What are the Emergency Severity Index (ESI) triage guideline recommendations?

From the Guidelines

The Emergency Severity Index (ESI) triage guidelines recommend a 5-level system, categorizing stroke patients as level 2, indicating the need for immediate assessment. This recommendation is based on the American College of Emergency Physicians and the Emergency Nurses Association's preference for the ESI system in busy EDs 1. The ESI system prioritizes patients based on acuity and resource needs, with level 1 being the most urgent and level 5 being the least urgent.

Key Considerations for ESI Triage

• Stroke patients should be categorized as level 2, similar to unstable trauma patients or critical care cardiac patients, as they require immediate assessment and timely intervention 1.
• The triage nurse should use specialized checklists, protocols, and tools to identify stroke patients and rapidly assess the initial time of symptom onset or the last known well time.
• Hypoglycemia, a common stroke mimic, can be quickly identified by measuring blood glucose during transport, and fingerstick tests can be performed if the emergency vehicle is equipped for it 1.
• The goal is to initiate thrombolytic therapy as soon as possible, with the NIH-National Institute of Neurological Disorders and Stroke (NINDS) benchmark treatment time for AIS with intravenous rtPA being within 60 minutes of arrival in the ED 1.

Implementation of ESI Triage

• The ESI process should be performed by experienced emergency nurses with specific ESI training.
• Regular quality improvement reviews are essential to maintain consistency and ensure that the ESI system is working effectively.
• The ESI system improves patient flow, reduces wait times for critical patients, and standardizes the triage process across providers, ultimately enhancing patient safety and departmental efficiency.

From the Research

Emergency Severity Index (ESI) Triage Guideline Recommendations

The Emergency Severity Index (ESI) is a five-level triage acuity scale used to rate patients from level 1 (highest acuity) to level 5 (lowest acuity) 2. The ESI version 3 is a valid and reliable instrument that predicts resource consumption 3.

ESI Level Definitions

• ESI level 1: highest acuity, requires immediate intervention 2
• ESI level 2: high acuity, requires immediate or prompt intervention, with two sub-levels:
  • those who require immediate intervention
  • those who are stable to wait for at least ten minutes 2
• ESI level 3-5: lower acuity, requires less urgent or no immediate intervention

Triage Recommendations

• ESI level 1 and 2 patients should be treated by a physician immediately or within 10 minutes, respectively 4
• Triage nurses should use their judgment to identify patients who require immediate intervention, especially those with airway or medication needs 2
• Revisions to the ESI level 1 criteria may be beneficial to reclassify some sickest level 2 patients as level 1 2

Implementation and Use

• The ESI is the most commonly used triage system in US hospitals, with over 70% of large hospitals and teaching hospitals using it 5
• More than 70% of ED patient visits are assessed using the ESI 5
• However, mandatory formal triage may not always identify high-acuity patients within recommended time frames 4