ESI question

  1. Had a pt present to ED... young female with a hx of splenic artery aneurism that had appointment to operate in one week with sudden onset of sharp, tearing abdominal pain that radiated to her back. HR 150 and BP 90/45. Diaphoretic and tachypneic. I triaged her as an ESI-1 and my supervisor changed her to a level 2 because "she is here all the time." Pt still got a high acuity room ASAP, but I'm pissed that my triage level was changed. Was I wrong to put her as a 1?
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    About peaches88, BSN, RN

    Joined: Feb '12; Posts: 35; Likes: 45
    Specialty: 6 year(s) of experience in ICU, ER, PACU


  3. by   Euro_Sepsis
    It's splitting hairs at a certain point because your supervisor could argue, "What immediate life saving intervention did the pt require?", but if she ended up on pressors or something that's deep in the 400-page ESI book as a qualifying level 1 criterion.

    Even if you're both right, your boss is more wrong only because of their justification.
  4. by   amzyRN
    I think it might be a little subjective. I think you are probably technically correct. You felt immediate life-saving intervention was necessary and a physician at the bedside immediately, that is an ESI 1. We have a 2 tiered triage process where a nurse is outside in the lobby and checks patients in, assigns an ESI, then a second RN gets vitals and other info and can change the ESI depending on vitals. Maybe your charge revitalized and found the vitals were different and changed it. Perhaps no immediate live saving intervention was needed.

    I have wrongly triaged before because I was unsure and did not have the vitals. There was a patient that I triage a 1 who was tachypneic and stated her asthma inhalers weren't working. I asked if she had ever been intubated before and immediately put her in a wheelchair and brought her to the second triage nurse. I assigned an ESI 2, she was upgraded to a 1 at the bedside and was given a series of breathing treatments, not intubated though and admitted for observation. I don't know if they put her on bipap or not. Technically I think she was an esi 1 because that breathing treatment was immediate lfe saving intervention and a physician was needed at the bedside immediately. My assessment was based on my tendency to only assign a 1 if the person is about to get intubated or CPR in progress or getting massive transfusions or chest tubes. But according to ESI this is wrong.

    I also assigned a new onset angioedema a 4 because I thought he needed IV meds and discharge. His symptoms evolved over the past few days. He was a really fat guy with kind of a weird looking face and said his face was a little more swollen than normal. My rationale was that I believed he needed IV meds and dc. I did not recognize the potential severity of this. In my experience, I have given IV meds to angioedema patients and depending on severity dc'd them. His ESI was changed to a 2 and he was put in one of the trauma rooms and admitted for observation. We sometimes do a rapid MSE at the second triage area and I think one of the providers said it was worse than it seemed and he needed immediate bedding. Looking back on this, I think I was wrong because this was a high-risk situation and he shouldn't wait. Any angioedema should probably be eyeballed by an MD really quickly. I just didn't recognize it in the guy initially because he was so large I thought he might just have a weird looking face. I have seen some very interesting looking people since working in the ED with very different features and anatomy.

    In your case the patient still went back and was seen quickly without an adverse outcome, so does it matter that she changed the ESI? Maybe she revitalized the patient and saw a different set of numbers and changed it back? Perhaps no immediate life-saving intervention was performed. Check the ESI manual and see what it says. The definitive test I think is if you needed an immediate life-saving treatment with a physician at the bedside. That is an ESI 1 as far as my understanding. My hospital just made us do a triage class because they thought we were under triaging.
    Last edit by amzyRN on May 23, '17
  5. by   peaches88
    My thought was that her aneurism could have ruptured, which is why I put her as a 1.
  6. by   amzyRN
    Quote from peaches88
    My thought was that her aneurism could have ruptured, which is why I put her as a 1.
    I think your rationale is correct, a ruptured aneurysm is a 1, a physician at the bedside immediately and live saving intervention needed.

    An about to rupture aneurysm would also be a 1, a physician at the bedside and life-saving surgical intervention.
    Last edit by amzyRN on May 23, '17
  7. by   Lev <3
    Saying "she's here all the time" is the type of triage language/tunnel vision that gets people killed.

    I agree with your ESI 1 designation. If she wasnt symptomatic (diaphoretic and tachypnic) then she would be an ESI 2. HR alone with a borderline BP and symptoms can put her in ESI 1 territory because either a) she will need fluid rescusitation and/or b) chemical/ electrical cardioversion (if afib rvr lets say)
  8. by   JKL33
    A case could be made for either 1 or 2, but your supervisor's rationale is ridiculous either way. After doing this for years...I can only say I would have to see/triage the patient for myself in order to tell you which I would've picked. I'd like to hope the supervisor actually laid eyes on your patient and had a different feel for the situation than you did, which is completely different than just saying the patient is here all the time so therefore can't be that sick.

    Judicious use of the different ESI levels can make or break lots of things...department's flow, assignments, and most importantly pt safety. ESI 1 patient is going to die and needs help this instant, not 5-10 minutes from now. Or being resuscitated. I've always operated with the understanding that, not only does this patient need a life-saving intervention, s/he needs it this instant. Which is different than, say, getting a neb tx 15 minutes from now. Someone who is not at all tolerating their condition and is essentially trying to die. With your case, the story is concerning, the vital signs are concerning...I can imagine a patient where I'd take those facts and make it a 1, and can imagine a patient where, with those same facts I would make it a 2.

    Emergency Severity Index Implementation Handbook: Table 3-1. Immediate Life-saving Interventions

    How did things turn out? BTW, the answer shouldn't and doesn't prove anything - I'm just curious.
  9. by   Pixie.RN
    With those vitals and presentation? Level 1 — possibly about to die unless there is intervention.
  10. by   ~Mi Vida Loca~RN
    So in the ESI classes I have taken I was always told that a patients ESI level could not be downgraded. (more so to do with billing or something) That it could always be upgraded, but that it can't be downgraded. Has this changed or is this more regional??

    As far as this case, I would have had to see the patient to decide if it was a 1 or 2.

    As the other poster stated though, that "she is here all the time" thought process is how things get missed and outcomes end up poor.

    We had a frequent flier patient once in our ED that was always in for either chest pain or psych issues. Her and her boyfriend. Legit one time I had to call (for the 2-3 day post discharge Studor calls) :| can her boyfriend was on the phone saying "Actually we are coming in right now, we will figure out why on the way there"

    However, she came in as normal another time. Same complaints, we had no beds and a lobby full of people. She complained of chest pain. Charge nurse rolled her eyes and did her triage and put her in the hall and asked me if I would get her vitals when I had a chance and put them in. So I finish the IV I was placing for another nurse and go to hook Suzie up to the monitor in the hall. My cardiac monitor isn't registering and reading funny. I check the cords and adjust the stickers, still isn't picking things up and it flashes real quick 218 and then back to trying to obtain a signal. Patient is looking fine and behaving how she normally is. Rest of vitals are OK. Charge says she paged EKG tech and he was on his way. Told her I was having trouble registering a heart rate, she told me not to worry about it that she would enter it later and asked me to go start another IV. But I couldn't just ignore that. So I grab the EKG machine to do it myself and sure enough her HR is up in the 220's. I grab my stethoscope and listen and sure enough her heart is just a pounding away. I go to tell the doctor and he rolls his eyes thinking I must be an idiot I guess and tells me nothing is ever wrong with Suzie, she is a headcase. I look at the PA and was like "this ladies heart is about to beat out of her chest, I am more than willing to carry on about my day and just chart Notified MD and PA, MD states "patient is a headcase". if you want but I am pretty sure that isn't going to end well" I leave the room and go get the stuff to put an IV in her. We were slamming adenosine within a few minutes.
  11. by   OlivetheRN
    I think every ED has that frequent flier who is fine until they're not. One day they walk in and something is off and you have to hope that everyone doesn't brush it off as "Oh that's just so-and-so, they're here all the time." I can't say that I'm blameless in this, in our dept we have a particular patient who will sometimes check in 3 and 4 times a night, and I will roll my eyes and sigh when I see them roll (or walk) in with EMS and put my finger on my nose and say "not it" (after very quickly doing hand hygiene, of course).
  12. by   Euro_Sepsis
    Count me in JKL's camp with regard to rating this pt or a moderately distressed asthmatic a solid 2. My department would have 10-20 1's a day if we scored that highly that easily
  13. by   Lev <3
    One of our usual drunks at my old ER coded (and lived).
  14. by   ~Mi Vida Loca~RN
    Quote from Lev <3
    One of our usual drunks at my old ER coded (and lived).
    We had a regular for chest pain for YEARS come in. We called him Santa Clause. Pretty sure he came for the food. He was always very nice and pleasant. The day his Toponin came back bumped I think we all almost had a MI. lol It was probably clogged arteries from all them turkey sandwiches.