Change Triage/ESI After Visit Complete

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Is it normal practice to change ESI/triage level after visit is complete? Some of our doctors order work ups on nearly everyone, so a patient I may consider a 4 or 5 will frequently end up being higher level. I am being told we should go back and change triage level to match number of resources so that the ER charges will match? Does this sound right?

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On 2/27/2022 at 11:06 PM, newlaRN said:

Does this sound right? 

No it is not right.

If the work-up is eventually overkill or otherwise not appropriate, that is not your problem or your concern as the person performing the triage. The process of assigning ESI is not meant to be influenced by knowledge of individual provider patterns. While provider patterns hopefully reflect the patient's actual acuity, they do not determine the patient's actual acuity. You should generally be coming up with an ESI level that a nurse who doesn't work in your facility would assign if they triaged the same patient at their place. For instance, if I see an uncomplicated patient with cystitis I'm assigning ESI 4. And if you see the same patient it shouldn't be a 3 just because your provider likes to CT everybody with cystitis sx. That patient isn't, in reality, any sicker just because your guy/gal decided to CT them for simple symptoms.

However, you do need to make sure you aren't overlooking or failing to get details that would have actually made these patients higher ESI at the time of triage.

Who is telling you that you need to change this after the fact, and--just curious--are they implying that you actually missed something or just that they want the patient to appear that they were sicker at triage because reasons? If it's the latter......they are up to no good.

 

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Specializes in Emergency.

The physicians at my place are also changing Triage hours after diagnostic tests such as labs and imaging are done.  My thought is that an initial triage should remain the same throughout the visit and not changed after more information is gathered.  Triage should be based on resources needed and initial presentation of life threatening acuity not test results. An example is changing a ESI 3 to a ESI 2 after discovering an out of range potassium or lactate values 2 hours is not correct.  Please tell me if I am correct.  

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11 hours ago, Nonnke said:

 Please tell me if I am correct.  

You are correct. However, you should find out why this is being done. I have seen docs want to change the ESI because it's one way to help keep patient situations straight when they are looking at a full board. They see some concerning results come back and don't want that patient to get lost in the shuffle of all the 3s. That still doesn't mean that the patient's acuity assignment as made at triage should be changed, but it is at least somewhat understandable.

 

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Specializes in Emergency.

I do think there are motivations for doing this to include wanting to appear to be taking care of sicker patients based on their orders.

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Specializes in Emergency Medicine.

Triage nurses should not change their ESI after they have done an assessment. As providers, we order things based on our assessments and billing is done based on how we chart, and we do justify in our charting with our findings why things are ordered. Sometimes as we assess, differentials pop up and we need to rule things out, etc…
 

I will often work up a patient that should have been a 3 that was initially triaged as a 4; maybe the triage nurse wasn’t aware of something I discovered or whatever… but billing doesn’t have much to do with the ESI specifically.

Triage the way you need to and let the provider do their thing. You’re not doing anything wrong. 

 

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Specializes in Emergency.

Thank you for confirming the triage and billing process.

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