What if ESI level-4 or 5 patients have danger zone vital signs?
Though it is not required to take vital signs in order to assign ESI 4 or 5 levels, many patients may have vitals assessed at triage if that is part of the particular ED’s operational process. Per the ESI triage algorithm, the triage nurse does not have to take the vital signs into account in determining that the patient meets ESI level-5 (no resources) or ESI level-4 (one resource) criteria. However, in practice, the prudent nurse will use good clinical judgment and take the vital sign information into account in rating the ESI level. If the patient requests only a prescription refill and has no acute complaints, but has a heart rate of 104 after walking up the hill to the ED, the nurse might still rate the patient as an ESI level 5. But if the patient requests a prescription refill and has a heart rate of 148 and irregular, the nurse should rate the patient as ESI level 2. The triage nurse must also consider the following dilemma: an elevated blood pressure in an ESI level-4 or 5 pat
