1. Multi-site Evaluation of ESI Triage Levels
and Medication Administration Times
Christy Starr, SN
Introduction/Background
There are many studies that focus on
the assignment/accuracy of Emergency
Severity Index (ESI) scores in an
Emergency Department (ED) setting
but there are very few that focus on the
relationship between assigned ESI
scores and their influence on timeliness
of pain medicine administration or
selection of pain medication.
§ The ESI score is determined through
assessment of each patient’s acuity
through interview, clinical evaluation
of presenting symptoms and vital
signs by the triage nurse and
assigned based on the acuity plus
the anticipated resources the patient
will require1
§ Pain is the most common presenting
symptom in the Emergency
Department (ED) and accounts for
up to 78% of visits, making its
management a priority of ED care2
§ A study by van der Wulp found that
pain was not associated with
urgency for analgesic administration3
Results/Findings
• No statistically significant differences
were noted when timeliness in pain
medication administration was compared
across the ESI triage categories.
Discussion
• Subjects triaged to higher acuity
categories received stronger pain
medications than those triaged to less
acute categories.
• Triage category was not related to
timeliness in pain medication
administration. This may be explained by
the fact that lower acuity patients are
treated in ED “fast track” areas designed
for low-acuity, quick visits.
References
Research mentor: Darrell Spurlock, Jr. PhD, RN-
Riverside Methodist Hospital.
Swailes, E., Rich, E., Lock, K., & Cicotte, C. (2009). From
Triage to Treatment of Severe Abdominal Pain in the
Emergency Department: Evaluating the Implementation of the
Emergency Severity Index. Journal of Emergency Nursing,
485-489.1,2
Van der Wulp, I., Rullmann, H., Leenen, L., & Stel, H. (2011).
Associations of the Emergency Severity Index triage categories
with patients' vital signs at triage: A prospective observational
study. Emergency Medicine Journal, 1032-1035.3
Aims/Purpose
The purpose of this study is to evaluate
the relationship between nurse-
assigned Emergency Severity Index
(ESI) scores (a measure of triage
acuity), selection of pain medication,
and timeliness in pain medication
administration.
Methods/Measurements
This study answers sub-questions from
a larger, combined retrospective /
prospective study in which retrospective
patient-level data from medical records
of patients receiving at least one of from
among four common opioid pain
medications in the emergency
department of a large urban ED
(>90,000 visits/year) in a Midwestern
city and a moderate sized (>60,000
visits/year) ED in a rural Appalachian
town were combined with prospective
ED conditions data collected hourly over
a 3 month period in 2013.
Patient-level data including chief
complaint, ESI score, number of
previous visits to the ED in the past 12
months, opioid administered and before
and after pain scores and other
variables were coded and entered into a
spreadsheet by trained research staff
and then analyzed using SPSS v 22.
Results/Findings
• The charts of N = 1,966 patients were
examined. The average age of subjects
was M = 46.2 (SD = 17.4) years. Subjects
were 46.6% male and 53.4% female.
• 77% of subjects were triaged as ESI level
3; an equal proportion, 11%, were triaged
at Level 2 and Level 4. Only .6% were
triaged at ESI Level 1 and .1% were
triaged at ESI Level 5.
• When the type of opioid administered was
compared across ESI triage categories,
there was a statistically significant
difference in proportions of subjects
receiving each medication (χ2 (12) =
394.03, p <.001.). Subjects triaged at ESI
2 and 3 (more acute on the ESI 1-5 scale)
were more likely to receive a stronger
opioid, e.g., hydromorphone or morphine,
than hydrocodone.
45.5%
53.1%
22.2%
45.9%
30.7%
7.4%
3.2%
3.2%
8.8%
5.5%
13.0%
61.6%
100.0%
ESI
2
ESI
3
ESI
4
ESI
5
0%
20%
40%
60%
80%
100%
Type
of
Pain
Medica;on
Received
by
ESI
Triage
Category
(N
=
1,966)
71
66
81
63
93
0
20
40
60
80
100
ESI
1
ESI
2
ESI
3
ESI
4
ESI
5
Median
Door-­‐to-­‐Medica;on
Minutes
by
ESI
Triage
Category
(N
=
1,966)