ESI question

I was originally trained in ED nursing by physicians (1 doc/1 nurse ED).

My favorite doc used to say, "Even turkeys get sick" and, "If you wake up every morning and think, 'I'm dying,' one day you'll be right"

On the other hand, a FF is like the boy who cried wolf and may well lead to their own demise in the absence of objective signs of serious disorders.

It can be hard to differentiate between the cry of 'wolf' and legitimate symptoms of concern.

To the OP's point: Symptomatic, MAP=60, and high-risk factors... that's a 1 in my book. The patient needs a couple of 14 or 16 ga lines, fluids, and a STAT CT.

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?

1) Triage acuity levels are determined by the information obtained and provided not with the help of a subjective opinion like "she is here all the time". That is the type of behavior that will get a patient killed and an ER nurse and facility caught in a legal situation.

2) The initial triage level should NEVER be changed (unless it is by YOU). Your supervisor could make the decision to document why the patient is being downgraded to a level 2 but you are the one with the initial visual of the patient who used your critical thinking skills, experience etc. to come up with the level 1 acuity. Books on triage (see Amazon) further clarify this point. I also agree with many of the other posters on the level 1 decision.

You weren't wrong to make her a 1, you wouldn't have been wrong to make her a 2 either. There are perfectly logical rationales for using one or the other. What is pretty clear is your charge nurse's approach as well as her rationale wasn't appropriate and obviously isn't based on ESI criteria. Being a frequent flyer shouldn't affect ESI level when the patient is clearly critical.

posted in wrong thread

Visits/week does not factor into esi level. Period.

2's can be 1's or 3/4/5's depending. 5's can be 1's....depending.

If you can justify your reason for picking X. Don't worry about it.

Sorry for the late post. It had turned out to be an ovarian torsion. FAST exam at bedside ruled out bleeding, then she had a CT and ultrasound. I wonder now, is a possible ovarian torsion a level 1? Testicle pain is a level 1 because it can cause loss Of a testicle, but I couldn't ever imagine assigning a level one to every child-bearing female with sharp abdominal pain.

Testicular torsion would be considered ESI 2 due to "limb-saving" (or whatever they call it). I would imagine ovarian would be the same.

Her vitals and clinical picture, I would of made this patient a level 1. Symptoms of a rupture!

I would have made this patient a 2, but not because of the reason cited by your supervisor. Your supervisor is playing a dangerous game making triage decisions based on how often the patient presents. The reason I would have made this patient a 2 is that she had vitals in the "danger zone" and a potentially high risk condition, and did not require immediate life saving intervention.

Just some thoughts, as a charge nurse i would never just change an acuity level. MAYBE once ever 2-3 months I will call out and ask why someone was made a particular ESI code if it seems low or high, sometimes we hit the wrong button or the nurse see's something that isn't conveyed in the chart. But I would never tell a triage nurse the had to change an ESI level or do it myself , it is there clinical judgement.

Based on the presentation I would have said 2, but can completely understand the rational for 1. If they were talking, pink, and upright (short of GSW to the chest) I will generally make them a 2. Level 1's i am riding the chest or bagging, or holding pressure on the arterial bleed as we run the litter back with the patient. But with those vitals it would have been an EKG being done while I called the charge to find a room. For a thin, tiny febrile women those vitals are not that scary, in and of themselves. But physical exam and hx definitely weigh in.

I would also have made her a 1. If I am unsure that they will survive from triage chair to trauma room, they get a 1. I don't 1 for severe pain, or for febrile neutropenia, though some folks suggest it would be appropriate. Just life threatening issues.

If your preceptor saw her daily with the same symptoms, and knows her BP is usually low, I'm sure she could easily be a 2. Knowing the diagnosis, I'd call her a 2 after the fact.

Sometimes I triage, and then watch after triage to see if the tremors, anxiety, and moaning continue in the waiting room. Running in from the parking lot causes diaphoresis and tachycardia. If there's a full waiting room, I want those that are very sick to get in ahead of those that have intermittent symptoms. But if you do that as a triage nurse, you can NEVER EVER forget to recheck them.