The Emergency Severity Index Version 4 is used to triage a patient in the Emergency Department. It is developed by the ESI Research Team, LLC.
Parameters:
(1) need for life-saving intervention immediately
(2) high risk situation
(3) confused, lethargic or disoriented
(4) level of pain and distress
(5) number of different resources needed (laboratory tests other than point of care, ECG, X-ray, CT/MRI, IV fluids, parenteral drugs, specialty consultation, simple procedure, etc)
(6) age in years
(7) heart rate in beats per minute
(8) respiratory rate in breaths per minute
(9) oxygen saturation in percent by pulse oximetry
Age, heart rate, respiratory rate and oxygen saturation were used to determine the number of vital signs in the danger zone.
|
Parameter |
Age |
Finding |
Points |
|
heart rate |
< 3 months |
<= 180 |
0 |
|
|
< 3 months |
> 180 |
1 |
|
|
3 to 36 months |
<= 160 |
0 |
|
|
3 to 36 months |
> 160 |
1 |
|
|
3 to 8 years |
<= 140 |
0 |
|
|
3 to 8 years |
> 140 |
1 |
|
|
> 8 years |
<= 100 |
0 |
|
|
> 8 years |
> 100 |
1 |
|
respiratory rate |
< 3 months |
<= 50 |
0 |
|
|
< 3 months |
> 50 |
1 |
|
|
3 to 36 months |
<= 40 |
0 |
|
|
3 to 36 months |
> 40 |
1 |
|
|
3 to 8 years |
<= 30 |
0 |
|
|
3 to 8 years |
> 30 |
1 |
|
|
> 8 years |
<= 20 |
0 |
|
|
> 8 years |
> 20 |
1 |
|
oxygen saturation |
NA |
>= 92% |
0 |
|
|
NA |
< 92% |
1 |
score for dangerous vital signs =
= SUM(points for the 3 parameters)
|
Life Saving Needed |
High Risk Situation |
Confused, Lethargic, Disoriented |
Pain and Distress |
Resources Needed |
Danger Vital Signs |
Triage Level |
|
Yes |
NA |
NA |
NA |
NA |
NA |
1 |
|
No |
Yes |
NA |
NA |
NA |
NA |
2 |
|
No |
NA |
Yes |
NA |
NA |
NA |
2 |
|
No |
NA |
NA |
severe |
NA |
NA |
2 |
|
No |
No |
No |
not severe |
>=2 |
>= 1 |
2 |
|
No |
No |
No |
not severe |
>=2 |
0 |
3 |
|
No |
No |
No |
not severe |
1 |
NA |
4 |
|
No |
No |
No |
not severe |
0 |
NA |
5 |
where:
• If any of danger vital signs are present for a patient assigned to priority 4 or 5 then a higher triage level would probably be warranted. This scenario would be unlikely since more resources would be used.
Specialty: Emergency Medicine, Surgery, orthopedic
