ESI practice thread

  1. I am starting this tread for people to post scenarios (easy or hard) and for others to say how they would triage this patient according to ESI and their rationale for doing so. I think we can learn a lot from each other. Especially newer ER nurses learning from those more experienced.

    Does anyone want to start?

    It can be based off real patient scenarios.
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  2. 121 Comments

  3. by   amzyRN
    Male patient 39 years old comes in with complaints of swollen cheeks and lip swelling. Pt says also has been having sore throat, cough, and fatigue. Pt comes in with his son who also has a cough and sore throat and wants to be seen. Pt is very obese has puffy cheeks and swollen lips but not our of proportion to rest of his body. Pt says he has a little more puffiness than usual in his face. Pt speaks in full sentances, denies swelling in tongue or throat. Vitals are stable, no swelling noted in mouth or uvula. Pt denies taking any medications that might have caused an allergy but states that he has had some type of cold or flu-like illness that both he and his son has had and though he should come in due to the swelling in his face. Assign an ESI.
  4. by   Pixie.RN
    Quote from amzyRN
    Male patient 39 years old comes in with complaints of swollen cheeks and lip swelling. Pt says also has been having sore throat, cough, and fatigue. Pt comes in with his son who also has a cough and sore throat and wants to be seen. Pt is very obese has puffy cheeks and swollen lips but not our of proportion to rest of his body. Pt says he has a little more puffiness than usual in his face. Pt speaks in full sentances, denies swelling in tongue or throat. Vitals are stable, no swelling noted in mouth or uvula. Pt denies taking any medications that might have caused an allergy but states that he has had some type of cold or flu-like illness that both he and his son has had and though he should come in due to the swelling in his face. Assign an ESI.
    Vital signs are part of the algorithm...
  5. by   JKL33
    Quote from amzyRN
    Male patient 39 years old comes in with complaints of swollen cheeks and lip swelling. Pt says also has been having sore throat, cough, and fatigue. Pt comes in with his son who also has a cough and sore throat and wants to be seen. Pt is very obese has puffy cheeks and swollen lips but not our of proportion to rest of his body. Pt says he has a little more puffiness than usual in his face. Pt speaks in full sentances, denies swelling in tongue or throat. Vitals are stable, no swelling noted in mouth or uvula. Pt denies taking any medications that might have caused an allergy but states that he has had some type of cold or flu-like illness that both he and his son has had and though he should come in due to the swelling in his face. Assign an ESI.
    I'd like to ask him if he's ever had anything like this before (the swelling part). Without any more information, a case could be made for ESI 3 (possible RST or other lab, possible imaging), ESI 4 (hedge a bet that one resource will be used), or frankly even 5.

    I'll be honest, this is the exact type of scenario where I would take a few extra seconds to get more info. I'd probably like more info about meds and med hx. Then there's the general appearance and a few general observations I am usually making while getting other info. For this case, I even have a couple of Ddx in mind that could lead me to make him a 2.

    If pinned down strictly on the info above and with the understanding that he is described as being quite stable, I say ESI 4.
  6. by   amzyRN
    At our hospital, we have a 2 tiered triage process. The nurse in the lobby takes basic info and puts the patient in the system gets brief info, like chief complaint and quick pertinent info and assign an ESI. Then based on that, the secondary triage takes the patient back, gets vitals, asks more questions like history and meds, then can change the ESI.

    I assigned a esi 4 and designated him fast track along with his son, which I gave a esi 5. When he went back the secondary triage nurse up-triaged him to a esi 2 and he went to one of our trauma rooms. We have a provider in the secondary triage area that sometimes that does a rapid MSE which sometimes helps us decide if the patient is more acute or can go to fast track in cases like this for example. I think the provider suggested bumping him to an esi 2. Anyway, the patient ended up getting admitted for observation due to angio edema. He might have gotten IV Benadryl and pepcid.

    I felt bad like I missed something but was out in the lobby doing the primary triage so didn't have the chance to ask more questions or get a set of vitals. I've taken care of patients like him in the past who have just got oral antihistamines and discharged, so I was basing my decision on past experience. I His symptoms seemed to be very low moving, he had developed swelling over the past several days.
  7. by   JKL33
    I was thinking of hereditary angioedema as something in the back of my mind that would lead me to ask a couple of questions and possibly just up-triage him for the idea of high-risk.
  8. by   ~Mi Vida Loca~RN
    Wrong thread.
    Last edit by ~Mi Vida Loca~RN on May 31
  9. by   Pixie.RN
    Quote from JKL33
    I was thinking of hereditary angioedema as something in the back of my mind that would lead me to ask a couple of questions and possibly just up-triage him for the idea of high-risk.
    Yep, because unless he's on an ACE inhibitor, this is probably one of those idiopathic things that doesn't really respond to our usual "allergic reaction" cocktail. But airway is a primary concern, of course. I can definitely see making him a 2 just as part of the "high risk" segment of the ESI algorithm.
  10. by   JKL33
    Yep. Sometimes, especially when gestalt/"6th sense" doesn't pick up on any non-medical overtones, I take heed with run-of-the-mill average people who become slightly concerned about themselves, especially after tolerating their symptoms for a couple of days. Not talking about the one who can't endure the average sniffles anymore, but the guy who figured he should find out why his FACE and LIPS feel swollen - I'm sure many here can imagine the scenario/patient I'm trying to describe! Angioedema of course has other triggers, so I might even persist in my concern after clearing his med list....the potential trigger I'd think of would be his report of recent likely-viral illness (by his description)

    BTW, I find it interesting and validating that the ESI manual mentions "sixth sense"!!!
    Is This a High-Risk Situation?

    Based on a brief patient interview, gross observations, and finally the “sixth sense” that comes from experience, the triage nurse identifies the patient who is high risk. Frequently the patient's age and past medical history influence the triage nurse's determination of risk.
  11. by   Pixie.RN
    Here's a question: do you (any of you) make all of your psych patients an ESI level 2?
  12. by   amzyRN
    Quote from Pixie.RN
    Here's a question: do you (any of you) make all of your psych patients an ESI level 2?
    We designate esi 2 for psychosis and/or suidal/homicidal thoughts. Usually, people with psych issues who come to us are having one or the other, so most of our psych patients are triaged an esi 2.
  13. by   JKL33
    Quote from amzyRN
    We designate esi 2 for psychosis and/or suidal/homicidal thoughts. Usually, people with psych issues who come to us are having one or the other, so most of our psych patients are triaged an esi 2.
    Same. And some psych presentations that may not strictly meet these conditions (don't admit SI, for instance) but are nonetheless concerning and high risk. We include victims of SA/CSA in this as well.

    And I take a LOT of latitude with peds psych presentation. I will make them ESI 2 if I get a whiff of anything high-riskish/concerning, with or without SI/HI/psychosis apparent. Severely depressed affect, acting out/violent behaviors for just a couple of examples.
  14. by   ~Mi Vida Loca~RN
    Quote from Pixie.RN
    Here's a question: do you (any of you) make all of your psych patients an ESI level 2?
    Our hospital protocol was that we had to unless they were coming in for med refill or something unrelated. But anything with a complaint of SI or an acute pysch issue was automatically a 2 and protocol put in place.

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