Question 1

What is the ESI triage algorithm and how do I apply it in the ED?

Accepted Answer

The Emergency Severity Index (ESI) is a five-level framework: ESI-1 (emergent, needs immediate resuscitation), ESI-2 (emergent, high risk), ESI-3 (urgent, many resources), ESI-4 (semi-urgent, few resources), ESI-5 (non-urgent, one resource). Start by asking 'Does this patient require immediate life-saving intervention?' (intubation, resuscitation, emergency surgery). If yes, ESI-1. If no, ask 'Is the patient high-risk?' (chest pain, dyspnea, unresponsiveness, severe pain, altered mental status, fever + unstable vitals). High-risk = ESI-2. Then estimate resources needed: admission, labs, imaging, procedures. ESI-3 = need many; ESI-4 = few; ESI-5 = one simple resource. Practice the algorithm until it becomes automatic so you spend seconds per patient, not minutes.

Question 2

What are the red flag conditions in triage that require immediate escalation?

Accepted Answer

Red flags that trigger ESI-1 or ESI-2 and demand immediate provider evaluation: altered mental status or unresponsiveness, respiratory distress or stridor, hypotension or signs of shock (cool skin, weak pulse, altered consciousness), chest pain or acute dyspnea, severe allergic reaction with airway swelling, active hemorrhage, severe trauma or head injury, sudden neurological deficit (stroke signs), severe abdominal or back pain with hemodynamic instability, and acute poisoning. Never delay a provider evaluation on these; call for help immediately and stay with the patient while awaiting assessment.

Question 3

How do you triage in a mass casualty incident when resources are overwhelmed?

Accepted Answer

START (Simple Triage and Rapid Treatment) is the field protocol: (1) Immediate/Red—can't walk, altered mental status, respiratory distress, uncontrolled bleeding, non-blanching rash (sepsis). (2) Delayed/Yellow—can walk, stable vitals, injuries that can wait hours. (3) Minor/Green—able to walk, talk, follow commands. (4) Expectant/Black—obviously deceased or catastrophic injuries incompatible with survival in a resource-limited setting. In a disaster, move patients quickly: red to ambulances, yellow to a holding area, green to a staging area. Mark patients with tape, stickers, or paint so the next responder knows the classification. The goal is rapid throughput and the greatest good for the greatest number.

Question 4

What vital sign changes signal deterioration and when do I escalate?

Accepted Answer

Watch for trending: a patient who is alert at triage but becomes drowsy, or vitals that are borderline-normal (BP 90/60, HR 120, RR 22) but trending worse. Any of these warrant immediate escalation to a provider: SpO2 <90%, HR <50 or >120, BP <90 systolic, RR <10 or >30, temperature >40°C, or the patient looks acutely ill regardless of the numbers. Sepsis can look deceptively normal early (just tachycardia and fever) but escalates fast; err on the side of escalation. Never wait until a patient 'looks bad enough'—early recognition saves lives.

Question 5

How do I differentiate between a patient with anxiety and one with acute chest pain or MI?

Accepted Answer

Both can present with chest pain, tachycardia, and shortness of breath, but MI kills quickly. ESI rule: chest pain is always ESI-2 until proven otherwise; get a 12-lead EKG immediately. Anxiety pain is often pleuritic (worse with breath), positional, or reproducible on palpation; MI pain is substernal, radiates to arm/jaw, is not reproducible, and is often accompanied by diaphoresis, nausea, or a sense of doom. Anxiety patients are often young with prior panic episodes; MI patients skew older or have cardiac risk factors. The provider and EKG make the call, but your job is to triage both as high-acuity until cardiac ischemia is excluded.

Question 6

What documentation do I need in the triage note and how detailed should it be?

Accepted Answer

Triage note: chief complaint in patient's own words (not 'AMS' but 'found unresponsive at home'), vital signs, ESI level with brief justification (e.g., 'ESI-2: chest pain, high risk'), any red flags observed, and relevant history (fever onset, trauma mechanism, last menstrual period if applicable). Be concise—10 to 15 seconds per note so the team knows why the patient was triaged at that level. Include time of arrival, mechanism of injury if trauma, and any immediate interventions started (oxygen, IV, monitor). Document clearly so a provider picking up the chart understands at a glance why the patient is in the waiting room or a bed.

Question 7

How do I handle a patient who refuses assessment or tries to leave without being seen?

Accepted Answer

Do not prevent a patient from leaving, but document a refusal of evaluation or against medical advice (AMA). Try briefly to explain the reason for triage (safety, ED flow, provider needs the information) and ask if there is a barrier (language, distrust, too long a wait). If they insist, walk them to the exit, document the time, their stated reason, and that you advised them to be seen. If the patient is a threat to self (suicidal) or others, or cannot make decisions (altered mental status, pediatric), notify your charge nurse and the provider immediately. Never argue or force; document and escalate.

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UK	£31k	£41k	£54k
EU	€36k	€48k	€63k
CANADA	C$58k	C$76k	C$95k

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