Triage tool in ED

2014-06-13
JNUH dep. of EM
Sung Wook Song
 The Emergency Severity Index
• Wuerz and Eitel – 1998
• Fundamentally the closest to when triage originated
• Principal goal of triage is to facilitate prioritization of patients based on
the urgency of the condition
– Which person is seen first
– How many resources will they require
• Patient sorting + patient streaming
• Underlying assumptions of the 1st 3 5-tier systems was “how long can
the patients wait
• There is no time allocation in ESI
• Dying patient- see immediately
• Sick appearing patient- “shouldn’t wait”
• The lower 3 levels are categorized based on resource needs
 Patient dying?
no
yes 1
Shouldn’t wait?
yes
no

How many resources

none one many 2

Vital signs
5 4 abnormal

no

3
 Decision Point A
• Is the patient dying

•Needs an immediate airway, medication, or other

hemodynamic intervention
•Is already intubated, apneic, pulseless, severe respiratory
distress, SpO2 < 90 percent, acute mental status changes, or
unresponsive
 Decision Point B
• Should the patient wait?

• Is this a high-risk situation?

• Is the patient confused, lethargic or disoriented?
• Is the patient in severe pain or distress?
 Decision Point C
• Resource Needs

•To identify resource needs, the nurse

needs to be familiar with ED standards
of care – EXPERIENCE!
 Decision Point D
• The Patient’s Vital Signs

•If out of range upgrade 3 to 4