EMERGENCY

SEVERITY INDEX
(ESI)

Sarah Pelletier, BSN, RN-BC

Sarah Espin, MSN, RN-BC, VHA-CM
Julie Alban, MSN, MPH, RN-BC, VHA-CM
Updated by Tania McMillan, MSN, RN-BC
Adapted from the Emergency Severity Index (ESI) Refresher PowerPoint by William Alt, BSN, RN Dayle Ann McCary, MSN, RN, CEN
OBJECTIVES
Identify the 5-level triage scale of the ESI
Describe the ESI Triage Algorithm
Identify resources that would affect the algorithm
Verbalize the process involved in patient transfers
Emergency Severity Index (ESI)
 ESI is a five-level triage scale developed by ED physicians and nurses

 Provides a reliable, valid tool for determination of acuity

 Describes parameters for the rapid identification of those who need

immediate care

 Discriminates between patients that need to be seen emergently versus

urgently

 Improves patient flow based on rapid sorting with projected resource and
operational needs

Get the right patient to right resources in the right place

at the right time
Institute of Medicine (IOM)Aims
 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

 Equitable Care
 Care that does not vary in quality due to personal characteristics (gender, ethnicity,
geographic location, or socio-economic status)
ESI Triage Algorithm
Decisions are based on 4 key questions:

A.Is this patient dying?

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

C.How many resources are needed?

D.What are the vital signs?

ESI TRIAGE ALGORITHM
 Decision Point Review
A. Determine if immediate life-saving intervention is required.

B. Is this a High risk situation? For example…

Is the patient confused or disoriented?
Is the patient in severe pain?

C. Consider the resources that the patient will require.

D. Review Vital Signs. Are they Danger Zone Vital Signs?: Consider triaging up to
ESI 2 if any vital signs are beyond patient’s normal parameters.
Adult:
HR >100
RR >20
Sa02 < 92% with clinically significant symptoms
RESOURCES NOT RESOURCES
 Labs (blood, urine) 
 History and physical (including pelvic)

 EKG, X-rays, 
 Point of Care Testing

 Saline or heplock
 CT,MRI, Ultrasound, 
 PO Meds
angiography

 Tetanus Immunization
 IV Fluids (Hydration)

 Prescription Refills
 IV, IM, nebulized medication

 Phone Call to PCP
 Specialty consultation

 Simple Wound Care
 Simple procedure = 1 (dressings, recheck)
(Laceration repair, Foley cath)
 Complex procedure =

 Crutches, splints, slings
(Conscious Sedation
 SUMMARY
Level 1 Resuscitation: Highest Priority
◦ Requires immediate life-saving interventions
◦ Is unresponsive
◦ May include suspected CVA with symptom onset < 3 hours
Level 2 Emergent : High risk situation
◦ Severe pain/distress, or
◦ Acute confusion, lethargy or disorientation
-----------------------------------------------------------------------------------------------------------------
Level 3 Urgent :
◦ Requires 2 or more resources as defined by Emergency Severity Index
Level 4 Less Urgent:
◦ Requires 1 resource as defined by Emergency Severity Index
Level 5 Non-Urgent: Lowest priority to be seen
◦ No resources required as defined by Emergency Severity Index

Levels 1 and 2 based on acuity

Levels 3, 4 and 5 based on anticipated resources
Case Scenarios

“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.

Case Scenario
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%.
Case Scenario
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.
Case Scenario
“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.
Case Scenario
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.”
Ambulatory Care Triage &
Transfer Note
Nurse Ambulatory Care Triage (T)
Nurse Ambulatory Care Triage (T)
Nurse Outpatient Triage Note (T)
 Nurse Outpatient to
Inpatient Hand-Off (T)
Nurse Outpatient to Inpatient
Hand-Off (T)
Nurse Outpatient to Inpatient
Hand-Off
Nurse Outpatient to Inpatient
Hand-Off (T)
 REFERENCES
Gilboy, N., Tanabe. P, Travers DA, Rosenau, A.M., Eitel, D.R.
Emergency Severity Index, Version 4: Implementation Handbook.
AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for
Healthcare Research and Quality. May 2005.

Alt, W. and McCary, D.A. Emergency Severity Index (ESI)

Refresher [PowerPoint slides].
QUESTIONS????