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Emergency Severity Index Pt.2: Practice Cases – 08 Elderly Patient With Pneumonia

November 8, 2019

[Music] Facilitator 1 (FA1): Next case. A 70 year
old male arrives
by ambulance from the nursing home. The nursing home reports a non-productive
cough since he choked on his lunch today. His baseline mental status is unchanged
and he’s normally confused. His skin is warm and moist.
His vital signs are the following: temperature (T): 100.2, heart rate (HR): 94, blood pressure (BP): 135/80 and his room air saturation (Sp02) is 94%. His respiratory rate (RR) is 20 and non-labored.
So, do I hear ESI Level 1 for this patient? Registered Nurse 1 (RN1): I don’t know. I don’t
think he needs to be intubated right now. FA1: Good, neither do I. You know, he really is not
in acute respiratory distress, but what about his mental status?
Does he meet ESI Level 1 criteria for this? Registered Nurse 2 (RN2): I don’t think so. FA1: Okay, why not?
RN2: Well, because he’s not unresponsive, he’s just confused.
So, maybe he meets a Level 2 criteria. FA1: So, what do the rest do
you think? ESI Level 2? RN1: Not really. He’s always confused
so it’s nothing new. FA1: What about severe distress or high risk? Do you think this is a high risk situation?
Would you give this patient your last open bed? Registered Nurse 3 (RN3): Well,
he comes in by ambulance and I really don’t want him in the waiting room. FA1: Nor do I, but all patients
that arrive by ambulance are categorized as ESI Level 1 or 2 only if they meet
the criteria. So, when you think about it, this patient does not meet Level 1 or 2
criteria and his vital signs are within normal limits. He does not violate any
vital sign criteria so he’s actually in ESI Level 3. He will definitely require
two or more resources – labs, x-ray, IV antibiotics. He most likely has
pneumonia. Facilitator 2 (FA2): But, you can still facilitate placement in a bed, but this case does
illustrate a really important point. Placement and triage category are
sometimes two different things. There are some Level 3 patients that can
go directly to a room, but others can actually wait for the triage process.

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