Triage Fundamentals: Emergency Severity Index (ESI)

The Emergency Severity Index or ESI is a five level triage system that is used in really almost all emergency departments in the US. While emergency nurses may have a strong command of the ESI algorithm, the rest of you listening who have been patients in the emergency department may have not realized that you were assigned a number from one to five.

A number reflecting both the severity of your condition and the level of resources for your care. One is the highest level, indicating a need for immediate life-saving intervention. With five as the lowest, given to patients who are non-urgent, who, for example, may need a simple med refill. Now, before you stop and say, hey, I'm not an emergency nurse, this podcast episode isn't for me. I am going to challenge

What is one of the most core fundamental skills of a nurse? What does the NCLEX test over and over and over again? Prioritization. That's right. In our reality as nurses, we have multiple patients with very finite resources, and we must have the crucial ability to triage our own patients. This is the constant undercurrent that directs our attention throughout our 12-hour show.

While non-emergency nurses may not use the ESI system, I would strongly argue that nurses who know how to triage are going to be even sharper at prioritizing their own patients' care in whatever department they want. And you know what I love about ESI is that it goes beyond simply categorizing patients based on their likelihood of immediate death, but encompasses a more holistic approach. that considers factors impacting patients' well-being and functionality.

This broader perspective acknowledges that patients' needs extend beyond immediate life threatening conditions. And emphasizes the importance of factors that may significantly affect their quality of life and ability to function and do all the things that we value so dearly in life. To guide us through triage, I have for us today my friend Kevin McFarlane. Kevin has over twenty years of experience in the ED and is the host of not just one, but two emergency nursing podcasts.

Throughout this episode, we'll dive deep into the Emergency Severity Index, exploring the five triage levels and the specific criteria used to assign each one. However, our discussion goes beyond just categorizing medical emergencies. You'll gain valuable insight into a more comprehensive approach to trial. One that accounts for psychological safety and quality of life impairment.

Be sure to stay tuned till the end when we peek into the future and examine how artificial intelligence could revolutionize emergency triage protocols in the years ahead. Welcome to the Up My Nursing Game podcast. My name is Annie. I've been a clinical nurse for eight years and I am curious. I use this podcast to address common clinical questions, share unique perspectives across a healthcare team. team and cover what's missed in nursing school.

Well, hi, my name's Kevin McFarlane, and I am the uh host of a podcast called The Art of Emergency Nursing and the co-host of a podcast called How Not to Kill Your Patient. I've been in emergency nursing in the emergency department for about twenty years. Uh I am a certified emergency nurse, certified trauma nurse. I have a bunch of certifications. I recently became a fellow in the Academy of Emergency Nursing, which was a huge honor.

I don't know how else to say it, but Kevin is kind of a big deal in the emergency nursing world. I've had him on the podcast multiple times already to discuss all things emergency. So when I had a listener request to talk about the emergency severity index, I knew exactly who to reach out to.

So ESI is is kind of like a brand. So it's kind of like a fl a s a particular flavor of what we call triage, right? And and triage I think is a concept that that emergency nurses feel very comfortable with, but not all em not all nurses do. Triage it comes from the comes from the French word to sort, and it's all about sorting your patients. Two

Make sure that the person who needs care the fastest the most is going to get that care first. So we're sorting out our patients so that we take care of our most severe and most critical patients first. And then the patients who are less severe are gonna be seen maybe a little bit later. I always remind nurses in outside of the emergency department.

is the most dangerous place in the entire hospital is the ER waiting room. Cause in the ER waiting room, if they haven't been triaged yet, we may not know how severe or how sick they really are. So one of the most important things we need to do is very quickly when they come into the emergency department, get them triaged, find out how severe they are, and then get them categorized accordingly.

What does triage look like? I mean, besides getting the patient's story for, you know, what brings you in today, are you getting vital signs? Are you drawing labs? Like w what goes on in that process? So the first process for triage is really kind of getting the history. You're gonna get the history from the patients. And one of the things that that E the n the new update of ESI triage, and we'll talk about how it was recently updated.

that it really kind of focuses on is making sure that we're getting vital signs, making sure we're getting vital signs so we can see physiologically how is that patient doing. We're gonna get a good history of what exactly brought them to the emergency department, what made them decide to seek out care, and then find out a little bit of their past medical history and see how that all kind of fits together.

to find out just how sick that person actually is. So who's performing triage? Is it a nurse? Is there ever like a role for a technician or a physician in triage? In all hospitals, nurses are are gonna be the ones who are doing the triage. Now, in in hospitals, depending on how busy they are, and in you know, the busy level one trauma center that I used to work at, we had a technician who was there in triage helping us get vital science.

helping us, you know, get the patient, you know, get the patients from one section to the next and help just kind of facilitating that triage process. And then then we also had a mid-level provider who might be able to do a little bit more, who might be able to say, okay, well let's go ahead and order, let's go ahead and order these labs, let's go ahead and order this, you know, this bundle of care. Um

So and but it it varies by hospital. The hospital that I work in now, it's just one nurse triaging, they're doing all the job themselves. And then and then getting as many patients through as we can. So it it just kind of varies depending on on how busy the organization is and the size of the organization. I mean w why is ESI important? Why is it important to, you know, a s assign a definitive number to a patient?

really what it's really designed to do is it's designed to see who needs care first. So if you think about the the typical hospital, if you're in a level one trauma center in an urban city, A waiting room at any one time can have twenty, thirty people in in the waiting room. And to find out from those twenty or thirty people who is the most at risk and who is who are we worried about needing care immediately and who has the the luxury of being able to wait.

So we always joke that, you know, being worse makes you first. And and and really with triage, that's kind of the thing. It's you know, the the sickest people are gonna get in and get seen the quickest. And then we could be able to to really kind of stratify, okay, these people might be able to wait, and these people can wait potentially a little bit longer. So it's it's it's all about providing the best care, the the quickest care to as many people as possible.

It it's essentially about assigning resources appropriately, right? Like Correct. utilizing your resources because every hospital, no matter how big they are, it has limited resources, right? We never have enough hospital rooms, enough hospital beds, enough nurses. take care for everybody. Very, very few hospitals have that luxury. So when that's the case, then we have to determine who's gonna get seen first and who can wait.

So l let's jump into it. Let's talk about the levels of care. So the levels go from one to five. In my mind, as someone who has limited experience with ESI, level one is like circling the drain. Like the person is unstable Maybe actively dying in like a code situation, but in your words, what is a level one and y what are the criteria for meeting it?

You're absolutely right. So level one, depending on where you are, what you are, you know, some people will call it a an A, some people will call it a level one. We'll stick with level one just to to make it easy. These are your people who need immediate intervention, immediate life-saving intervention. These are folks who need to be actively resuscitated. Now, these are people who are are quite sick and need immediate.

immediate intervention, whether it be medication or maybe it's a procedure. Maybe they need to be intubated quickly. Maybe they need to be have a a medication that's going to keep them from from dying, or whatever the case may be.

But these are your people who need immediate care. So these are often people that that in triage we may not even get to the place where we're doing vital signs on them. We may be like, okay, l this may be like an immediate recognition that we're gonna go ahead and take back to a care area. So Things like someone who needs to be intubated, things like people who are experience a cardiac arrest.

where they need CPR immediately, or they need defibrillation immediately. Maybe they need immediate with either medications or or or electricity or procedures. Those are going to be your ESI ones. These are people that we're not even in oftentimes in triage, the ones aren't even going to get tree. We're not going to do the vital signs necessarily in triage. We're going to take them immediately back to a care area and get the care started there with the care team.

To me, the classic example is a is an active heart attack. And those are the patients are whom we we see them clutching their chest and they're looking gray and you immediately take them back and they're off to the cath lab within, you know, fifteen minutes. I think a great example for for like an ESI triage, for instance, maybe uh imagine somebody who's having a narcotic overdose, right?

So someone's experiencing a narcotic overdose, they're not breathing, they have, you know, they're found to have very pinpoint pupils, they have very slow respirations, they need to be actively resuscitated in order to maintain life, right? So that would be an example of somebody who would be a level one triage because we need to actively intervene right now or this patient's not going to do well. Would anaphylaxis be part of a ESI one?

Anaphylaxis is a is a great example because anaphyla anaphylaxis is my favorite disease, right? Like it's it's it's something trying to kill you in a lot of different ways. But anaphylaxis would be a great example of a a a disease that would be immediate intervention. Like'cause'cause we we know how to fix that. We have the medications to to fix anaphylaxis, but it needs to be acted on immediately.

It's a great example. Yeah. I like that that's your favorite disease. It it must be because it's very fixable. And I think, you know, just gonna throw this out there, being of the male gender, you like to fix things. True, true. But if you think about anaphylaxis, anaphylaxis is a cool thing, because it is a cool thing because it's really your body trying to kill you, right?

So your throat is tightening, your your airway is closing, at the same time your vasculature is opening, right? So you're having vasodilation. Right. So your your your tank suddenly is bigger than it was, right? Your your your Circulate circulation system, you're gonna vasodilate, you're gonna your capillaries are gonna open up, and that's where you get that eutycharia, right?

And you so you have vasodilation, you have bronchoconstriction, and your body's just really trying to like fight whatever that that antigen was. And in in the meantime it's it doesn't realize it's trying to kill you too. It's the coolest disease. It's the coolest disease. And the nice and and and the nice thing is is it's super fixable, right? Like we give them some epi and bam. You know, the vasodilation's gonna get better, the bronchoconstriction's gonna get better.

Yeah, it's one of those things that like it's super cool when you when you see true anaphylaxis, which uh you know, when you when you really see anaphylaxis it's it's one, it's Two, if you've ever seen somebody who needs, you know, these are sometimes you'll see people who have anaphylaxis have the little epipens. Because again, it's an immediate need, and that epi pen certainly can can reverse all that stuff.

Yeah. I've never seen it. Personally, I've seen some pretty severe scary, scary reactions, but like a true systemic NFL axis. I gotta tell you, I think I've it it's not super common. Like everyone thinks that like it happens all the time, and thank God it's not. I think I've seen probably, I don't know, four or five cases of true anaphylaxis where I was like, they need the appe and they they need it now. What about seizures? Are they gonna at all like a active Tonoclonic seizure.

If if they're having an active an active seizure and they need immediate interventions for medications, yeah, that could be an ESI that could be an ESI one. type of an emergency if they need immediate intervention. Because if you think about seizures, it unless we get benzos, sometimes uh and you know, the nice thing about seizures is that oftentimes they're self limiting.

But if it's not self limiting, if they're, you know, in in that, you know, status epilepticus, for instance, where they need medication to actually break that seizure, that could very well be an ESI one patient. Okay. So it sounds like ESI one is going to be your respiratory arrest. narcotic overdose, your your active MIs, your anaphylaxis, for w ones for whom you need to intervene now to save a life.

Absolutely. And uh you know, things like hypoglycemia could be potentially an ESI one, even though it's it's even though it's a quick fit. Even though it's a quick fix, they do need immediate intervention. So and and that's one of the things that in the the they recently updated ESI and they included all those things in that ESI one. And ESI one it used to be, you know.

Are they, you know, do they need to be shocked? Do they need to be intubated? Do they, you know, are they actively dying? But realizing that that time sensitive emergency, even like hypoglycemia, which is, you know, if we know the cause, then we know the fix. But that does require an inter immediate intervention. That would still be a good example of an ESI one.

One of the changes they recently made in the ESI is don't focus on the trajectory. Don't focus on like the long term, but focus on the immediate need. What is the immediate need? And if the immediate need is high and immediate, that's a level one. Even though it might be something that, you know For instance, hypoglycemia. If someone comes in and they have hypoglycemia, that may very well be an ESI1 because there is immediate need. Now, that person still may very well get discharged.

But if we don't intervene immediately then They could die. And and that's one of the things that the the the new ESI algorithm is kind of focused on is don't focus on the trajectory, focus on the right now. Got it. That's really interesting. So this actually shifts things in my mind a little bit from it's not necessarily the number of resources, it's the timeliness of the resource.

Yeah, we'll talk about resources as we get into the lower levels of triage because then resources become really, really important, but and and they are important, but what we're looking at is we're looking at the timeliness is really the the focus of ESI one. Okay. That's that's a really good point to make and that is definitely like a frame shift for Okay. So we talked about ESI ones.

Moving on to ESI level of two. Okay, so what once you get past that, whether or not this is uh a high risk situation or something with like a life or death situation with immediate need, the next kind of decision point is whether or not this is what we consider a high risk situation. So those are your ESI twos. These are your people who are very sick.

They may not need immediate intervention, but they do need intervention. So these are gonna be the people who who have the potential to deteriorate somewhat quickly. and have a high acuity, yeah, there's like a a high acuity in in whatever change is going on. These are patients who are in severe pain, who are in severe distress, either psychologically or physically. Those all fit in that triage two category. Got it.

maybe their vitals are stable now, but you're there's a high chance that they'll quickly become unstable. Yeah. So this might be like your active chest pain that we're suspicious for the a coronary syndrome. This might be your patient who's a stroke, for instance, who may need immediate intervention for for the stroke, like a a clot busting drug. someone who needs uh intervention pretty quickly. This could be somebody like a a sepsis patient. Sepsis patients are kind of classic level twos.

where they're very sick and though though they may not be actively needing resuscitation right now, if we don't intervene, they're soon going to get to that spot. So those are the those are those kind of level two patients. These you know things like sepsis, stroke, cardiovascular. But also one of the things that we we talk about when we talk about level two is this

is their psychological safety. Like are they at risk for wanting to hurt themselves? Like are are they a uh an immediate risk to themselves? A suicidal patient is always a level two, right? 'Cause they need immediate intervention. If they if they didn't have that, they might hurt themselves. So that's kind of your your your next level once you get past the immediate resuscitation piece. How does pregnancy influence any of these?

Preg pregnancy is pregnancy is kind of one of those those funny things that, you know, it could very well need immediate interventions. But oftentimes these patients aren't going to be cared for in the emergency department. These are p patients who are going to be Shipped off to labor and delivery pretty quickly. Like if you want to scare if you want to scare an ER nurse, give them a pregnant patient who's about to deliver. They they're gonna want they're

That's like it's like the emergency nurse kryptonite, right? We're gonna wanna get them off to labor and delivery just as quickly as we can. We we try our best not to deliver patients in the emergency department. I remember when I was a nursing student and I was completing my last semester in an emergency department, I saw a patient come in for suicidal ideation and he was assigned an ESI of five.

And I went to my preceptor and I intuitively like I I was part of myself. Like I I I was like Y'all, it's bad. Is that right? Should that really be a five? And he got up so fast, walked over to triage, and the next thing I knew that patient was a two. And yeah, so it's one of those like their vitals are okay. Probably. But we need to, you know, think about their safety.

Absolutely. And when you when you said there were a triage five, the audience didn't see this, but my eyes like my eyes got really big, like, what? Huh? I had probably the same reaction your preceptor had, because the reality is

is those guys are at high risk, those suicidal patients. And suicidal patients are ones that I think a lot of nurses have a little bit of a hard time with. Cause when we say suicidal, it could be of anywhere from, you know, somebody who's actively trying to take take their own lives to somebody who is, you know, this is kind of a cry for help and a pretty minor suicide. But the the reality is is is we don't know. We can't secure their safety until we truly secure their safety.

That's why they're always gonna be a level two. Yeah. Yeah. That's an important one to point out. I think as nurses we tend to focus on the medical side of things, but yeah, we do have to take into account the Psychological safety. Yeah. Psychological safety is is a is a great thing to keep in mind for not only is it their physiologic safety, but their psychological safety as well.

When I was in fast track as a nurse who was floating over to the emergency department, I remember getting in a patient with eye pain. And he went to the eye room. We had a specific eye room, which was in fast track. Sorry, it wasn't fast track. It was it was a little more acute than fast track, but it was like a low acuity area.

So I was so surprised to see that they would send an ESI2 to this less acute area of the emergency department. And when I questioned this, they said, well, we're talking about someone losing their vision. Um and that surprised me'cause kinda going back to this thought that while his vital signs are stable, he's not going to imminently die. It is at utmost emergency to lose one of your sons.

One hundred percent. And and eyes are eyes are one of those things that are a little bit weird and that they can appear very vitally stable. But they could have a potentially life changing event. Oh I mean losing your sight would be life changing, right? Oh your life. So yeah, certainly they they so those are ones that would be a high triage category.

But potentially, depending on how the the the department is set up, might be able to be seen in a in a lesser acuity area because again the immediate intervention they may need is, you know, an ophthalmologist who's gonna come d come down and see them and and oftentimes they bring their own toys.

But the reality is is, you know, they what they need is they need a a a place in the in the the department so that we can kinda get things started for them. So yeah, it wouldn't surprise me to see a high acuity in a low acuity area just based on that that kind of complaint, that wouldn't surprise me at all. Are there any other kind of unexpected ESI twos? Well one of the ones that that the the new ESI update particularly mentions that I think is is an important thing is

healthcare workers who have had a a needle exposure, a blood exposure. Not something that, you know, typically, you know, you have, you know, Joe coming down from the fifth floor and he says, Oh geez, I had a needle stick. And, you know, he's just more pissed off that it happened in reality and you know and and looks fine, but he's still very well maybe a triage to

because of the time sensitive nature of of making sure that we are are are doing kind of prophylactic treatment just as quickly as possible. So that's one that that often gets kind of triaged as kind of a lower category when reality should be probably a little higher. Any other curveball twos? No, it not that I can think of. Okay. So chest pain, strokes. Yeah. Uh suicidal ideation.

Anyone who's confused, lethargic, disoriented, new, new onset confusion, new onset lethargy, disorientation, you know, all those kinds of things would be that potential high risk situation. Okay. Sepsis.

Yeah. Big yeah, sepsis would be a big one. Cool. So let's talk about level three. What are some of the criteria for level three? So the criterion for level three is basically if you're not a level one, you're not a level two, then we need to figure out if you're a three, four, or five, right? So so we're gonna kind of talk about those kind of all together.

And a lot of the patients that come into the emergency department fall into that probably that three category where they they need some stuff. But but they may not need it right the second, right? It's not a time sensitive emergency and and and always telling patients that is always kind of a hard thing where you're like, okay, I know you're sick and I know you don't feel good and you need some stuff.

But you're not dying right now. You're you're doing okay. So those three fours and fives, you that's when we start talking about resources. How many resources are they gonna need? Are they gonna need no resources? Then they're gonna be a level five. If they're gonna need just one resource, then they're gonna be a level four.

And then if they're gonna need many resources, that's gonna be a level three. So you're you're putting on your your fortune telling hat in the emergency department and and kinda guessing Wha how many resources are those people actually gonna need? So things that are things that it would be resources are are they gonna need labs? Are they gonna need blood? Are they gonna need urine? And that's

Almost everybody in the emergency department, right? We're gonna try to get some blood. We're gonna try to get some urine to help kind of figure out physiologically what's going on with them. Are they gonna need any kind of imaging? X rays, ultrasounds, CTs, those things are all resources. Right. They're gonna need a CT and an MRI. That's you know, that's two separate resources. Are they gonna need intervenous fluids? That's a resource.

Things like medications, intermuscular medications, any kind of medications that they're going to be given, those are resources. So for instance, your patient who comes in with a uh with an asthma attack, they very well may need you know, I am, you know, maybe they're gonna need like an IM steroid or an IV, you know, IV steroids.

But they're also going to need a nebulized medication. That's another resource. And then are they going to need any kind of specialty consultations? If they're going to need any specialty consultations, again, they're going to fall in that three category. Three is your typically gonna be your broadest bucket. Like so when I look at the board and our emergency department, I see, you know, maybe one or two ones, maybe one or two twos, and then I'm gonna see a whole lot of threes, right?

Threes are gonna be your most common. Now, your fours and fives, depending on your your hospital system, those may be people that we either refer to to urgent care, if there's an urgent care on site or or they may be like what you mentioned earlier, like a fast track care area. Mm-hmm. Yeah. In my experience, you know, talking about resources, like the ESI three's can be heavy, heavy on the resources. So in my mind, like a classic ESI three will be abdominal pain.

And that is like the black hole of an emergency department is getting in a an abdominal pain patient. 'Cause they're probably gonna need an IV, they might need fluid resuscitation, they might need antibiotics, they will need to go to ultrasound, C T and like the the diagnosis is is not often very obvious. So It all makes sense now to me when you explain that ESI one and two is more an assignment based on immediacy than that three and five then are about resources.

Yep. And that's exactly what it is. Uh an abdominal pain, like you mentioned, is the classic example of an ESI three. Cause you know they're they're likely to get IV meds, they're likely to get CT'd. X-rayed, they're gonna get labs. I mean they're gonna use many, many resources. to figure out what exactly is going on with them. Now now they very well may be sick. They very well may be sick and and don't Don't think that your your threes aren't sick. Your threes are kinda like

bread and butter E D cases, right? Like they're, you know, your an appendicitis, for instance, very well may be, you know, where they they very well may need a surgical intervention. That's probably gonna be an ESI three. What about the instance when abdominal pain means something? very life threatening. Like, I don't know if this would you ever change the ESI rating based on what's found in diagnostics? That is such a great question'cause once the care has started

ESI is basically how soon do we need to get them to see a provider? Once the provider is seen and once that care is started, ESI doesn't matter. So typically you're not going to go back and change an ESI triage category most of the time. Now, where you might change the categories if they have not seen a provider yet. So if for instance they're in triage, you're doing an you're doing a triage, you're kind of working them up for abdominal pain.

And then suddenly it's it's realized that they are indeed an ectopic pregnancy. Or there's you know, the thought that it is an ectopic pregnancy, then that very well may be. An ectopic pregnancy very well could be a level two. That could be life threatening. It's a good example of of one of those things that kind of fly under the radar, but could be life threatening. Yeah. Yeah. I remember the charge nurse kind of hammered into our heads.

A woman of childbearing years plus abdominal pain is ectopic pregnancy until ruled otherwise. Uh I uh uh uh oftentimes I'll say a woman woman of childbearing years is pregnant until proven otherwise, right? Like like Trust tr trust all but get the pregnancy test, right? Like and we used to see that in in both in PEADs too. Yeah, PEDs, we would as young as 12 years old, we're getting pregnancy tests.

Like it's just part of the workup. If they're they come in with abdominal pain, they're gonna get a pregnancy test. And we'd often ask, hey, is there any chance you can be pregnant? And the answer is always no, right? Like there's always like no, no chance, no way. And and then, you know, you're still gonna get a pregnancy test. That could be a podcast episode in and of itself. Patients who find out they're pregnant and, you know you hear stories all the time.

All all the time. So, you know, I I always laughed when I you know, I would always laugh when I'd hear, you know, someone say, Oh, well, she didn't even know she was pregnant. You're like, How did she not know she's pregnant? But it happens all the time. I've had I've had women give birth and they're like, I didn't know I was pregnant and they're like not s not unsmart women, right? Like these are not like

Clueless women. These are like normal, you know, women who are like just maybe had no clue. Yeah. I've heard of this before, but I don't know. It's it's really, really hard for me to understand because I Definitely knew I was pregnant when I was pregnant. So I I have a a friend who was pregnant and I didn't know she was pregnant until she was very pregnant. Like she was kind of a she was kind of a a bigger gal.

And and just wore it well. Like I mean, if you are pregnant, you are clearly gonna be visibly pregnant, right? But but someone who's kind of big anyway, yum it could be easily missed. Yeah. Like it could happen. It could. So it could. What are some other examples of a ESI3? So we talked about kind of classic abdominal pain. What are some other ones? Headaches very well may be an ESI treatment.

Three, if we've ruled out that, you know, if you know, if they're not having the worst headache of their life, for instance, you know, when when someone says this is the worst headache of my life, or you know, they even if they have a history of migraines and they say this is a hundred times worse than my normal migraine. That that might recommend a a a higher level, you know, a higher level acuity.

Uh but for the most part, like a lot of times your person who comes in with a migraine, your person who comes in with a headache might be a an ESI either three or four, depending on on the the situation. Well you know, one of the things that that we really gonna focus on is we uh in in that determination of the threes, the fours and the fives, one of the things we have to look at is we have to look at their vital signs. We have to look at the vital signs in are these

Are there vital signs outside of what we would consider the normal? If so, then that may get'em bumped up to the next level, right? So if they're there and they have that, you know. classic case headache, but they're also tachycardic. They're also tachypnic. You know, things like that may end up getting them uh bumped up a level in in in triage. Would you say that's being captured more now with the the latest guidelines?

The latest guidelines have really kind of emphasized I uh I'll here's a perfect example. When I was a an ER manager. I went out and I watched the person who is our triage expert. Triage and I went out there and I watched her triage and she was bringing patients in. She was getting a history. She was writing a couple things down and then she was sending them out to the waiting room.

And I was like, wait, you you haven't even done vital signs on these patients. And she was like, Well, the ESI guidelines don't require that you do vital signs. And in the old guidelines it would say consider vital signs. Well, a lot of people thought took that to mean consider taking vital signs. But really what I think they meant, and then this is me giving them the benefit of the doubt, I think what they really meant was consider the vital signs in in your triage acuity

not consider doing them. You have to get the vital signs. And the the new fifth edition of ESI really emphasizes this. You gotta get the vital signs. You have to do them. And you have to consider whether or not these are high-risk vital signs. Are they tachypnic? Are they tachycardic? Are they hypotensive? Those are all things we have to consider when we are determining a triage category and and and exactly how sick those people are. It seems like a a needed clarification.

It was probably the thing I was the most excited about with this with this update. was they really kind of focused on, hey, like like look at the vital signs and physiologically look at what is going on with your patient. Cause I think oftentimes people kind of discount that and and that's critical.

'Cause emergency nurses think that they have like the sixth sense that says, Oh, I can tell if somebody's sick or not. Well, you might, but if you can't verify that with vital signs, then then you're you know, you're you're just guessing.

So we'll quickly move down to f fours and fives here. So let's talk about some classic fours. So you said only one resource is expected for this kind of patient. So what are some like Classic level fours. Gosh, let me think. I was gonna say, what about like a possible fracture, like toe pain, arm pain? Yeah, I mean if if the the one thing you're gonna need, if the one thing you're gonna need is an x ray, for instance.

That would be a good example of a level four because they're gonna come in, they're gonna need an x-ray to determine what exactly, you know, what the extent of the injury is. That's a great example, classic example of an ESI forward. Again, depending on whether or not you're gonna need uh any resources or not. I think as important it is about talking about resources, it's also important to talk about what's not a resource. And this might be a good time to do that is things that

that that aren't considered resources because you're gonna do them on every single patient. Like getting a history and physical exam on every patient is is just what you're gonna do. That's not a resource, right? If they're going to get just a saline lock or a heplin heparin lock, like uh just a IV access as we're drawing the blood, for instance, that's not necessarily going to be a resource. If they're going to need oral medications, that's not necessarily going to be a resource. Um

And then like simple wound care. Like a good example for a four or five kind of triage level might be wound care, for instance. Like if someone comes in with a a simple laceration, a simple laceration where we're not gonna we're not gonna need much. you know, if all they're gonna need, the only the only intervention they're gonna need is the wound care and the tetanus shot, that's not a resource heavy patient, right? That might very well be a four or or very or could even be a five.

So I know we're kind of talking about these kind of all together, but you almost have to on the fours and fives because sometimes they're they can be pretty close. Yeah, sure sounds like it. The reality is like the the ESI triage system is kind of an amazing tool. In that it it really kind of quantifies, okay, how many resources are they going to need, then, then they're going to be probably this level. Now,

things change, you know, people are people are dynamic, right? Like you can come in and they seem like a a a straightforward ESI three and then all of a sudden they have some kind of event that makes them, you know You know, like, wow, okay, now they're really sick.

And that isn't necessarily someone you'd change their triage category, but you you know, if they're already seeing a provider, you're just gonna do what you need to do. Yeah. Maybe move them to a you know, higher acuity area of the emergency department, but not necessarily like touch their Their ESI now. Yeah. That ESI is is just for the initial sorting of of when they come into the emergency department. It's like the sorting head.

in Harry Potter. If if we only had that in triage, we could just put the swordy hat on you and say, You're a two Go on. Boy, that'd be amazing, right? Like either that or we need those those little scanners they have in like Star Trek. We're like okay. This is what's going on with you.

Maybe Nicotine to ask like are is there any area for AI and triage in the future? Oh, that's a Gosh, that's a good question. So there are companies that are they're using kind of an AI algorithm, I I I guess you would say for triage, but there's you know, there's a company that they have a a product that basically kind of sits in the background of the the medical record and and some of the medical records are doing this now too.

Where it's gonna look at those vital signs and then it's gonna say, okay, you've triaged this person to category three. maybe consider making them a two based on this. And and say, you know, based on this high heart rate, based on this low blood pressure, they might be maybe someone you would consider putting, you know, upping a level in triage.

There's a a company that's doing that now and and it's being built into some of the things like Epic and Cerner is is trying to have that that basically looking at those vital signs and saying, hey, based on this. maybe consider. I think nurses are really good at unfortunately ignoring data. Um

Blowing through it. And kinda blowing through the data and just kinda thinking you know, relying more on their gut. When if they rely more on that objective information, that's gonna be more predictive of what w what your patient's ultimate outcome will be. I mean I think I think that's a good thing.

the more information you can get because cause what we know for sure is we know patients are poor historians, right? Like patients are patients can be very poor historians. I always use the example of my brother. My brother

Called me up one time and said, Hey, I'm having this chest pain. Really don't feel good. Uh yeah. I got this this kind of pressure on my chest, kind of going into my arm. And I'm like, dude, you're having a heart attack. Go to the hospital. He's like, I don't think I'm having a heart attack. I think I'm fine.

And finally, uh, like I asked his wife, I'm like, how does he look? She goes, Oh, he looks pale, he's sweaty. I'm like, oh Jesus, go to the hospital. He's calling me to ask for advice, right? So finally finally he goes to the hospital and he goes he called me up later and he goes, Well, I told you that I wasn't having a heart attack. I go, Yeah, what did they tell you? They said, It's an acute MI Oh. Okay.

Okay. Okay. Glad it's not that heart attack. That would be bad. Yeah. And then fast forward, I don't know, six months, eight months, a year, whatever it was, he was being triaged in my emergency department where I worked. And I just happened to be there'cause he he asked me to be there as as they were kind of triaging him and they were asking him, Do you have any medical history? And he's like, Nope. Oh yeah. Medical history at all. No, no I'm good.

And I'm like, what about this? What about this? What about this? What about this? And they're like, oh, oh yeah, oh yeah, I get oh yeah, I have that stuff. Patients are really poor historians. If we have AI, if we have that AI concept that can can look through previous visits, yes, and and kind of comb through and say, hey. Even though they're they're telling you they may not have a diagnosis of this.

they they had this. This is something that was diagnosed a year ago, two years ago, and they may not even know. They may not even know about it. Yeah. I think I think there's a lot of potential for AI

in in healthcare. Like I I'm I'm excited to see what the future holds. I know a couple of Stanford professors recently came out with a paper about the role of AI in writing history and physicals. And I think like that's a great great opportunity for AI because I mean history that could be very extensive for patients and, you know, you got hospital doctors, you know, are so time strapped that I think that could be a great application for coming up with a a history.

Imagine if if when you open the patient's chart. You had like a true hist like a true history based on, you know, their twenty last ER visits. You know, they have they've had these things. And and now you see this already in in a lot of medical records where they show previous diagnoses.

that may or may not may or may not still be pertinent to what you're you're talking about. But imagine if it it kind of put this together and said, hey, this patient in their last three visits ended up becoming hypotensive and ended up in the ICU. having something that could flag those charts and say, Hey, the last time the patient was here they they clinically deteriorated pretty quickly. That might put'em in a higher category, that might help, you know, make you a little bit more suspicious of

Of the potential. Yeah. Oh this is really interesting. I I I I think the future is exciting. I I if we're still podcasting in five years Maybe we could come revisit ESI and see how much of it is being automated by AI. One hundred percent. I I I can't imagine AI is not gonna become a bigger deal. I mean, I don't think it's ever gonna replace Yeah, a good history in physical and a g a physician, uh you know, a well trained physician.

But imagine how how much information that physicians are expected to just keep at the the tip of their tongue or at the top of their brain. And and it's just not as possible as as it would be with AI. Totally.

Well this is a great discussion and I I love the twist at the end to it, you know, talking about how AI is going to influence triage in the future. So yeah. Yeah. I think the ESI tenth edition may look very, very different. than than what we're we're dealing with now. I think that the future is bright. All right. Thank you so much for joining today, Kevin. I appreciate you sharing your time. Oh. Thanks for having me on the podcast. It's always great to hang out and talk to you. Yeah.

All right, thank you for listening. If you want to catch more of what Kevin is doing, check out his podcasts, The Art of Emergency Nursing, as well as How Not to Kill Your Patient, which he co-hosts with Dr. Lisa Wolf. If you've made it this far into the episode, I can only assume you found value in our discussion. I'd greatly appreciate it if you could take a moment to leave a five-star rating or review wherever you listen to your podcast.

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