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Facilitator 2 (FA2): Let's do an eye case. So, you have a patient who comes in
and says, "Well, my eyes are just all red and crusty."
She's a 19 year old female. She said
she's had red itchy eyes for two days. She has no medical problems.
She takes birth control pills, has no allergies.
Her vitals are: T 98.6, HR 72, RR 16 and BP 122/76.
Her visual acuities are 20/20 in both eyes.
So, what do you think is going on with this patient?
Registered Nurse 1 (RN1): She probably has conjunctivitis. The red, itchy, goopy eyes.
FA2: Absolutely. Now, is that a high-risk situation?
RN1: Oh no, it's a very common complaint
FA2: Okay. So, now we have to move on to resources.
How many resources do you think it's going to take
to get this patient out of the emergency department?
RN1: Just one: an eye exam.
FA2 : Okay. And does that count as a resource?
RN1: Well, no - I guess not.
Why not? It's pretty important.
FA2: That's a great question. When ESI was developed, the researchers
made some really thoughtful decisions about what does and does not count as a
resource. If everything that we did counted as a resource, we wouldn't have
any Level 4 or 5 patients. Every patient gets a physical exam,
so it's decided that the physical exam doesn't count.
Facilitator 1 (FA1): Let me talk a little bit more about physical exam.
The patient who comes in with an eye complaint is going to need a
slit lamp exam. That is part of their physical. It would be just like a woman
with lower abdominal pain. She would require a pelvic exam and again, that's
part of the physical exam of that patient.
So, does this patient require any resources?
RN1: I guess not.
FA2: So, what level is she?
RN1: Well, if no resources, then I guess she's an ESI Level 5.
FA2: Great! So, let's talk a little bit more about eye complaints.
This patient most likely has conjunctivitis, which is a common complaint in which
patients often seek treatment in the emergency department.
Most eye complaints often end up being triaged as either ESI Level 5 or 2,
because they represent a high risk to the loss of eyesight.
FA1: Well, in this particular case, and this one's triaged as an ESI Level 5,
conjunctivitis is not an acute eye problem that is considered high-risk.
What's another example of an eye complaint that might be an ESI level 5?
Registered Nurse 2 (RN2): What about someone that comes in complaining of
something in their eye, but has severe pain?
FA2 : That's an excellent question. So, you have to actually ask two questions.
First, is this a high risk situation and second,
Do they have severe pain?
Registered Nurse 3 (RN3): Well, it's certainly not high risk.
People come in the ED all the time thinking they have something in their eye,
but they have 10 out of 10 pain, so that makes them meet the ESI Level 2 criteria.
RN2: True, but you could put opthane in her eye. The protocol states that in
order to be Level 2 criteria, you have to have pain of 7 out of 10 or greater that
you can't do anything about in triage. So, in this case, we could put some topical
anesthetic in her eye to make her feel much better and then therefore we can
make her a Level 5. But if your hospital doesn't have such protocols, then I would
make her a Level 2 based on severe pain.
FA2: Okay, good. Let's talk about some examples of high risk eye situations.
Can you guys think of any?
RN2: How about a sudden loss of vision in one eye?
FA2: Absolutely. That could be central retinal
artery occlusion or retinal detachment. Can you think of some other examples?
RN1: Chemical splash?
FA1: Definitely. It's safe to assume that most patients with the
chemical splash are going to require a rapid irrigation.
An eye problem that requires irrigation, but not necessarily high risk, would
require one resource and that would be an ESI Level 4 patient.
So, those are both great examples, but there's a one more I'm thinking of.
Can you think of something else?
RN2: How about trauma to the eye or a foreign body, like a nail?
FA2: Absolutely. Patients who have obvious trauma
are at risk for a lot of injuries and obviously foreign bodies
are really bad as well.
A hyphema is another good example that should be
considered ESI Level 2. Another example of a patient
with an eye complaint that's considered ESI Level 5 would be someone with a
foreign body sensation and pain to the eye.
FA1: Often patients present either with
something that blew in their eye or pain from contact lenses.
These patients who usually have a corneal abrasion
and, again, only require an eye exam.
These patients also complain of severe pain.
However, if the triage nurse can instill a
few drops of topical anesthetic at triage and decrease the pain, then they
meet ESI Level 5 criteria.
FA2: And, finally, just as an aside, if possible, it is
recommended to obtain visual acuities at triage. This is a really important vital
sign for patients with eye complaints,
even more so than a temperature or pulse and respirations.