INTRODUCING EMERGENCY SEVERITY INDEX (ESI) FOR BETTER PATIENT OUTCOME
Introducing Emergency Severity Index (ESI) for Better Patient Outcome
Introduction to ESI
The core objective of various triage tools across the emergency department attributes to the systematic prioritization of the patients in accordance with the severity of their clinical conditions in the context of determining the period until which the patient might wait in the emergency department before his/her evaluation by the healthcare professionals (Gilboy et al., 2011). The nurse professional after executing a focused assessment of the patient determines the waiting time and accordingly provides a triage acuity level of the patient in the emergency department. The patient needs to wait in the emergency department in accordance with the assigned acuity level while making sure that his/her safety is not compromised in the waiting duration. The Emergency Severity Index (ESI) consists of five scales configured in accordance with the urgency of clinical intervention in a real time environment (Elias et al., 2015). The ESI system assists the physicians in catering to the medical needs of the patients in accordance with the severity of their ailments for streamlining the process of treatment and reducing the waiting time of the patients who require immediate treatment in cases of acute medical emergencies.
Evidence-based research literature considers ESI triage system as a reliable tool in tracking the patients affected with high-risk conditions across the emergency department (Mirhaghi et al., 2015). The ESI triage tool assists in systematizing the provision of care for the patient population in the context of timely rendering of medical services to the critically ill patients. The triage decisions of the physicians, nurses and other healthcare professionals across the emergency department facilities streamlined with the implementation of ESI tool and the corresponding patient casualties minimized while reducing the time lag in treatment of the patients who require immediate attention of physicians in accordance with the criticality of their clinical conditions. The objective assessment of the vital signs of patients by the nurse professionals is the very first method of determining the level of triage across the emergency department. The findings by (Travers et al., 2009) reveal moderate reliability of Pediatric ESI triage system as compared to other age groups. This rationally indicates ESI triage system proves to be an effective tool in streamlining the emergency department care and therapy of infants, children and young adults concomitantly with the care of adults and elderly subjects. The literature review by (Christ et al., 2010) describes the ESI system as the best method for evaluating the severity of clinical manifestations of patients across the emergency setting. Therefore, this method not only streamlines the treatment schedule of patients, it rather assists physicians in configuring appropriate medical measures in accordance with the complexity and severity of clinical manifestations of the affected patients. Evidence-based findings describe ESI in terms of a valid indicator of the pattern of hospital admission of patients (Green et al., 2012). Particularly, the specialists of pediatric medicine and pediatric triage nurses preferably practice the ESI tool in prioritizing the care and therapy to the clinical subjects. Conventions by US department of health and human services state that level – 1 triage allocated to the patients who arrive in the emergency department in unresponsive state and experience breathlessness in a state of intubation (AHRQ, 2015). The level – 1 triage covers the severely acute and debilitating conditions that require instant treatment in the context of safeguarding the life of the affected patients (Maleki et al., 2015). The level – five triage attributes to those patients who require minimal assistance and experience mild clinical manifestations. Research findings by (Garbez et al., 2011) indicate that the triage level – 2 patients require diagnostic assistance with the utilization of electrocardiogram, cardiac monitoring as well as specialty consultation and therapeutic interventions. A retrospective triage analysis by (Howard et al., 2014) indicates the significance of "RN greeter" in the context of identifying the level – 2 patients particularly in the scenarios when duel-tiered triage system overloads with additional volume across the emergency department setting. Any miscalculation in identifying the triage level 1 or 2 might lead to the pattern of "undertriage" when the significant number of high risk patients experience a delay in treatment interventions leading to the eventual intensification of clinical manifestations and fatalities (Platts-Mills et al., 2010). The nurse professionals and healthcare teams require a thorough understanding of the factors that potentially influence the triage acuity levels of patients across the emergency setting. The research findings by (Hiestand et al., 2011) indicate that the patients that arrive with the utilization of emergency medical services and affected by the patterns of acute abdominal pain remain predisposed towards an elevated triage level. However, the means of arrival in calculating the triage level still not considered a significant attribute as per ESI conventions. Evidence-based research literature considers abnormal vitals of patients attributing to low oxygen saturation and respiratory rate as the essential elements that make them eligible for a triage level – 3 (ESI-Triage-Research-Team, 2016). If only one resource is required for assisting the affected patients, they might be eligible for a level – four across the emergency care setting. Indeed, the nurse professionals require considering many factors while assigning any particular triage level to the patients across the emergency department setting. Any error in making the triage level decision can destabilize the pattern of patients’ prioritization leading to unprecedented adverse consequences in terms of clinical complications and fatalities.
Comparison of ESI with the Manchester Triage System
Manchester Triage System (MTS) differs from ESI in the context of the fact that the triage levels in this system segregated in accordance with the expected evaluation duration for the patients affected with various mild to moderate clinical manifestations. Each triage level under MTS is represented by a unique color assigned to the patients after carefully assessing their clinical conditions. A red tag indicates zero minute while blue tag represents four hours of target time for emergent and non-urgent cases accordingly. Similarly, the orange, yellow and green tags classified in accordance with 10 minutes (i.e. very urgent), 1hour (urgent) and 2hours (little urgent) of target times under the MTS system (Gouvêa et al., 2015). Evidence-based research literature reveals the potential of MTS categorization in terms of generating accurate predictive value regarding the risk of patients towards the development of mild to serious clinical manifestations in accordance with the assigned MTS scores (Guedes et al., 2015). Contrarily, the findings by (LaMantia et al., 2013) reveal that the elderly patients evaluated with the ESI tool experience the risk of "misdiagnoses" and assigned an inappropriate triage level, and eventually many of the critically ill elderly patients remain devoid of timely medical interventions in the context of controlling their life threatening clinical manifestations. However, research findings by (Wulp et al., 2009) describe ESI tool as a preferable indicator of patterns of hospital admission as compared to the MTS tool. This is because of the reason that the predisposition of patients towards hospital admission decreased more effectively with the utilization of ESI tool during the course of the research study.
Relationship of ESI with ED Nursing
Evidence-based research literature reveals the increased acceptance of version 4 of ESI among pediatric triage nurses in the context of evaluating the triage category of pediatric patients requiring treatment across the emergency department setting (Durani et al., 2009). Indeed, the ESI system implemented with the objective of elevating the reliability pattern between ED nurses and physicians while identifying the diagnostic evaluation and hospital admission requirements for the selected patients across the emergency department (Lines & Ash, 2012). Nurse professionals utilize the ESI tool across emergency department facilities in accordance with the pattern of resource utilization, severity of clinical conditions, and consultation requirements (Elshove‐Bolk et al., 2007). Indeed, the ESI tool deployed by nurses for evaluating the triage score of patients across emergency department while evaluating their present conditions and ignoring the referral status or previously configured diagnoses. The findings by (Vigil et al., 2015) indicate the probability of ethnic biasing by the nursing professionals across the emergency department settings in the United States in the context of evaluating the ESI triage scores of patients pertaining to the underprivileged sections of the society. This finding rationally indicates the requirement of unbiased execution of the ESI guidelines by nursing professionals in reducing the deprivation of the critically ill patients pertaining to the ethnic minorities in terms of attaining the medical interventions in a timely manner.
Change Implementation Planning and Associated Challenges
Evidence-based research literature signifies the requirement of experienced pediatric nurses as well as physicians in the context of the accurate assignment of ESI triage scores to the infants, children and young adults across the emergency departments (Jafari-Rouhi et al., 2013). Therefore, the change requirement for evaluating the pediatric population across the nursing care facilities attributes to the deployment of experienced and qualified nurses across the emergency care settings in the context of the appropriate utilization of ESI tool for enhancing the patient outcomes. Emergency care facilities require configuring real time tools in the context of evaluating the ESI implementation skills of nurses prior to deploying them for providing triage levels to the selected patients across the emergency care settings (Jordi et al., 2015). The greatest challenge in implementing the ESI tool across the emergency care facilities relates to the generation of accurate level – 1 and level – 2 triage scores by the qualified nurses in a real time environment (Wang et al., 2011). patterns of mis-triage across the emergency department lead to the considerable delay in the treatment of critically ill patients that reciprocally affects the quality of treatment and the corresponding patient outcomes. Undertriaged subjects therefore experience extended waiting duration that requires due attention by the healthcare teams in the context of reducing the risk of fatalities and deterioration of clinical complications among these patients (González & Soltero, 2009). Another challenge in generating accurate acuity scores of patients across the emergency care setting attributes to the implementation of an integrated decision support system with the application of information technology in the context of taking assistance in triage decision-making (Aronsky et al., 2008).
The Change Model
The change model warranted in the context of generation of accurate ESI scores, reduction in the waiting time of patients and elevation in the rate of patients’ satisfaction with the implementation of Lewin’s force field analysis model across the hospital environment (Phillips & Gully, 2014, p.504). With the application of Lewin’s force field analysis model, the execution of step – 1 attributes to the effective segregation of the problem attributing to the fact that the nurse professionals and healthcare teams at times fail to calculate the correct ESI scores for the patients requiring treatment across the emergency room setting. Secondly, in the context of force field analysis, the change objective attributes to the development of a well-defined nursing information system for the effective improvement of the quality of patient care services across the emergency department (Kahouei et al., 2014). The driving forces for the effective implementation of the change model are the healthcare policies and conventions that warrant the nurse professionals to undertake evidence-based measures in effectively calculating the accurate ESI scores for the patient population. The restraining forces include the unwillingness of the nurse professionals in surpassing the cultural bias and giving due attention to each patient in the context of evaluating the appropriate ESI score for the eligible subjects. The change strategy in accordance with the force field analysis model warrants attributes to the elevation of awareness level of the nurse individuals in the context of following the healthcare conventions and overcoming their thoughts related to cultural bias while assigning an ESI score to the eligible candidates. The weakness of this change model attributes to the formalization of standard healthcare conventions with the mutual agreement of the members of the healthcare teams; however, the strength accounts for the equitable rendering of healthcare services to the patient population across the emergency care setting.
Evidence-based research literature advocates the systematic utilization of the ESI 3 flow model in the context of reducing the length of patients’ across the emergency care setting (Arya et al., 2013). This model requires the remodelling of emergency care setting with the configuration of the waiting room and treatment location following the initial evaluation in the context of effectively segregating the ESI-3 candidates in terms of their high and low variability patterns. However, this model selectively segregates the patients with particular set of conditions in terms of their reduction in length of hospital stay; however, the RTT model provides a system based approach to facilitate the overall improvement in the quality of emergency care services across the hospital environment. The MTE (Medical Team Evaluation) model advocates the effective change in the process of triage with the development of an effective registration process, reconfiguration of EMR and triage locations to improve the length of stay, triage level scores and waiting time of patients across the emergency department setting (Lauks et al., 2016). The utilization of ordinal logistic regression in evaluating the vital signs and pain scale of patients across the emergency department also proves to be an effective method for correlating the intensity of patients’ clinical manifestations with the ESI scores (Bendall et al., 2011). However, these change models cover selected aspects of patient care as compared to the RTT model that believes in facilitating effective coordination between members of the healthcare teams in the context of improving the healthcare outcomes following the timely administration of medical interventions to the eligible subjects across the hospital environment. The model of interest requires effective implementation with the application of Lewin’s force field analysis approach while elevating the driving forces and reducing the influence of restraining forces on the healthcare teams across the emergency care setting. The stages of unfreezing, moving and refreezing of force field analysis are comparable to the Lippitt’s change theory that warrants the effective planning of guidelines in phase I and assessing the change capacity and resistance in Phase II of the change convention . Lewin’s force field analysis model supersedes the Lippitt’s conventions in the context of the fact that former theory facilitates the effective removal of restraining forces across the healthcare environment.
Conclusion
The findings in the academic literature evidentially indicate the efficiency of ESI tool in terms of systematizing the healthcare interventions across emergency setting for the patients affected with various mild to moderate clinical conditions. However, various models of care advocate the appropriate and unbiased utilization of ESI strategy by nurses as well as physicians and other healthcare professionals. The healthcare teams need to gain the requisite experience and knowledge regarding various evidence-based tools and applications in the context of accurately generating the triage acuity levels for patients across the emergency care environment. The appropriate configuration of triage scores following the systematic assessment of patients with the effective coordination between nurses and physicians promises to bring a revolution in the process of healthcare administration and reciprocal enhancement of wellness outcomes.
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