The Emergency Severity Index: A Five Level Triage Tool Available For Download

Any physician or nurse who treats acutely ill patients can benefit from reviewing The Emergency Severity Index (ESI) Version 4 which is available for download.*
The ESI is a five stage triage tool used in American emergency departments.

The triage nurse, or first clinician to evaluate the patient asks three questions:

1. Is the patient dying? If the answer is yes then the patient is ESI Level 1 and needs immediate treatment involving the airway, emergency medicines, or hemodynamic support .

One to three percent of emergency department patients are ESI Level 1.

2. Is the patient one who should not wait? If the answer is yes, then the patient is assigned ESI Level 2.

ESI Level 2 patients are at high risk and studies show that 20 to 30% of emergency department patients are Level 2.

3. If the patient is not assigned to Level 1 or Level 2, how many different resources will it take for the patient to be adequately evaluated for his or her problem? None, One, or Two or More.

Based on the answer to question three the patient will be classified into Levels 3, 4, or 5.

A Level 5 patient requires no resources other than nurse and physician evaluation and care. An example would be a healthy appearing 3 year old with an earache.

A Level 4 patient requires one resource in addition to nursing and physician care. An example of this would be a healthy 24 year old woman complaining of urinary tract symptoms. Such a patient might receive a urine pregnancy test and urinalysis (two labs which is one resource).

A Level 3 patient requires two or more resources in addition to the ED clinical care. An example might be a 24 year old man who is experiencing right lower quadrant abdominal pain. Resources used might appropriately include a CBC, Chem profile, and urinalysis (All labs so they count as one resource) and an abdominal ultrasound of right lower quadrant or CT scan of the abdomen (the second resource).

The patient who requires two or more resources (defined below)**, should next have consideration of his or her vital signs. Are any of the patient’s vital signs in the danger zone as defined in the Handbook? If the answer is yes, then the clinician should consider up-triaging the patient from Level 3 to Level 2.

Danger Zone Vital Signs:

newborn to < 3 months—Heart rate > 180, Respiratory rate > 50, Oxygen saturation < 92% (by oximeter)

3 months to 3 years—Heart rate > 160, Respiratory rate > 40, Oxygen saturation < 92% (by oximeter)

3 to 8 years—Heart rate > 140, Respiratory rate > 30, Oxygen saturation < 92% (by oximeter)

> 8 years—Heart rate > 100, Respiratory rate > 20, Oxygen saturation < 92% (by oximeter)

So the 24 year old Level 3 patient above, should be considered for up-triage to level 2 if any of his vital signs are in the danger zone.

The initial chapters in the Handbook well describe the triage algorithms. In Chapter 9, there are 100 practice cases for the learner to triage.

There is an online ESI triage course available that is outstanding.***

There is an entire chapter in the Handbook devoted to Pediatric Triage. I’ll go over that chapter in tomorrow’s post.

*Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage
Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition.
AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality.
November 2011. available at

**The concept of resources is well defined in the Handbook. Examples are helpful. A number of lab tests would be considered one resource (CBC, lelectrolytes, U/A, etc. X-rays and physiologic tests (EKG) are considered one resource. And scans (MR, CT, and ultrasound) one or more would be considered one resource. Consultation with a specialist would be considered one resource. A simple procedure such as placing a foley catheter or repairing a laceration is one resource. An example of a complex procedure requiring two resources would be a laceration repair that required conscious sedation.

***There is an ESI web based training course available at Go to the website and click on the web course.

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