EMERGENCY SEVERITY INDEX

1. EMERGENCY SEVERITY INDEX
USMAN KHALID

2. Overview of ESI
ESI is a five level triage Algorithm that categorizes
ED patients by evaluating both
PATIENT ACUITY (URGENCY) AND
RESOURCE NEEDED.

3. “Triage” is derived from the French verb
“trier,” to “sort” or “choose.”
Originally the process was used by the
military to sort soldiers wounded in battle
for the purpose of establishing treatment
priorities.

4. DEFINITION OF TRIAGE
Classification of patient acuity that characterizes
the degree to which the patient’s condition is life
or limb threatening and whether immediate
treatment is needed to alleviate symptoms

5. WHAT CONSTITUTES A GOOD TRIAGE
INSTRUMENT?
• Facilitates the prioritization of patients based on
the urgency of the patient’s condition
▫ “Who should be seen first?”
▫ “How long can everybody wait?”
▫ “Which resources are needed?”
• Patient streaming:
▫ Getting the right patient to the right resources at
the right place and at the right time

6. INTRODUCTION TO ESI
(EMERGENCY SEVERITY INDEX)
• Simple to use
• 5 levels of triage
• Categorizes patients by evaluating patient acuity
and resources
• Acuity is determined by the stability of vital
functions and potential for life, limb, or organ
threat

7. Triage Nurse
Assesses only the acuity level
Based on his/her pervious
experience with patients presenting
with similar injuries or complaints.

9. Four Decision Points
• A …Does Patient require immediate life
saving intervention?
• B…Is this a Patient who should NOT wait?
• C…How many resources will this patient
need?
• D...What are the Patient's Vital Signs?

10. A
B
C
D

11. Decision Point A
• Does the Patient Require Immediate Life Saving
Intervention?
▫ Airway
▫ Breathing
▫ Circulation
▫ Life Saving Medication?
▫ Life Saving Procedure?

12. Decision point A is this patient dying ?
• Does this patient require immediate life saving
intervention?
 Airway Obstructed or partially obstructed.
Unable to protect their own airway.
Breathing Apneic
Intubated prehospital
Sever respiratory distress
Spo2 less than 90%

13. Aggressive Life-saving Intervention
Will this intervention save this person’s life?
• Airway Breathing
▫ Intubation
▫ Surgical airway
▫ CPAP , BIPAP
▫ Bag Valve mask
ventilation
• Defibrillation
• External pacing
• Chest needle
decompression
• Hemodynamics
▫ Significant IV fluids
resuscitation
▫ Blood administration
▫ IV medication –
vasopressors
• Control of major
bleeding

14. ALGORITHM
DECISION POINT A
• Does the patient require immediate life-saving
intervention?
▫ Level 1 patients are seen immediately because
timeliness of interventions can affect morbidity
and mortality
 Immediate physician involvement in the care of the
patient is a key difference between level 1 and level 2
• UNRESPONSIVENESS
▫ Goal is to identify the patient who has an acute
change in LOC—compare with baseline

15. EXAMPLES OF LEVEL 1
• Cardiac arrest
• Respiratory arrest
• Spo2 < 90%
• Critically injured trauma patient who presents unresponsive
• Overdose with a RR of 6/min
• Severe respiratory distress with agonal or gasping respirations
• Severe bradycardia or tachycardia with signs of hypoperfusion
• Trauma patient who requires immediate crystalloid and
colloid resuscitation
• Chest pain, pale, diaphoretic, BP 70/P
• Weak and dizzy, HR =30
• Anaphylactic reaction
• Baby that is flaccid
• Unresponsive with strong odor of ethyl alcohol, or ethanol
• Hypoglycemia with a change in mental status

16. B
C
A
D

17. ALGORITHM
DECISION POINT B
• Should the patient wait?
▫ 3 questions to determine level 2
 Is this a high risk situation
 A patient whose condition could easily deteriorate
 Is the patient confused, lethargic, or disoriented
 Is the patient in severe pain or distress
 Self reported pain level of 7 or higher on a 0-10 scale
 Clinical observation
 Severe distress
• If the answers to the questions at the first two
decision points are “no,” the triage nurse moves
to Decision Point C

18. ESI LEVEL 2
• A potential major life or organ threat
• Unsafe to remain in waiting room for any length
of time
• Need for care is immediate
• Appropriate bed needs to be found
• Use “sixth sense”
• Consider patient’s age and PMH
• While ESI does not suggest specific time
intervals, ESI level 2 patients remain a high
priority and generally placement and treatment
should be initiated within 10 minutes of arrival

19. EXAMPLES OF LEVEL 2
• Active chest pain, suspicious for coronary
syndrome, but does not require an immediate
life saving intervention (stable)
• Needle stick in a health care worker
• Signs of stroke, but does not meet level 1 criteria
• Rule out ectopic pregnancy, hemodynamically
stable
• Patient on chemo, and therefore
immunocompromised, with a fever
• Suicidal or homicidal patient

20. ESI LEVEL 2
In general, care of ESI level-2 patients should be
rapidly facilitated and patients should ideally
wait no longer than 10 minutes to be placed in
the treatment area. All level-2 patients are still
very ill and require rapid initiation of care and
evaluation

21. A
B
C
D

22. ALGORITHM DECISION POINT C
• “How many different resources are needed?”
• Be familiar with the ED standards of care to
identify resource needs
• Resource prediction is only used for less acute
patients and is an integral part of the ESI levels
3, 4, or 5

23. ESI LEVEL 3
• Patients who are expected to need two or more
resources are designated an ESI level-3. Once
the triage nurse has identified two probable
resources, there is no need to continue to
estimate resources
• 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
• Usually, a patient requires either no resources,
one, or two or more resources

24. RESOURCES
RESOURCES NOT RESOURCES
• Labs (blood, urine)
• EKG, X-rays
• CT, MRI, U/S
• IV fluids(hydration)
• IV or IM or nebulized meds
• Simple procedure =1 (lac repair,
foley)
• Complex procedure =2 (conscious
sedation)
• Specialty consultation
• H & P (including pelvic)
• Point-of-care testing
• Saline lock
• PO meds
• Tetanus immunization
• Prescription refills
• Simple wound care (dressings,
recheck
• Crutches, splints, slings
• Phone call to PCP

25. ESI LEVEL 4 AND 5
If your patient does not need two resources, you
must determine how many resources if any to
decide on an ESI Level 4 or 5
▫ Level 4 – One resource
▫ Level 5 – No resources

27. SCENARIO 1
• 22 year old male with RLQ pain since early this
morning, also c/o nausea and no appetite
• PREDICTED RESOURCES:
 2 or more: lab studies, IV fluids, Abdominal CT,
possible surgery consult
• ESI TRIAGE CATEGORY:
 3

28. SCENARIO 2
• 45 year old obese female with left lower leg pain
and swelling which started 2 days ago, after
driving in a car for 12 hours
• PREDICTED RESOURCES:
• Labs, ultrasound, possible anticoagulant therapy
• ESI TRIAGE CATEGORY:
• 3

29. SCENARIO 3
• Healthy, 19 year old female who twisted her
ankle playing soccer. Edema at lateral
malleolus; hurts to bear weight
• PREDICTED RESOURCES:
• Ankle x-ray
• ESI TRIAGE CATEGORY:
• 4

30. SCENARIO 4
• Healthy 29 year old female with UTI symptoms,
appears well; afebrile; denies vaginal discharge
• PREDICTED RESOURCES:
• Urine and urine culture, possible urine hCG
• ESI TRIAGE CATEGORY:
• 4

31. SCENARIO 5
• Healthy 10 year old child with poison ivy on
extremities
• PREDICTED RESOURCES:
• None
• ESI TRIAGE CATEGORY:
▫ 5

32. SCENARIO 6
• Healthy 52 year old man ran out of BP
medication yesterday. BP 150/84. No acute
complaints
• PREDICTED RESOURCES:
• None
• ESI TRIAGE CATEGORY:
• 5

33. A
B
C
D

34. DECISION POINT D
DANGER ZONE VITAL SIGNS
• At this point in the algorithm, the triage nurse
has already determined that the patient is
considered a level 3
• If the danger zone vital sign limits are exceeded,
the triage nurse must consider up-triaging the
patient from a level 3 to a level 2
• HR, RR, O2 Sat in all patients and temperature
in children under age 3 are the vital sign
parameters considered in decision point D

35. PEDIATRIC VITAL SIGNS
• The ESI Research Team recommends that vital signs
in patients under age 3 be assessed at triage.
▫ Vital sign evaluation is essential to the overall
assessment of a known febrile infant under age 36
months.
▫ This helps to differentiate ESI level-2 and 3 patients
and minimize the risk that potentially bacteremic
children will be sent to the waiting area and experience
an inappropriate wait.
• When triaging a child between 3 and 36 months of
age who is highly febrile, it is important to assess the
child’s immunization status and whether there is an
identifiable source for the fever

36. ESI PEDIATRIC
TEMPERATURE CRITERIA
AGE TEMPERATURE ESI LEVEL
1- 28 Days Fever > 100.4˚F 2
1-3 Months Fever >100.4˚F Consider 2
3-36 Months Fever > 102.2˚F Consider 3

37. SCENARIOS IN WHICH FLOW AND
TRIAGE CATEGORY MAY CONFLICT
TRAUMA
The patient 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-1. However, the
patient is at high risk for a liver laceration and
other significant trauma, so should be triaged as
ESI level 2.

38. CHEST PAIN
If a patient is physiologically stable but
experiencing chest pain that is potentially an
acute coronary syndrome, the patient meets
level-2 criteria. They do not require immediate
life saving interventions but they are a high risk
patient. Their care is time-sensitive, an EKG
should be performed within 10 minutes of
patient arrival. But the patient with chest pain
who presents to triage diaphoretic, with a BP of
80/palp would meet level-1 criteria.

39. STROKE
A patient who present with signs of an acute
stroke. Again, if physiologically stable, a 10
minute wait to initiate care will probably not
further compromise the patient. However, the
patient with signs of stroke that is unable to
maintain an airway meets ESI level-1 criteria.

40. CONSIDER PAIN
An elderly patient 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

41. ARRIVING BY AMBULANCE
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