Emergency Medicine Book

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Emergency Department Triage System

Aka: Emergency Department Triage System, Emergency Severity Index
  1. Protocol: Emergency Severity Index or ESI (Richard Wuerz MD, 2000)
    1. Resource Criteria (for each category, assign 1 point unless otherwise noted)
      1. Lab (blood or urine)
      2. Electrocardiogram or plain-film XRay
      3. Advanced Imaging (CT, MRI, Ultrasound)
      4. Intravenous Fluids (IV Access alone is not a resource)
      5. Intravenous or Intramuscular medications
      6. Specialty Consultation
      7. Procedure (simple=1 point, complex=2 points)
        1. Simple procedure (Laceration Repair, Incision and Drainage, Foley Catheter placement)
        2. Complex procedure (e.g. requiring Conscious Sedation)
    2. ESI 5
      1. No resources needed (e.g. Otalgia)
    3. ESI 4
      1. One resource needed (e.g. Pharyngitis with likely strep test)
    4. ESI 3
      1. Many resources needed, but Vital Signs not significantly abnormal (see ESI 2 for vital cutoffs)
    5. ESI 2
      1. High risk situation
      2. Confused, lethargic or disoriented
      3. Severe pain or distress
      4. Many resources needed AND significantly abnormal Vital Signs
        1. Oxygen Saturation <92% at any age
        2. Age <3 months
          1. Heart Rate >180
          2. Respiratory Rate >50
        3. Age 3 months to 3 years old
          1. Heart Rate >160
          2. Respiratory Rate >40
        4. Age 3 years to 8 years old
          1. Heart Rate >140
          2. Respiratory Rate >30
        5. Age >8 years old and adults
          1. Heart Rate >100
          2. Respiratory Rate >20
    6. ESI 1
      1. Immediate life saving intervention needed
  2. Precautions
    1. ESI 3 patients are the most troublesome for triage systems as 50% of ED patients fall into this category
    2. ESI 3 subdividing tools that may allow for better patient flow
      1. Vertical flow
        1. Patient is evaluated, tested in exam room and returns to waiting room
      2. Provider in triage
        1. May identify subtle presentations of severe disease
        2. Initiates targeted work-up quickly
      3. Split flow
        1. Low variability group (predictable workup)
        2. High variability group (more complex workup)
      4. Electronic triage system
        1. Experimental application of machine learning to further categorize severity
        2. Levin (2017) Ann Emerg Med +PMID:28888332 [PubMed]
  3. Resources
    1. AHRQ
      1. https://www.ahrq.gov/professionals/systems/hospital/esi/index.html
    2. GridLockED Game (for medical students, interns)
      1. https://www.gridlockedgame.com/
  4. References
    1. Mason and Chan in Herbert (2018) EM:Rap 18(5): 12-3

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