but staff needs

to develop a clear understanding of each of the

decision points. Application to realistic cases

will reinforce learning.

3. The change process is never easy. An

implementation team provides input from

various members of the department. The team

can assist in developing and carrying out the

implementation plan.

A–10

Appendix A. Frequently Asked Questions
Chapter 8

Frequently Asked Questions

1. What if we don't have good electronic

data monitoring systems for QI efforts?

Although it is very helpful and will expand the

number of indicators you can monitor, you do

not have to have electronic data monitoring to

perform ESI QI.

2. Can staff nurses monitor each other for

the accuracy of the ESI triage acuity

rating?

No. An expert nurse in triage should determine

whether the acuity ratings are correct.

3. How many indicators should we be

monitoring?

This is a decision to be made by the leadership

team. Select only those indicators that have

been identified as important to your ED and

select only the number of indicators you have

the resources to monitor.

Reference

Travers D, Waller A, Katznelson J, Agans R (2009).

Reliability and validity of the Emergency Severity Index

for pediatric triage. Acad Emerg Med. 16(9):843-849.

A–11

Appendix A. Frequently Asked Questions
B–1

Appendix B.

ESITriage Algorithm, v.4
B–2

Appendix B. ESITriage Algorithm, v 4

Notes:

A. Immediate life-saving intervention required: airway, emergency medications, or

other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO

NOT count); and/or any of the following clinical conditions: intubated, apneic,

pulseless, severe respiratory distress, SPO2<90, acute mental status changes, or

unresponsive.

Unresponsiveness is defined as a patient that is either:

(1) nonverbal and not following commands (acutely); or 

(2) requires noxious stimulus (P or U on AVPU) scale.

B. High risk situation is a patient you would put in your last open bed. 

Severe pain/distress is determined by clinical observation and/or patient rating of

greater than or equal to 7 on 0-10 pain scale.

C. Resources: Count the number of different types of resources, not the individual 

tests or x-rays (examples: CBC, electrolytes and coags equals one resource; CBC

plus chest x-ray equals two resources).

Resources

• Labs (blood, urine)

• ECG, X-rays

• CT-MRI-ultrasound-angiography

• IV fluids (hydration) 

• IV or IM or nebulized medications 

• Specialty consultation 

• Simple procedure =1

(lac repair, foley cath)

• Complex procedure =2

(conscious sedation) 

Not Resources

• History & physical (including pelvic)

• Point-of-care testing

• Saline or heplock

• PO medications

• Tetanus immunization

• Prescription refills

• Phone call to PCP

• Simple wound care 

(dressings, recheck)

• Crutches, splints, slings

D. Danger Zone Vital Signs

Consider uptriage to ESI 2 if any vital sign criterion is exceeded.

Pediatric Fever Considerations

1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)

1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F)

3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), 

or incomplete immunizations, or no obvious source of fever

© ESI Triage Research Team, 2004 – (Refer to teaching materials for further clarification)
AAA Abdominal Aortic Aneurysm

AAP American Academy of Pediatrics

ABCD Airway, Breathing, Circulation,

Disability

ABCDE Airway/Breathing/Circulation/

Disability/Exposure-Environmental

Control

ACEP American College of Emergency

Physicians

ACS Acute Coronary Syndromes

ADHD Attention Deficit Hyperactivity Disorder

AHA American Hospital Association

AHRQ Agency for Healthcare Research and

Quality

APLS Advanced Pediatric Life Support

ASA Acetylsalicylic Acid

AVPU Alert, Verbal, Pain, Unresponsive

BP Blood Pressure

C Centigrade

CBC Complete Blood Count

CDC Centers for Disease Control and

Prevention

CNS Clinical Nurse Specialist

COPD Chronic Obstructive Pulmonary Disease

CPR Cardiopulmonary Resuscitation

CSF Cerebrospinal Fluid

CT Computed (axial) Tomography

CTAS Canadian Triage and Acuity Scale

DKA Diabetic Ketoacidosis

ECG Electrocardiogram

ED Emergency Department

EMS Emergency Medical Services

EMT Emergency Medical Technician

ENA Emergency Nurses Association

ESI Emergency Severity Index

F Female or Fahrenheit

HR Heart Rate

HRSA Health Resources and Services

Administration

HTN Hypertension

IOM Institute of Medicine

IV Intravenous

M Month or Male

MRI Magnetic Resonance Imaging

NORC National Opinion Research Center

OTC Over the Counter

Palp. Palpated or Palpable

PALS Pediatric Advanced Life Support

PAT Pediatric Assessment Triangle

PEG Percutaneous Endoscopic Gastrostomy

PEPP Pediatric Education for Prehospital

Professionals

PMH Past Medical History

QI Quality Improvement

RN Registered Nurse

RR Respiratory Rate

SIRS Systemic Inflammatory Response

Syndrome

SpO2 Oxygen Saturation

T Temperature

TTS Taiwan Triage System

URI Upper Respiratory Illness

UTI Urinary Tract Infection

VS Vital Signs

VSS Vital Signs Stable

Y Year

C–1

Appendix C. Abbreviations and Acronyms

(as used in this handbook)
high risk situation?

or

confused/lethargic/disoriented?

or

severe pain/distress?

danger zone

vitals?

<3 m >180 >50

3 m-3y >160 >40

3-8 y >140 >30

>8y >100 >20

how many different resources are needed?

none one many

ESI Triage Algorithm, v4

© ESI Triage Research Team, 2004

1

2

5 4

3

A

B

C

D

requires immediate 

life-saving intervention?

yes

no

no

yes

consider

RR

HR

SaO2<92%

A

high risk situation?

or

confused/lethargic/disoriented?

or

severe pain/distress?

danger zone

vitals?

<3 m >180 >50

3 m-3y >160 >40

3-8 y >140 >30

>8y >100 >20

how many different resources are needed?

none one many

ESI Triage Algorithm, v4

© ESI Triage Research Team, 2004

1

2

5 4

3

A

B

C

D

requires immediate 

life-saving intervention?

yes

no

no

yes

consider

RR

HR

SaO2<92%

A
Notes:

A. Immediate life-saving intervention required: airway, emergency medications, or

other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO

NOT count); and/or any of the following clinical conditions: intubated, apneic,

pulseless, severe respiratory distress, SPO2<90, acute mental status changes, or

unresponsive.

Unresponsiveness is defined as a patient that is either:

(1) nonverbal and not following commands (acutely); or 

(2) requires noxious stimulus (P or U on AVPU) scale.

B. High risk situation is a patient you would put in your last open bed. 

Severe pain/distress is determined by clinical observation and/or patient rating of

greater than or equal to 7 on 0-10 pain scale.

C. Resources: Count the number of different types of resources, not the individual 

tests or x-rays (examples: CBC, electrolytes and coags equals one resource; CBC

plus chest x-ray equals two resources).

Resources

• Labs (blood, urine)

• ECG, X-rays

• CT-MRI-ultrasound-angiography

• IV fluids (hydration) 

• IV or IM or nebulized medications 

• Specialty consultation 

• Simple procedure =1

(lac repair, foley cath)

• Complex procedure =2

(conscious sedation) 

Not Resources

• History & physical (including pelvic)

• Point-of-care testing

• Saline or heplock

• PO medications

• Tetanus immunization

• Prescription refills

• Phone call to PCP

• Simple wound care 

(dressings, recheck)

• Crutches, splints, slings

D. Danger Zone Vital Signs

Consider uptriage to ESI 2 if any vital sign criterion is exceeded.

Pediatric Fever Considerations

1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)

1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F)

3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), 

or incomplete immunizations, or no obvious source of fever

© ESI Triage Research Team, 2004 – (Refer to teaching materials for further clarification)

Notes:

A. Immediate life-saving intervention required: airway, emergency medications, or

other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO

NOT count); and/or any of the following clinical conditions: intubated, apneic,

pulseless, severe respiratory distress, SPO2<90, acute mental status changes, or

unresponsive.

Unresponsiveness is defined as a patient that is either:

(1) nonverbal and not following commands (acutely); or 

(2) requires noxious stimulus (P or U on AVPU) scale.

B. High risk situation is a patient you would put in your last open bed. 

Severe pain/distress is determined by clinical observation and/or patient rating of

greater than or equal to 7 on 0-10 pain scale.

C. Resources: Count the number of different types of resources, not the individual 

tests or x-rays (examples: CBC, electrolytes and coags equals one resource; CBC

plus chest x-ray equals two resources).

Resources

• Labs (blood, urine)

• ECG, X-rays

• CT-MRI-ultrasound-angiography

• IV fluids (hydration) 

• IV or IM or nebulized medications 

• Specialty consultation 

• Simple procedure =1

(lac repair, foley cath)

• Complex procedure =2

(conscious sedation) 

Not Resources

• History & physical (including pelvic)

• Point-of-care testing

• Saline or heplock

• PO medications

• Tetanus immunization

• Prescription refills

• Phone call to PCP

• Simple wound care 

(dressings, recheck)

• Crutches, splints, slings

D. Danger Zone Vital Signs

Consider uptriage to ESI 2 if any vital sign criterion is exceeded.

Pediatric Fever Considerations

1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)

1-3 months of age: consider assigning ESI 2 if temp >38.0 C (100.4F)

3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), 

or incomplete immunizations, or no obvious source of fever

© ESI Triage Research Team, 2004 – (Refer to teaching materials for further clarification)
U.S. Department of

Health and Human Services

Agency for Healthcare Research and Quality

540 Gaither Road

Rockville, MD 20850

AHRQ Pub. No. 12-0014

November 2011

www.ahrq.gov

ISBN: 978-1-58763-416-1