As with any process, if left to operate in an environment without a system of checks and balances, the expected outcome of the process can become unreliable and vulnerable to subjective influences. Poor implementation or a lack of a strong educational foundation can have a detrimental effect on ED patient flow and ultimately put patients at risk.
Strengthening the ESI to improve patient care With the recent acquisition of the ESI by the ENA, there are anticipated updates to the tool to improve patient care by enhancing how nurses initially assess patients in the ED. So how does a leader determine if the system is hardwired and working as intended? We have found the following to be most effective:
• A comprehensive education program to assure initial understanding: A strong education program helps to level-set nurses’ understanding of how to appropriately triage patients. This includes a strong introduction and conclusion that provides a brief overview of the ESI’s relevance, background, and the impact it has on their practice. The program should also include a pre-test and a post-test to ensure competency and demonstrate improved understanding, with a score of at least 80% needed to pass the post-test. The training session should also incorporate a considerable level of hands-on and role-play training, and staff should have the opportunity to provide feedback on the training.
• Validation in the clinical setting: In order to ensure the ESI is hardwired and effective, leaders need to establish a standardized plan for validating processes, including review, tracking and analysis. A validation and achievement of at least five accurate ESI ratings out of six attempts is recommended. Leaders also need to ensure validation is required of new hires.
• Quality improvement audit system: In order to validate that nurses are applying the algorithm correctly, once in-person validations are completed, a plan for long-term auditing helps to ensure ongoing compliance and inter-rate reliability. This can be done by auditing documentation on a standardized form for reviewing, tracking, and analysis.
• Remediation and retraining: When you find that staff are falling out of compliance, or struggling with proper ESI scoring, remediation and retraining may be needed to assure ongoing learning. This type of remediation is to be determined on a case-by-case basis and may include retaking the class, one-on-one retraining, repeating the post-test, or revalidation.
