Training and ESI Adherence Improve Triage Accuracy

Since it was developed in 1998 by a group of emergency physicians and nurses, the Emergency Severity Index has become the leading triage resource for emergency nurses in the United States. Eighty percent of U.S. hospitals use ESI to triage patients.

Rapid and accurate triaging is vital for successful ED operations and optimizing patient outcomes, but it can be difficult to pinpoint how quickly a patient requires care, especially compared to other patients waiting to be seen.

Rachael Smith, an associate professor at Three Rivers Community College and part-time staff nurse at Shoreline Medical Center, discussed these nuances and identified effective triaging strategies in her presentation “Deciding Between ESI 2 vs. ESI 3.”

According to a study cited by Smith, appropriate ESI adherence to assign triage categories correctly could be as low as 60 percent. When patients are under-triaged, they are at risk for deterioration while waiting and have an increased likelihood of critical outcomes. This can lead to increased hospital admission rates, Smith explained. When a patient is triaged at a level that’s too high for the level of care required, it leads to inappropriate use of resources, diverting the ED staff’s time and tying up patient beds.

“We need to take time to carefully listen to our patients, honing our assessments, questions and considerations of all those problems that could be there,” Smith said.

She identified four barriers to accurate triage: time restraints with patients, varying experience levels of triage nurses, triaging to a specific department rather than focusing on patient acuity and implicit biases that can affect a provider’s perception of the patient.

To overcome these challenges, Smith stressed the need for adequate training on ESI as well as re-training with triage audits.

“Maybe a nurse has never had that patient with that tearing chest pain. They’ve never encountered that before,” Smith said. “By going back through their triages and seeing, ‘I didn’t realize that could be a potential diagnosis for that complaint,’ it only helps to build their repertoire and increase their experience.”

Smith also advocated for closely following the updated ESI algorithm.

“It’s like when you’re on a diet and you do really well for the first couple of months, and then next thing you know you’re like, ‘Why haven’t I lost any weight?’ Well, because you stopped using the algorithm,” Smith said. “The same thing goes with triage. This could be as simple as keeping a copy next to the computer to easily refer to it.”

Smith presented the audience with a series of patient scenarios, including cardiovascular, respiratory, trauma and behavioral health cases. She challenged attendees to determine whether each patient should be triaged at ESI 2 or ESI 3. Generally, patients were prioritized higher if they were described as exhibiting signs of high-risk behavior, such as a potential threat to their lives, limbs or organs, as appearing confused or disoriented, or as experiencing severe pain or distress.

The Opening Session was live-streamed and will be available to registered Emergency Nursing 2022 attendees in the on-demand library through Jan. 31, 2023, on the online meeting platform shortly after the conference’s conclusion.