Barbara Weintraub, RN, MSN, MPH, PCCNP, CEN
Coordinator, Pediatric Emergency Services
Northwest Community Hospital
Date: Fri, 6 Aug 2004 14:30:47 -0700
From: Nancy Piotrowski <[log in to unmask]>
Subject: 5 level triage utilizing the ESI
Childrens Hospital of Wisconsin will be implementing the 5 level Emergency Severity Index later this fall. Some issues in utilization of the tool for pediatric patients have come up.
The basic ESI protocol is clear, however what appears to be a gray area exists in anticipating the number of resources required, particularly in our asthmatic population who do not necessarily meet Level 1 and Level 2 criteria. Since VS and POX readings come into play ONLY after determining a patient meets Level 3 criteria, how does one conclude the resources required?
While we can assume that wheezing patients will require at least one resource - an aerosol treatment (meeting with Level 4 criteria), the issue becomes cloudy when determining other resources which may or may not include a CXR and/or addtional O2, (elevating the patient to Level 3 status.)
[BAW] additional O2 is not considered a resource, according to the ESI authors. As for anticipating other resources, the ESI is not a perfect tool. It does the best it can, but sometimes severity changes once the rest of the assessment is done, as with all other triage systems. If your write a protocol that requests routine pulse oximetry on all patients presenting with wheezing, you can answer some of the additional questions below. Additional education at triage may be helpful, in looking for subtle signs such as nasal flaring, which you must closely observe for.
CXR's (an additional resource) are usually obtained in asthmatic patients presenting with fever, low sats, or failure to improve after aerosol treatments. Oxygen (another resource) is reserved for patients requiring supplemental O2.
The question becomes: How do we assume the number of resources required without obtaining VS/POX readings?
1. Fever - Parents/guardians are not always good historians so we may not be able to rely on fever history.
2. Since we cannot predict which patients will not improve after 3 treatments, we are left to predict which patients will have fever or low sats.
3. It may not always be easy to predict which children with respiratory symptomatology will have low sats (another resource), since pediatric presentation may be deceiving.
Another question: Although the risk of sepsis is greater in febrile patients with sickle cell disease, would a non-toxic appearing patient with sickle cell who presents with fever and a source (i.e.sore throat, ear ache) still meet Level 2 (high risk) criteria?
Yet one last question: Are Social Work or Interpretor services considered resources since they are often necessary to determine an accurate history?
Thanks in advance.
[BAW] Hope this was some help!
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