00:01
What do you do when you are so overwhelmed?
You have so many things to do.
00:05
You don't know where to start.
00:07
Well, it doesn't feel very good, but imagine
how it would feel if you were the triage nurse
in an emergency room.
00:14
It could feel terrible if you had people
coming at you from there tired of waiting.
00:18
They want to be seen. They want to go home.
00:20
They don't feel good.
00:21
Well, they needed to come up with a system
that would be systematically based in research
on who needs to be seen first, not by what
the patient feels, but by the severity of
their illness. So that's what ESI is.
00:37
It's an emergency severity index.
00:40
This is a consistent, systematic tool that we
can use to be safer about how we identify
which patients need to be seen first.
00:49
Because if you've ever been in a triage in a
full E.R.
00:52
waiting room, it can be really overwhelming.
00:55
This is what helps everyone make the same
decision day after day after shift after shift
based on the client's needs.
01:03
So I emergency severity index, this is a tool
that's evidence based.
01:09
That means they've looked at research and
outcomes and decided this is the best tool we
have up to this point.
01:15
So it's based on the severity of illness.
01:18
It's also based in research.
01:20
You're going to primarily use it in the
Department of E.R.
01:23
So you might call it urgent care, but we're
likely thinking about a hospital E.R.
01:28
unit. Now, the algorithm, as you answer
questions and evaluate the patient in a
systematic way, this is going to give you all
the clinically statistic information that you
need about that patient status, health and
health care needs.
01:43
Now, it's going to put them into five groups.
01:45
One is the group you do not want to be in,
right?
One is the most urgent.
01:50
They go directly in and do not pass.
01:52
Go five is the least urgent, which they need
care, but they're going to be waiting a long
period of time because their needs are not as
severe.
02:01
Remember, it's all based on acuity, not who
you like, not who's the kindest, not who's the
most important.
02:07
It's all based on how sick they are and what
their urgent and emergent needs are.
02:13
So one, that's the sickest.
02:15
They go directly back.
02:17
Five. Those are the least urgent.
02:19
They might need something, but they're not
going to take precedence over a one, two, 3 or
4. So let's talk about what's unique about
triage.
02:28
Systems have been around for a long period of
time, but this particular one with the
research was funded by the Agency for
Healthcare Research and Quality, the AHRQ.
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Now, you might not be impressed, but you
really should.
02:42
This is what they do now to show you how good
this is or effective this is the Emergency
Nurses Association have endorsed this as
being an excellent evidence based tool to use
to triage patients.
02:55
So this one, remember, has five levels, one
being the most severe, five being the least
severe. Now, other triage systems may have
three, but this one has five.
03:07
So level one, immediate care patients, level
two and three need care within 15 minutes,
levels four and five need care within 30
minutes.
03:18
Okay. Not always possible in an E.R., you're
going to take all the ones before you take the
twos, the threes, the fours and the fives and
so on.
03:26
But the idea of this is AI is meant to kind
of decentralize medical care and make
consistent, systematic decisions in
determining who needs care first.
03:36
Okay. So just for fun, let's apply this to a
patient scenario.
03:40
So you've got a patient there, a 35-year-old
male.
03:42
They've been brought in by the ambulance
after a motor vehicle accident.
03:46
Now, this client is responsive, but seems
kind of dazed.
03:50
Now there's an obvious fracture in the left
leg, a minor laceration on his forehead, and
he's complaining of chest pain.
03:58
Okay. Now, most times when we read a scenario
to you, it's easy to really check out.
04:03
So what I want you to do, this is a great
test taking strategy.
04:06
Go back through that and let's read all of
the descriptors.
04:09
So what's particular or unique about this
patient?
They're 35, they're male.
04:15
They came in by ambulance.
04:17
They've been in a motor vehicle accident.
04:20
So we're already thinking about trauma.
04:22
They're responsive, which is good, but
they're not normal.
04:26
Right? They're days.
04:27
You can hope they've got a fracture in their
left leg, a minor laceration on their
forehead, and they're complaining of chest
pain.
04:35
Wow. That's a lot.
04:36
You almost have to know, like, where do we
start?
Well, you go right to the tool.
04:39
So let's walk through this one.
04:41
Step one, there's three steps.
04:43
You're going to apply this.
04:45
Step one, does the patient require immediate
life saving interventions?
Well, ABC, the patient is breathing, but he
is dazed and he's having chest pain.
04:56
So there could be some internal injuries.
04:57
Remember, he was in a motor vehicle accident.
05:00
Well, he's not in immediate respiratory or
circulatory failure.
05:03
We are kind of concerned that there is
potential, however, since.
05:07
This patient does not require immediate
life-saving interventions.
05:10
We should go on to step two before we go.
05:13
We're walking you through the patient's
breathing.
05:16
But there are days and this and that.
05:17
This is clinical nursing judgment.
05:19
These are the things that you're going to
learn.
05:22
We're just explaining to you how an
experienced nurse would work through triage.
05:26
You don't put a new grad in triage, right?
This is someone who's developed their
assessment skills and their expertise.
05:32
So don't get hyped up.
05:34
Like I would know that.
05:35
I would know that it's normal that you
wouldn't know that as a nursing student.
05:39
But that's the level we want you to grow into.
05:42
So step one, we listed the things they're
breathing, but they're dazed.
05:46
They have some potential injuries.
05:48
And so we're thinking we've got some real
potential to need to be seen fairly quickly.
05:53
But as for now, we're just going on to step
two.
05:55
Now, Step two is a patient in a high-risk
situation?
Are they confused, lethargic, or they are in
severe pain or distress?
Well, let's think back to this guy.
06:06
He's post trauma from.
06:08
He's been a pretty significant mechanism of
injury.
06:11
Right? He's been in a motor vehicle accident.
06:14
Those are large bodies of metal that go at
high speeds.
06:17
So we know he's after that type of trauma.
06:20
He's been in a car accident.
06:21
So, yeah, there's potential for high risk
injuries, especially ones we can't see, like
internal ones. He's telling us he has chest
pain.
06:30
So that's telling us something really could
be going on internally that we might not see
externally yet.
06:37
And you got that leg fracture and the
laceration.
06:40
Now, they're not the most obvious concern.
06:42
We're always worried about airway, breathing,
circulation, but still they do matter.
06:46
And he staged.
06:48
That's not normal.
06:50
He's been in a traumatic accident these days.
06:52
So he might be in some type of possible head
injury or in shock.
06:58
Okay. Those are big problems.
06:59
So our decision here would be that he's got
the high-risk complications that are a strong
potential with this type of injury.
07:08
We're going to likely make him an S1 or a
level two.
07:12
So now we have to decide, is he one or is he
two?
What do you think?
Well, we're going to go on to step three,
Right.
07:21
If we if we didn't know in step two, like,
no, I know what their number is based on my
experience, me practicing using this system
in step three, you ask yourself, Hey, how many
different resources is a patient going to
need?
Are they need lab tests, EKGs, MRI, CT scan,
I.V.
07:36
fluids, imaging? What are they going to need
If they're going to need a lot that kind of
bumps them up the severity.
07:42
So to help you kind of understand what we
would do here, this particular patient, the
one in the trauma, would likely get an x ray
or possibly a CT scan for the head and chest.
07:53
We're going to probably give them IV fluids.
07:55
We're going to manage their pain, and they're
probably going to have some lab values to kind
of help us if the patient has internal
injuries.
08:02
So because this patient is kind of like in
between, we would knowing all the resources
they're going to need, we would make them a
level two.
08:12
So even if he wasn't a level two from the
prior step, we would make him a level two
because we know that he's going to require
lots of resources in the E.R.
08:21
So given that we've now decided that this
patient is in level two, they would be seen
urgently right after any level one, because
level ones are immediate resuscitation
patients, Right? Those are the ones who are
coding or come in coding.
08:37
So now what do you do as a nurse?
Well, you start giving people a heads up that
we need to take care of this patient and
they're a level two. So you would do things
like alert the trauma team and let them know
the nature of his injuries.
08:49
Start pain management, get IV access
established, always critical in a patient with
these types of injuries.
08:56
Now think about the types of imaging and
tests that you're going to need and
collaborate with the health care provider to
get those ordered continuously.
09:03
Monitor this vital signs, get them on the get
them on a cardiac monitor, get them on a pulse
ox, do all those things that you can do in an
E.R.
09:11
that will help you monitor their respiratory
and cardiac functions.
09:14
Because if he starts to decompensate and to
get worse, you want to know as early as
possible. Now, if there's any risk of a
cervical spine, make sure that it is protected
until that can be ruled out.
09:26
And then you're going to want to obviously
watch for the injuries like the leg fracture
or other injuries that you might assess.
09:33
Okay. I've just given you a lot of words.
09:35
So we went through step one and we learned
about him.
09:37
He's 35, the motor vehicle accident, the
laceration, the leg.
09:41
Step two, we thought about, hey, what kind of
things does he need?
Is he in a high risk situation?
Is he confused or lethargic and severe
distress?
Well, he's in a high risk situation because
he was in a car accident.
09:53
He is kind of dazed.
09:54
I would imagine he's having pain, even though
we didn't really describe it there.
09:57
But we established that in step two.
10:00
Step three, We know because of the potential
injuries, that he might have internal
injuries. Cervical spine injury.
10:08
We know that he's going to require a lot of
resources, testing, lab work, imaging.
10:14
So that's why we made him a level two.
10:16
If he's a level one, he'd be like needing to
be resuscitated right now.
10:20
He's not at that point.
10:22
So we know he's a level two, so we know where
we are on high alert.
10:26
That's how we get the trauma team.
10:28
We make sure we're trying to manage his pain,
get IV access or the tests that we know the
health care provider is going to want
consistently and continuously monitor him for
any signs of decompensating and make sure we
keep that neck and cervical spine safe and
protected until that's ruled out and then
deal with the leg fracture and the lacerations
and the bleeding.
10:49
Okay. So you did it.
10:50
Congratulations. Now, after this video,
you're obviously not completely prepared to be
able to run a triage on your own.
10:58
But when you do get to spend some time in
triage, ask the nurses to talk you through it.
11:02
They do this stuff almost instinctively
because they've done it so many times, but
they will most likely be happy to teach you
how you apply this system in real life,
because these triage systems are what gives
us structured but a flexible approach to
determine how sick or how high the acuity of
the needs of the patient are.
11:22
Why does that matter?
Look who's right in the center of an ESI.
11:27
Yes, we're all getting patient-centered care,
but it's the nurse using their clinical
nursing judgment based on their experience
that can help move a patient to the front of
the line who might experience some very
difficult outcomes if it wasn't recognized
that they are in trouble. And they're a
process through the triage system.
11:47
So it's really cool when you get in practice,
try it, spend some time in the triage, ask to
be there, work with the nurse, have them
explain it to you as you go.
11:56
And it can be a very exciting place to be
because, hey, look at this scenario.
12:00
The trauma patient with his potential
injuries and his mechanism of injury, a car
accident, this patient would be a high priority
or a level two in the emergency department.