ESI Education Medical Presentation

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Published on : May 07, 2018 | Views : 2882 | Downloads : 7

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dr.ssmohit

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ESI Training Baochau Doan RN, BSN, CEN, TNS 1 11/17/2017
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History of Triage Derived from the French word “trier” meaning – to sort or select The concept was originally applied around 1792 by Dominique Jean Larrey, Surgeon in Chief to Napoleons Imperial Guard. Who was credited with designing a flying ambulance Also help develop the organizational structure necessary to handle the growing number of casualties in modern warfare 2 11/17/2017
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What is ESI? Emergency Severity Index Five level triage scale that uses prioritization based on urgency (acuity) of condition but also considers resources needed to get the patient through to ED disposition. Endorsed by ACEP and ENA 3 11/17/2017
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So… A 5 level Rating? 5 levels provides greater range of acuity between each level compared to the previous 3 level systems 5 Level is researched based, standardized and reliable between users. ESI levels can be used to describe acuity of your department Track acuity volumes based on annual visits and number of patients for each level. Can be used to justify staffing 4 11/17/2017
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Emergency Severity Index (ESI) Acuity assessment Airways,breathing and circulation Potential for life,organ or limb threat How soon the patients needs to be seen Expected resource assessment Number of resources, as estimated by the triage nurse, that a patient is expected to consume in order to discharge 5 11/17/2017
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Emergency Severity Index (ESI) Five defined categories Mutually exclusive Differs from a complete assessment Requires sufficient information in order to assign an ESI level Allows for quick sorting 6 11/17/2017
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ESI Algorithm 7 11/17/2017
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Decision Point A: Is this patient dying? 8 11/17/2017
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Decision Point A: Is this patient dying? Does this patient require immediate life saving intervention? Circulation - Pulseless or concerned about rate, rhythm or quality Drugs – Hemodynamic interventions, immediate IV medications to correct hemodynamic instability 9 11/17/2017
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Aggressive Life-Saving Interventions Will this intervention save this person’s life? Airway and Breathing Intubation Surgical airway CPAP or BiPAP Bag Valve Mask Ventilation (BVM) Defibrillation External Pacing Chest Needle Decompression Hemodyamics Significant IV fluid resuscitation Blood administration IV Medications Vasopressors Control of major bleeding 10 11/17/2017
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Interventions: NOT Life Saving Diagnostic Tests EKG Lab Studies Oxygen Monitor IV access Medications ASA Nitroglycerine Pain medications Antibiotics Heparin 11 11/17/2017
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Decision Point A Does this patient have an acute mental status change that requires immediate life saving intervention? Examples: Hypoglycemia needs glucose Heroin OD needs Narcan Subarachnoid bleed needs airway protection Is this patient a “P” or “U” on the AVPU scale A=Alert V=Verbal Stimuli to elicit a response P=Painful stimulus required for response U=Unresponsive 12 11/17/2017
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ESI Level 1 Patient is physiologically unstable Requires immediate aggressive life-saving interventions MD evaluation Nursing care Team response Most patients will be hospitalized 13 11/17/2017
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ESI Level 1 Examples – v4 Cardiac or respiratory arrest Overdose with a respiratory rate of 8 Severe respiratory distress with agonal or gasping respirations Acute SOB with SpO2 < 90% Anaphylactic Shock 11/17/2017 14
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ESI Level 1 Examples – v4 Critically injured trauma patient GSW to abdomen with BP 88/palp Chest pain, pale diaphoretic Dizziness, recent LOC, HR = 40 Chest palpitations, HR 180+ Unresponsive with string odor of alcohol Severe stroke needs airway protection 11/17/2017 15
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Decision Point B Is this a high risk situation? 11/17/2017 16
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Decision Point B: Is this a high risk situation? Determination is based on a brief patient interview, gross observation, “sixth sense” Do not require a full set of vitals Unsafe for the patient to wait Suggestive of a condition that could easily deteriorate Symptoms of a condition that’s treatment is time sensitive Potential major life or organ threat 11/17/2017 17
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Examples of “High Risk” Episode of chest pain, denies other symptoms, known cardiac history R/O PE Newborn with a fever (<12 weeks) Rule our ectopic pregnancy Neutropenia with a fever Suicidal/homicidal Needle-stick in a healthcare worker 11/17/2017 18
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Decision Point B: Is this patient confused, lethargic or disoriented? Is there an acute change in level of consciousness? Is this a situation where the brain is structurally or chemically compromised? 11/17/2017 19
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Examples: New onset of confusion in an elderly patient 30 year old with a known brain tumor whose wife reports that he is confused Adolescent found confused and disoriented 11/17/2017 20
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Decision Point B Is this patient in severe pain or distress? Is this patient currently in pain Pain is subjective – it is whatever the patient says it is… How can we quantify it? Research based Documented on all ED patients. 11/17/2017 21
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Decision Point B: Is this patient is in severe pain or distress? Is this patient currently in pain? Pain intensity rating Chief complain PMF, medications VS, physical assessment findings Assign ESI Level 2 is and ONLY if: Self reported 7/10 or greater AND RN cannot intervene AND they require immediate intervention Do you want to give your last bed to this patient??? 11/17/2017 22
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ESI Level 2 Pain Examples Kidney stone Burn Victim Oncology patients Possible dislocated shoulder Questionable Compartment Syndrome 11/17/2017 23
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Decision Point B: Is this patient is distress – Physiological or Psychological? Sexual Assault Victim Combative patient Homicidal/suicidal patient Bipolar patient who is manic Acute grief reaction Known alcoholic with minor head trauma 11/17/2017 24
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Decision Point C How many resources? 11/17/2017 25
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Decision Point C: How many resources? Determined by the experienced ED RN at triage Based on the standard of care Independent of type of hospital, location physician on duty, and acuity of the department 11/17/2017 26
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Resources: Count number of different types of resources not individual test or x-rays (ex: CBC, electrolytes, and coags equal one resource; CBC plus chest x-ray equals two resources.) 11/17/2017 27
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Resources Examples CBC, BMP, PT/PTT = One Resource CBC, CXR = Two Resources CXR, ABD series = One Resource CXR, CT Scan = Two Resources CBC, CT Scan, EKG = Three Resources 11/17/2017 28
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ESI Level 5 No resources Examples: Healthy 10 year with “poison ivy” Healthy 52 year old who ran out of his blood pressure medication yesterday 22 year old, involved in a care accident 2 days ago and wants to be checked. Nothing hurts 46 year old with a cold 11/17/2017 29
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ESI Level 4 Stable, can safely wait hours to be seen Care by mid level providers in fast track or express care setting Requires a physical exam and one resource 11/17/2017 30
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ESI Level 4 Examples: Healthy 19 year old with a sore throat and fever Healthy 29 year old with a UTI, denies vaginal discharge Healthy 43 year old with a stubbed toe – “I think I broke it!” Healthy 12 year old with a minor thumb laceration 11/17/2017 31
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ESI Level 3 30-40% of patients seen in the ED Require in-depth evaluation Long length of stay Before assigning a patient to ESI Level 3 the nurse must consider the patients vital signs. 11/17/2017 32
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Decision Point D: What are the patient’s vital signs? Consider Vital Signs Are they outside the acceptable parameters for age? If unacceptable consider up-triage to ESI Level 2 11/17/2017 33
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Pediatric Fever Criteria 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 years of age: consider assigning ESI 3 if temp > 39.0 C (102.2), or incomplete immunizations, or no obvious source of fever 11/17/2017 34
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ESI Level 3,4, or 5 Examples: ESI Level 3 Fractured ankle Abdominal pain Most migraines ESI Level 4 Sprained ankle, toe Abscess ESI Level 5 Toothache 11/17/2017 35
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Frequently Asked Questions Why isn’t a splint a resource? The application of a simple pre-formed splint is not considered a resource. This is not being used to make the disposition decision. The x-ray showing the injury makes the discharge decision. Why are the following considered resources: Eye irrigation, nebulized meds, and blood transfusions? All three are considered resources for the purposes of ESI. They tend to be used on patients that are more acute, require significant ED time, and are like to have longer LOS. 11/17/2017 36