Using ESI Levels to establish vital sign reassessment intervals

[Lunah, MSN, RN]

Okay, smarties .... I need some assistance. Our ED is getting ready to revise our policies/procedures related to vital sign reassessment intervals, and we are leaning toward basing the vital sign reassessment intervals on ESI Level. We're looking at something like this, which I found on the ENA document sharing section from another facility:

ESI Level 1: Every 5-15 minutes as needed and no less frequently than every hour for the first four hours, then every 2 hours if clinically stable.

ESI Level 2: Vital signs no less frequently than every hour for the first four hours, then every 2 hours if clinically stable.

ESI Level 3: Vital signs no less frequently than every two hours for the first four hours, then every four hours if clinically stable.

ESI Level 4: Vital signs per acuity and clinical assessment, but no less than every four hours.

ESI Level 5: Vital signs per acuity and clinical assessment, but no less than every four hours.

The question is this: does anyone know if the ENA recommends or provides any guidance on this? I do know that the ESI folks have specifically decided to NOT make recommendations for vital sign reassessment intervals based on ESI Level because every department is different. Please tell me what your departments are doing, and if there is any guidance on which you've based it. We'd like to have some kind of reference to point to as to why we're doing it this way, and I know this is done in other facilities. Thanks!!

[hiddencatRN, BSN, RN]

We do it like that, except in order to go from q15 vitals on an ESI 1 to q1hr vitals, we need an order in the chart (Vitals Q1h, Q2h, etc). We usually only request those orders once a patient has been admitted and is awaiting a bed. So ours would look like:

ESI 1: q15 minute vitals

ESI 2: q1hr vitals

ESI 2: q2hr vitals

ESI 4 & 5: q4hr vitals

Our chart keeps time for us, so if you click on a patient's chart and haven't entered vitals in a while it lets you know they are overdue. It does not go based on specific orders in the chart though (so an ESI 2 who has been ordered q4hr vitals in anticipation of going to a med surg floor will still flash a late vitals message at you once it's been 1 hour since the last set).

I'm honestly not sure what informed out policy though. Have you tried asking the ENA listservs?

[Lunah, MSN, RN]

I haven't asked there yet -- came here first because I know the best & brightest are on allnurses. But I'll try that as well.

[EDRN10]

Our ED does not have a system so basically all vital signs are left up to nursing judgement unless a md instructs something specific. This is an okay system so long as all your nurses know what they are doing, but as I am sure most places are we have nurses that just don't seem like they have a clue sometimes. I know I personally do vitals q30-60mins on most regular pt's, minor stuff I get vital's at triage and d/c, and critical pt's I do vitals q15mins or less. I'm going to keep checking back to see what you find out lunahrn because we really need a system in our ED.

EDRN10

[thelema13]

We do vitals based upon our judgment, unless there is an order for continuous monitoring. if they are continuous, we do vitals q30, unless they are a high acuity or a pressor or nitro is hanging, then we do q5-15 minutes. It all ports over through the computer system. Fast track or RME pts get vitals at triage and DC, unless it is a fever and then we re-check temps as needed.

Don't know if this helps, but we have enough policies to tie us down. I am also unsure if there is a policy for ED vitals, but we do them off of our own expierence and clinical judgment.

[Lunah, MSN, RN]

Thanks for all the feedback thus far, peeps. :) I also asked on the ENA managers listserv, and so far no one has been able to point me to any ENA reference that supports or discourages the practice of basing it on ESI level. I think we are looking at not rechecking vitals on ESI level 4s or 5s, unless there was anything out of norm or based on condition (e.g., fever). Of course, we would always use our nursing judgement!

[traumaRN1908, RN]

Lunah that is what I am currently using. I can attempt to get an electronic copy for you, but the time frames are the same.

[Lunah, MSN, RN]

Lunah that is what I am currently using. I can attempt to get an electronic copy for you, but the time frames are the same.

If you can get your hands on an electronic copy of your SOP, that would be great! Otherwise, no biggie ... our assistant head nurse is going to be writing the SOP and she probably has enough with what I've given her. :)

[rndiver82]

LunahRN~

I'm in a Level 1 Pediatric Trauma Center that went to an ESI-based system. While we go follow the guidelines, we have a tweak to it simply because of the patient age we are dealing with.

ESI 1: q5 min vitals x3 then q10 x3 then q15 x3 then q30x3 (This kid better be getting to the ICU at this point).

ESI 2: q10 x3, q15 x5, q30 x3 etc by 30 min incriments.

ESI 3: q15 x3 then q30 x2 then hourly

ESI 4: vitals every 2 hours while in the ER

ESI 5: vitals every 4 hours while in the ER.

All of these patients also must have a full set of vitals at least 30 minutes prior to discharge from the ER. It may seem a bit cumbersome, the theory is that we are showing any trending in the vitals to establish stable vs unstable. If we are unable to get a BP, we will also chart other clinical findings (some of the little kids are harder to get a BP on while wiggling) such as a GCS, skin turgor or CRT, mental status, etc.

[Lunah, MSN, RN]

rndiver82, thanks for that!! We see a TON of peds in our ED, and it would be helpful to have parameters specific to that segment of our population. :)

[hiddencatRN, BSN, RN]

Q10 and Q15 on level 2 and level 3 kids? Dang! I work in a level 1 peds hospital as well and getting vitals from a kid of varying cooperation takes plenty of time. If we had to do vitals that frequently I'm not sure when we'd get anything else done. The Q3 vitals especially seem pretty intense on what are pretty stable patients.