ESI Triage concerns

[Mobeeb, RN]

Does anyone out there have concerns about the ESI Triage protocols, specific to the length of stay incurred when a certain "number" ESI score is given? It's not news to anyone that over the past 2 years, the volume of ER patients has grown exponentially and folks are waiting in the lobbies longer. The majority of patients who are triaged "3" compose the largest number of patients. Here's where my concern comes in: Patients who have lacerations, fractures of single limbs, head injury with LOC, etc., are given scores of "4", so they are waiting for hours while abdominal pain for months, etc., are being seen because they use more resources. As an experienced ER nurse, I can project what the cited "4" examples will require as part of their treatment, but there are a lot of newbies out there who cannot.

At what point does management step in and say "Hey, let's use some common sense here", and get the injured folks seen before the belly workups, especially the ones who had the same workup last month, and the month before and the month before? {{{ sigh }}}

[Altra, BSN, RN]

ESI is a well-validated tool to indicate both patient acuity and the amount of "resources" that are likely to be required to care for a patient.

However, as always, the devil is in the details: the details of what your hospitals *does* with that ESI number.

When you speak of protocols - those are specific to your hospital. In other words, in your ER, if ESI 3 patients are always prioritized over ESI 4 patients - that is because your department has established that practice / policy.

There are as many ways to manipulate patient flow as there are impediments to patient flow, and they all have their ups and downs. The concept of a fast track or minor care area to expedite the flow of ESI 4 / 5 patients seems like a great concept ... until you consider that the ultimate outcome can be viewed as a "rewarding" of overuse of the ER for "my ankle has been hurting for 3 months"-type complaints ... while that ESI 3 abdominal pain waits for hours.

Does your ER utilize protocol orders which can be completed while the patient is waiting?

[Anna Flaxis, BSN, RN]

Remember that you can always increase the acuity level if VS are not WNL, or if the person looks potentially sicker than their chief complaint would have them be. Technically that possible fracture might be a 4 because all they'll need is an x ray and maybe a splint and some PO pain med, but if you have a high index of suspicion that the limb is fractured and that the person will need procedural sedation, then make them a 3. If that head injury with LOC looks like all they might need is a head CT, but something is telling you that they might have a bleed or a fracture, then make them a 3 (or even a 2). If ever in doubt, triage up. Studies show that under triaging is one of the causes of delay in recognition of severe illness and subsequent admission to the ICU.

Even though that Level 3 abdominal pain has been worked up seven ways to Sunday for the same thing, there are reasons we keep working them up every time they come back. Recently, we had a guy who had been in 3 days prior, worked up, sent home. He was a seedy looking and squirrely acting guy and we thought he was FOS, but it turned out he did have a raging pancreatitis and was admitted to the hospital. This stuff happens.

All of that aside, I do have similar concerns sometimes, when things are really busy, and a person is waiting for several hours just to have a lac sutured, while the person with pelvic pain x6 months is getting the full meal deal in the back. What I will sometimes do is, instead of prioritizing numbers and acuity levels (other than 2s, obviously), if the 3s who are waiting in the lobby are all hemodynamically stable and look really benign, I might pull a 4 or 5 who has been waiting for a really long time into the back. It's a total judgment call, and sometimes I'll run it by the doc on duty first. If everyone in the back is in process and just waiting for results, the doc might be able to go in and do a quick suture and get the person in and out. Or, if it's the last hour of their shift and a new doc is coming on soon, they might whip out a few low acuity patients rather than start in on full workups at the end of their shift. So you can see, we don't really have a Fast Track, but we can "Fast Track" patients here and there.

Also, we will start workups in the lobby- we can give PO Zofran, Tylenol, etc. as appropriate, order xrays and urines, and sometimes blood work can even be started if we're really bogged down- we don't have a really great system for phlebotomy draws on waiting room patients (this is something I'd like to change), so usually they don't get a lab draw until they get into the back.

[Lunah, MSN, RN]

When I am in charge, I consider more than just the ESI score to facilitate patient flow. I can and have brought a 4 back before some of the 3s, it's just based on the triage story and what is going on in the ER at the time. We also start things from the waiting room, like UAs/Urine HCG, x-rays, even ultrasounds. Some of our 4s can't go to our fast track by the nature of their complaint (which annoys me, but that's another story), so they are seen in the core and will sometimes bump a 3. ESI is just a piece of it.

[TexanTough]

*Sigh*

This is a huge source of frustration for me. First and foremost, facilities where I have worked will let green and inexperienced nurses in triage. This results in an ESI of 4 assigned to the full blown aids patient complaining of dental pain who has a HR in the 120s, is febrile, and has a muffled voice. Said patient marches off to fast track where I am now drawing BC x 2, sending the patient to CT of the head and neck, and starting broad spectrum abx.

I'm done ranting. Now for the question at hand. If your nurses are truly following proper ESI scoring, it should be noted that PAIN alone can make someone a 3 vs a 4. Also, I'm a little shocked your facility does not utilize a 'fast track' for ESI 4s and 5s. This usually decompresses the waiting room of ortho/musculoskeletal complaints. If your facility truly pulls back by acuity, there needs to be a balance between length of stay AND acuity. There are several matrices available online to assist personnel with this.

In terms of belly complaints. The abdomen is a veritable pandora's box. Your patient could have anything from pelvic inflammatory disease to and ileus to a dissection. This is why abdominal pain (at least where I have worked) should not be dismissed.

[Christy1019, ASN, RN]

I agree with the above posters, but on a side note, I would never make a head injury with positive LOC an ESI 4, nor has that been the norm at either facility I've worked for, one being a large level 1 trauma/teaching hospital. In my experience, those pts would be a minimum of a 3, depending on the story, and assessment.

[Mobeeb, RN]

Yes, protocols are used in the Triage process.

[Mobeeb, RN]

We do have a Fast Track as well as Emergent, Urgent and 4 Trauma bays (soon to be increased to 8).

[Mobeeb, RN]

Thanks, guys, for your responses. I think it helps this old nurse to read your comments (especially the rants) because I am reminded that the problems (or challenges---management term) of nursing are the same, no matter where you go. :)