||Marilyn Ho, RN, (left) and Virginia Tufaro, RN, (right) at Jacobi
A worried mother rushes into Jacobi Medical Center's Pediatric Emergency Department with her sick two-month-old baby. The mother says the baby has not been eating. The ED's triage nurse immediately assesses the boy's condition, noting that the infant appears dehydrated and listless. The nurse touches the soft spot on the infant's head, and finds that it is swollen.
The nurse assesses the baby's condition based on the ESI: Emergency Severity Index, a five-level scale that classifies cases from the most critical -Levels 1 and 2 to the less urgent - Levels 3, 4 and 5. The nurse believes the baby boy may have meningitis. She rates his condition as Level 2 - high priority - and ensures that he is swiftly moved from triage to the next step, a sepsis workup.
A year ago there were significant differences in the way hospitals handled the critical triage process. Now, every Adult and Pediatric ED in the HHC system processes patients through triage the same way - guided by the five-level ESI.
“Triage is simply how we sort patients in the hospital,” said Virginia Tufaro, Assistant Director of Nursing, Jacobi Medical Center. “The goal is to get the patient who comes into the ED to the right place at the right time to receive the right resource. That resource might be a specific test or it might be an immediately needed treatment, such as suturing a severe cut.”
ESI gives top priority to patients whose condition is life-threatening or limb-threatening. Triage nurses aim to ensure that the sickest patients are seen first, but can also expedite urgent tests or procedures for those patients.
The system is improved because all ER nurses are approaching triage in the same way, asking the same questions, and using critical thinking skills taught in the program to ask highly targeted follow-up questions, according to Lauren Johnston, HHC Senior Assistant Vice President and Chief Nursing Officer. That allows medical staff to care for the most seriously ill or injured patients faster while getting every patient the appropriate care and ensuring the best outcome.
Between June and September of 2010, more than 500 ED nurses from all HHC hospitals received ESI training. The instructional team included Tufaro and Jacobi nurse leaders Marilyn Ho, Pediatric Emergency Department Supervisor, and Cathy Lind, Director of Nursing for Emergency, Trauma and Critical Care, and ED staff members from throughout HHC.
“Almost all of the EDs took part in planning and developing the course, and in teaching it,” Lind says. “It built a lot of bridges. It just shows how much we can accomplish when we work together.
“The course is very interactive,” Ho said. “It enables us to be patient centered, to prioritize and to focus on quality and safety.”
They frequently bring up real-life cases that they have encountered in their ED work, and lead discussion about what questions might have been asked to determine ESI level.
“Staff benefits through having structured and streamlined processes that help facilitate interventions and patient treatment. Patients benefit through more targeted interventions and better clinical outcomes,” Tufaro said.