What acuity level should be assigned to a patient reporting sexual assault with stable vital signs and no visible injury using the five-tier Emergency Severity Index (ESI) criteria?

Emergency Severity Index (ESI) Triage for Sexual Assault Patients

A patient reporting sexual assault with stable vital signs and no visible injury should be assigned ESI Level 2 (needs immediate assessment) according to the Emergency Severity Index triage criteria. 1

Rationale for ESI Level 2 Assignment

• The Emergency Nurses Association and American College of Emergency Physicians recommend a 5-level Emergency Severity Index as the preferred system for triage in a busy ED, with sexual assault patients placed in the level 2 or "needs immediate assessment" category, the same as for an unstable trauma patient or a critical care cardiac patient. 1
• ESI Level 2 is appropriate because sexual assault is considered a high-risk situation requiring prompt medical and forensic attention, even when the patient appears stable with no visible injuries. 1
• The ESI triage system is the most commonly used triage system in the United States, used by 56.9% of hospitals and covering 72.1% of all ED patient visits. 2

Clinical Assessment Considerations

• While the patient has stable vital signs and no visible injuries, sexual assault victims may have non-visible injuries or psychological trauma requiring prompt intervention. 1
• Patients reporting sexual assault often have injuries that may not be immediately apparent during initial assessment, with studies showing that ano-genital injuries are found in 28% of patients who undergo a gynecological examination. 3
• Inappropriate triage of sexual assault victims to lower acuity levels (undertriage) can lead to longer waiting times, potentially compromising evidence collection and patient care. 4

Time-Sensitive Aspects of Care

• The ESI Level 2 designation ensures that sexual assault patients receive timely care, which is critical for:
  • Collection of forensic evidence, which is most effective when performed within 72 hours of the assault 3
  • Timely administration of emergency contraception, which is most effective when given as soon as possible 1
  • Prompt prophylaxis against sexually transmitted infections 1

Comparison with Other Triage Systems

• Studies comparing ESI to other triage systems like START (Simple Triage and Rapid Treatment) have shown that ESI better identifies patients needing urgent care and intervention. 5
• ESI has demonstrated reliability and validity as a five-level triage system, making it superior to three-level systems that may not adequately prioritize sexual assault cases. 2

Common Pitfalls to Avoid

• Undertriage of sexual assault victims is a significant concern, with studies showing that 41% of patients may be assigned an ESI level of lesser acuity than appropriate. 4
• Patients who are undertriaged face inappropriate waiting times (median of 58 minutes for those incorrectly assigned ESI-4 instead of ESI-2), which can compromise care quality and evidence collection. 4
• Avoid being influenced by the absence of visible injuries or stable vital signs, as these do not diminish the urgency of care needed for sexual assault victims. 1

Special Considerations

• Sexual assault patients require a private, safe environment for examination and interview, which should be facilitated promptly. 1
• The psychological impact of sexual assault requires immediate attention, even when physical injuries are not apparent. 1
• Documentation of the time of assault is critical for both medical and legal purposes, as it affects decisions about prophylactic treatments and evidence collection. 1, 3

By assigning ESI Level 2 to sexual assault patients, emergency departments ensure these patients receive the prompt, comprehensive care they need while acknowledging the time-sensitive nature of both medical treatment and forensic evidence collection.