Chapter 10. Competency Cases | Agency for Healthcare Research & Quality

Emergency Severity Index (ESI): A Triage Tool for Emergency Department

Chapter 10. Competency Cases

This chapter can be used to assess competency. Two sets of 25 case studies have been included. The cases are divided into two sets to allow flexibility in ESI competency evaluation. For example, Set A can be used for initial assessment and Set B can be used for remedial or follow-up assessment. Both sets contain realistic patient scenarios that a triage nurse would encounter in any emergency department. Please read each case and, based on the information provided, assign a triage acuity rating using ESI. Answers to all cases follow after Set B.

Set A Competency Cases

"I think I picked up a bug overseas," reports a 34-year-old male who presented in the emergency department complaining of frequent watery stools and abdominal cramping. "I think I am getting dehydrated." T 98°F, RR 22, HR 112, BP 120/80, SpO2 100%. Pain 6/10.
When asked why she came to the emergency department, the 18-year-old college student begins to cry. She tells the triage nurse that she was sexually assaulted last night at an off-campus party.
"I don't know what's wrong with my baby girl," cries a young mother. She reports that her 2-week-old baby is not acting right and is not interested in eating. As you begin to undress the baby, you notice that she is listless and her skin is mottled.
"My pain medications are not working anymore. Last night I couldn't sleep because the pain was so bad," reports a 47-year-old female with metastatic ovarian cancer. "My husband called my oncologist, and he told me to come to the emergency department." The patient rates her pain as 9/10. Vital signs are within normal limits.
A 48-year-old male tells you that he has a history of kidney stones and thinks he has another one. He has right costovertebral angle pain that radiates around to the front and into his groin. He is nauseous but tells you he took a pain pill, and right now he has minimal pain. He denies vomiting. T 98°F, RR 16, HR 80, BP 136/74, SpO2 100%. Pain 3/10.
"After my pediatrician saw my son's rash, he said I had to bring him to the emergency department immediately. He has this rash on his face and chest that started today. He has little pinpoint purplish spots he called petechiae. My son is a healthy kid who has had a cold for a couple of days and a cough. My pediatrician said he had to be sure nothing bad is going on. What do you think?"
"Her grandfather pulled her by the wrist up and over a big puddle. Next thing you know, she is crying and refusing to move her left arm," the mother of a healthy 3-year-old tells you. Vital signs are within normal limits.
A 46-year-old asthmatic in significant respiratory distress presents via ambulance. The paramedics report that the patient began wheezing earlier in the day and had been using her inhaler with no relief. On her last admission for asthma, she was intubated. Vital signs: RR 44, SpO2 93% on room air, HR 98, BP 154/60. The patient is able to answer your questions about allergies and medications.
A 56-year-old male with a recent diagnosis of late-stage non-Hodgkin's lymphoma was brought to the ED from the oncology clinic. He told his oncologist that he had facial and bilateral arm swelling and increasing shortness of breath. The patient also reports that his symptoms are worse if he lies down. Vital signs: BP 146/92, HR 122, RR 38, SpO2 98% on room air, temperature normal.
EMS arrives with a 28-year-old male who was stabbed in the left side of his neck during an altercation. You notice a large hematoma around the wound, and the patient is moaning he can't breathe. HR 110, RR 36, SpO2 89%.
An 11-year-old presents to triage with his mother, who reports that her son has had a cough and runny nose for a week. The child is running around the waiting room and asking his mother for a snack. Vital signs are within normal limits.
"I don't know what is wrong with my son," reports the worried mother of a normally healthy eight-year-old male. "He's losing weight and acting so cranky. Last night he was up to the bathroom every hour, and he can't seem to get enough to drink." The child is alert and appropriately. Vital signs: T 98.6°F, RR 30, HR 98, BP 92/78, SpO2 98%.
"He has had diarrhea for 2 days, and he just started throwing up this morning. This has been going around the family, and he seems to have it the worst. He has been drinking before today, but now he doesn't want anything to drink," reports the mother of a 19-month-old. The toddler is awake and alert but quiet in the mother's arms, and you notice his lips are dry and cracked. Vital signs: T 99°F, RR 30, HR 130, SpO2 100%.
EMS arrives with an 87-year-old male who slipped on the ice and injured his right hip. His right leg is shortened and externally rotated. The patient's only complaint is hip pain. He rates his pain as 5/10, and his vital signs are within normal limits.
"My baby is having a hard time drinking his bottle," reports the young mother of a 3-month-old. The baby is alert and looking around. You notice a large amount of dried mucus around both nares. T 98°F, RR 40, HR 132, SpO2 99%.
A 72-year-old female is brought in by ambulance from the nearby nursing home. They report that she has become increasingly confused over the last 24 hours. She is usually awake, alert, and oriented and takes care of her own activities of daily living. At triage she has a temperature of 99.6°F, HR 86, RR 28, BP 136/72, SpO2 94% on room air.
Melissa, a 4-year-old with a ventriculoperitoneal shunt (drains excess cerebrospinal fluid), is brought to the ED by her parents. The mother tells you that she is concerned that the shunt may be blocked because Melissa is not acting right. The child is sleepy but responds to verbal stimuli. When asked what was wrong, she tells you that her head hurts and she is going to throw up. T 98.6°F, RR 22, HR 120, SpO2 99% on room air, BP 94/76.
The overhead page announces the arrival of the Code STEMI. Paramedics arrive with a 62-year-old male with a history of a myocardial infarction 4 years ago who is complaining of chest pressure that started an hour ago. The field EKG shows anterior lateral ischemic changes. Currently, the patient's heart rate is 106, RR 28, BP 72/53, SpO2 is 95% on a nonrebreather mask. His skin is cool and clammy.
"I had a knee replacement 3 months ago. Now look at it!" states a 64-year-old male. The knee is red, swollen and tender to touch. Vital signs: T 99°F, RR 20, HR 74, BP 164/74, SpO2 97%. Pain 6/10.
"This is so embarrassing," reports a 29-year-old male. "For the last 12 hours, I have had this thing stuck in my rectum. I have tried and tried to get it out with no success. Can someone help me?" The patient denies abdominal pain or tenderness. Vital signs are within normal limits. Pain 4/10.
EMS arrives with a 67-year-old female who lives alone. The patient called 911 because she was too sick to get herself to the doctor. The patient has had a fever and cough for 3 days. She reports coughing up thick green phlegm and is concerned that she has pneumonia. She denies shortness of breath. Past medical history HTN, T 102°F, RR 28, HR 86, BP 140/72, SpO2 94%.
EMS arrives with a 14-year-old male who was snowboarding at a nearby ski area, lost control, and ran into a tree. The patient was wearing a ski helmet, is currently aware, alert, and oriented and is complaining of left upper-quadrant pain and left thigh pain. His left femur appears to be broken. BP 112/80, HR 86, RR 14, SpO2 98%, and temperature is normal.
"I woke up this morning, and there was a bat flying around our bedroom. Scared me half to death, and now I am so worried about rabies," an anxious 48-year-old female tells you. "My husband opened the window, and the bat flew out." Past medical history of ovarian cysts, no med or allergies, vital signs are within normal limits.
The family of a 74-year-old male called 911 when he developed severe mid-abdominal pain. "My husband is not a complainer," reports his wife. "The only medication he takes is for high blood pressure." On arrival in the ED, the patient's HR is 140, RR 28, SpO2 94%, BP 72/56.
"I woke up this morning, and my eyes are all red and crusty," reports a 29-year-old kindergarten teacher. "I think I got it from the kids at school," she tells you. She denies pain or other visual disturbances. Her vital signs are within normal limits.

Set B Competency Cases

"Without the helmet, I would have been really hurt," reports a 19-year-old healthy male who was involved in a bicycle accident. He lost control of his bike when he hit a pothole. He has a 2-centimeter laceration on his arm and pain over his left clavicle. Vital signs: T 97.4°F, RR 18, HR 62, BP 122/70, SpO2 100%. Pain 6/10.
When asked why she came to the emergency department, the 18-year-old college student begins to cry. She tells the triage nurse that she was sexually assaulted last night at an off-campus party.
"I have this skin rash in my crotch. It looks like jock rot. Probably got it from not washing my gym clothes," reports a 19-year-old healthy male. No abnormal vital signs.
"The doctor told me to come back this morning and have my boil checked. He lanced it yesterday and packed some stuff in it. He said he just want to make sure it is healing OK," reports a 54-year-old diabetic male. The patient goes on to tell you that he feels so much better. T 98°F, RR 16, HR 64, BP 142/78, SpO2 98%. Pain 2/10.
A 16-year-old high school hockey player collapsed on the ice after being hit in the anterior chest by the puck. The coaching staff began CPR almost immediately, and he was defibrillated three times with a return of spontaneous circulation. He arrives in the emergency department intubated.
"I have been wheezing for a few days, and today I woke up with a fever. My rescue inhaler doesn't seem to be helping," reports a 43-year-old female with a past history of asthma. Vital signs: T 101.4°F, RR 26, HR 90, BP 138/70, SpO2 95%.
"This sounds really strange. A bug flew into my right ear while I was gardening. I tried to get it out by using a Q-tip. I just don't know what else to do, but this buzzing noise is driving me crazy," a 55-year-old female tells you. No previous medical history and vital signs are within normal limits.
"This morning, I stepped on a rusty nail, and it went right through my shoe into my foot. I washed it really well. I read on the Internet that I need a tetanus shot." No previous medical history, and vital signs are within normal limits.
"I was having breakfast with my wife, and all of a sudden I couldn't see out of my right eye. It lasted about 5 minutes. I'm just scared because I've never had anything like this happen before," reports a 56-year-old male with a history of HTN and high cholesterol.
"I was walking down the street and twisted my ankle as I stepped off the curb. I don't think it's broken, but it hurts so much," report a 43-yearold female with a history of colitis. Vital signs: T 98°F, HR 72, RR 18, BP 134/80, SpO2 100%. Pain 8/10.
A 16-year-old female is brought to the emergency department by her mother, who reports that her daughter took more than 30 acetaminophen tablets about 30 minutes before admission. The tearful girl tells you that her boyfriend broke up with her this morning. No previous medical history, and no allergies or medications. Vital signs within normal limits.
"My colitis is acting up," report a 26-year-old female. "It started with an increased number of stools, and now I am cramping a lot. My gastroenterologist told me to come to the emergency department to be evaluated." No other past medical history. T 97°F, RR 18, HR 68, BP 112/76, SpO2 100%. Pain 6/10.
"I was so disappointed about not making the varsity soccer team that I punched a wall," reports a 15-year-old healthy male. His hand is swollen and tender to touch. Vital signs: T 97°F, RR 16, HR 58, BP 106/80, SpO2 100%. Pain 5/10.
A 46-year-old female with a history of sickle cell disease presents to the emergency department because of a crisis. She has pain in her lower legs that began 8 hours ago, and the pain medication she is taking is not working. Currently, she rates her pain as 8/10. She has no other medical problems, and her current medications include folate and vicodin. Vital signs are all within normal limits.
"I take a blood thinner because I have had clots in my legs," reports a 54-year-old black male. "They told me that medicine would prevent them, but today I have pain and swelling in my lower leg. It started out just being sore, but now I can hardly walk on it." Denies any other complaints. Vital signs within normal limits.
A 65-year-old female is brought in by ambulance from the local nursing home for replacement of her PEG tube. The information from the nursing home states that she had a massive stroke 3 years ago and is now aphasic. Her condition is unchanged, and she is a do not resuscitate/do not intubate. Vital signs within normal limits.
A 26-year-old female presents to the ED because she can't get an appointment with her therapist. She went home for the holidays, and the visit brought back many issues from her childhood. She is unable to sleep and has been drinking more than usual. She admits to thinking about hurting herself but has no plan. History of previous suicide attempts. Vital signs within normal limits.
"I am here on business for a week, and I forgot to pack my blood pressure medication. I haven't taken it for 2 days. Do you think one of the doctors will write me a prescription?" asks a 58-year-old male. BP 154/88, HR 64, RR 18, T 98°F, SpO2 99%.
"I fell running for the bus," reports a 42-year-old female. "Nothing hurts, I just have road burn on both my knees, and I think I need a tetanus booster." Vital signs within normal limits.
EMS radios in that they are in route with a 21-year-old with a single gunshot wound to the left chest. Vital signs are BP 78/palp, HR 148, RR 36, SpO2 96% on a non-rebreather.
A 51-year-old presents to triage with redness and swelling of his right hand. He reports being scratched by his cat yesterday. Past medial history gastroesophageal reflux disease. Vital signs: BP 121/71, HR 118, RR 18, T 101.8°F, SpO2 98%. Pain 5/10.
EMS arrives with a 52-year-old female overdose. The patient took eight 75 mg tabs of wellbutrin 2 hours ago because her husband left her for another woman, and now she wants to die. She is awake, alert, and oriented.
The local police arrive with a 48-year-old male who was arrested last night for public intoxication. He spent the night in jail, and this morning he is restless and has tremors. The patient usually drinks a case of beer a day and has not had a drink since 7 p.m. Vital signs: BP 172/124, HR 122, RR 18, T 98.6°F, SpO2 97% Pain 0/10.
A healthy 10-year-old male is brought to the emergency department by his mother, who reports that her son has not moved his bowels for a week. He is complaining of 7/10 generalized abdominal pain, nausea, and lack of appetite. Vital signs: BP 107/66, HR 75, RR 20, T 98.6°F, SpO2 99%.
EMS arrives with a 22-year-old woman with asthma who began wheezing earlier this morning. She is sitting upright on the ambulance stretcher leaning forward with an albuterol nebulizer underway. The patient is diaphoretic, working hard at breathing and unable to answer your questions. EMS tells you that they think she is tiring out. Her respiratory rate is 48, SpO2 is 94%, and she has a prior history of intubations.

Set A Competency Cases—Answers

ESI level 3: Two or more resources. From the patient's history, he will require labs and IV fluid replacement—two resources.
ESI level 3: Two or more resources. It looks as though this patient has a displaced fracture and will need a closed reduction prior to casting or splinting. At a minimum, he needs x-rays and an orthopedic consult. This patient may also require procedural sedation. However, there are already two or more resources, so it is not necessary to be overly concerned about counting resources beyond two.
ESI level 1: Requires immediate lifesaving intervention; possible aggressive fluid resuscitation.
ESI level 2: Severe pain or distress. This patient needs aggressive pain management with IV medications. There is nothing the triage nurse can do to decrease the patient's pain level. The answer to "Would you give your last open bed to this patient?" should be yes.
ESI level 3: Two or more resources. The patient is presenting with signs and symptoms of another kidney stone. At a minimum, he will need a urinalysis and CT scan. If his pain increases, he may need IV pain medication. At a minimum, two resources are required. If the pain level was 7/10 or greater and the triage nurse could not manage the pain at triage, the patient could meet level-2 criteria.
ESI level 2: High risk. Rashes are difficult to triage, but the presence of petechiae is always a high-risk situation. Even if the patient looks good, it is important to recognize that petechia can be a symptom of a life-threatening infection, meningococcemia.
ESI level 4 or 5: This case is an example of variations in practice around the country. Many emergency departments would examine the child and then attempt to reduce the dislocation of the radial head without an x-ray. Others may x-ray the child's arm, which is considered one ESI resource. Relocation is not considered a resource.
ESI level 2: High-risk. An asthmatic with a prior history of intubation is a high-risk situation. This patient is in respiratory distress as evidenced, by her respiratory rate, oxygen saturation, and work of breathing. She does not meet the criteria for ESI level 1, requires immediate lifesaving intervention.
ESI level 2: High risk. This patient is demonstrating respiratory distress with his increased respiratory rate and decreased oxygen saturation. Symptoms are caused by compression of the superior vena cava from the tumor. It is difficult for blood to return to the heart, causing edema of the face and arms.
ESI level 1: Requires immediate lifesaving intervention. Depending on the exact location penetrating neck trauma can cause significant injury to underlying structures. Based on the presenting vital signs, immediate actions to address airway, breathing, and circulation are required. Intubation might be necessary due to the large neck hematoma, which may expand.
ESI level 5: No resources. This healthy-sounding 11-year-old will be examined by a physician and then discharged home with appropriate instructions and a prescription if indicated.
ESI level 2: High risk. This patient has an elevated respiratory rate and heart rate. The symptoms of polydipsia and polyuria are two classic signs of diabetic ketoacidosis.
ESI level 3: Two or more resources. This 19-month-old is dehydrated and will require a minimum of two resources: labs and IV fluids. In addition the physician may order an IV antiemetic.
ESI level 3: Two or more resources. This patient probably has a fractured hip and will need an x-ray, IV pain medication, and an orthopedic consult. If the reason for a fall in the elderly is unclear, the patient should be assigned ESI level 2 to rule out a cardiac or neurological event.
ESI level 5: No resources. Following a physical exam, this baby will be discharged to home. Prior to leaving, the mother needs to be taught techniques to keep the baby's nares clear of mucus.
ESI level 2: High risk. An elderly patient with increasing confusion and a fever needs to be evaluated for an infection. UTIs and pneumonia need to be ruled out. This patient may be septic and requires rapid evaluation and treatment.
ESI level 2: New-onset confusion, lethargy, or disorientation. The mother of this 4-year-old knows her child and has probably been through this situation before. A child with a ventriculo-peritoneal shunt with a change in level of consciousness and a headache is thought to have a blocked shunt until proven otherwise and may be experiencing increased intracranial pressure.
ESI level 1: Requires immediate lifesaving intervention. This patient is experiencing another cardiac event that requires immediate treatment. His vital signs and skin perfusion are suggestive of cardiogenic shock, and the patient may require fluid resuscitation or vasopressors to treat hypotension.
ESI level 3: Two or more resources. The patient is presenting with signs and symptoms of an infection. At a minimum, he will require labs, an x-ray, an orthopedic consult, and IV antibiotics.
ESI level 3: Two or more resources. An x-ray is needed to confirm placement in rectum. Then IV sedation and analgesia may be used to enable the physician to remove the foreign body in the ED, or he may be admitted for surgery. In this situation, two or more resources are required.
ESI level 3: Two or more resources. This elderly patient may have pneumonia. Labs and a chest x-ray are required, in addition to IV antibiotics. If vital signs are outside the accepted parameters, they may be considered high risk and meet ESI level-2 criteria.
ESI level 2: High risk. The mechanism of injury represents a high-risk situation. His left upper-quadrant pain could be due to a splenic rupture or injury. He may also have a fractured femur, another source of volume loss. This patient's vital signs are stable, so there is no need for immediate lifesaving intervention, but he is at risk for hemorrhagic shock due to volume loss.
ESI level 4: One resource. It is unknown whether the patient was bitten by the bat because they were sleeping, so postexposure prophylaxis will be initiated. One resource—an intramuscular medication.
ESI level 1: The patient is presenting with signs of shock, hypotension tachycardia, and tachypnea. He has a history of HTN and is presenting with signs and symptoms that could be suggestive of a dissecting aortic abdominal aneurysm. On arrival in the emergency department, he will require immediate lifesaving interventions such as immediate IV access, aggressive fluid resuscitation, and perhaps blood prior to surgery.
ESI level 5: No resources. Following a physical exam, this patient will be discharged to home with a prescription and appropriate discharge instructions. No resources are required.

Set B Competency Cases—Answers

ESI level 3: Two or more resources. Based on the mechanism of injury, this patient will require an x-ray of his clavicle and suturing of his arm laceration. In addition, he may need a tetanus booster, but that does not count as a resource. If the mechanism of injury was higher, the patient could meet ESI level-2 criteria, high risk. The patient's pain rating is 8/10, but the triage nurse can intervene by applying a sling and providing ice to decrease the pain and swelling.
ESI level 2: Severe pain or distress. This patient needs to be taken to a safe, quiet room within the emergency department. Her medical, emotional, and legal needs must be addressed in a timely manner.
ESI level 5: No resources. Following a physical exam, this young man will be discharged to home with a prescription and appropriate discharge instructions.
ESI level 5: No resources. This patient was instructed to come back to the emergency department for a wound check. He will be examined and discharged to home. No resources are required. A point-of-care finger stick glucose is indicated, but this is not a resource. If the patient came back with a fever or increasing pain and redness, then his ESI level would reflect the additional resources he would require.
ESI level 1: Requires immediate lifesaving interventions. From the history, it sounds like the hockey player experienced a disruption in the electrical activity in his heart due to the blow to the chest from the hockey puck. He will require immediate lifesaving interventions to address airway, breathing, and circulation. This patient is intubated, which meets criteria for lifesaving interventions.
ESI level 3: Two or more resources. This patient has a history of asthma that is not responding to her rescue inhaler. In addition, she has a fever. At a minimum, she will need two resources: hand-held nebulizer treatments and a chest x-ray.
ESI level 4: One resource. This patient will need an ear irrigation to flush it out.
ESI level 5: No resources. This patient will require a physical exam then a tetanus booster, which is not considered a resource.
ESI level 2: High risk. This patient is exhibiting signs of central retinal artery occlusion, which represents an acute threat to loss of vision. Rapid evaluation is necessary.
ESI level 4: One resource. To rule out a fracture, this patient will require an x-ray, one resource. The application of a splint and crutch walking instructions are not counted as resources. This patient does not meet the criteria for ESI level 2 for pain because nursing can immediately initiate interventions to address her pain.
ESI level 2: High risk. An overdose is a clear high-risk situation. This patient needs to be seen immediately, and interventions to prevent liver damage must be initiated. At the same time she needs to be placed in a safe, secure environment and monitored closely to prevent harm to herself.
ESI level 3: Two or more resources. The patient is presenting with a colitis flare. She will need labs and possibly an IV and a CT of the abdomen, especially in light of her presentation with normal vital signs. Two resources.
ESI level 4: One resource. This young man presents with a mechanism of injury suggestive of a boxer's fracture. An x-ray is indicated to rule out a fracture,—one resource.
ESI level 2: High risk. Sickle cell disease requires immediate medical attention because of the severity of the patient's pain, which is caused by the sickle cells occluding small and sometimes large blood vessels. Rapid analgesic management will help prevent the crisis from progressing to the point where hospitalization will be unavoidable.
ESI level 3: Two or more resources. This patient will need lab tests and lower-extremity vascular studies to rule out a deep vein thrombosis.
ESI level 3: Two or more resources. This patient will need to be seen by surgery or GI and her PEG tube reinserted—two resources.
ESI level 2: High-risk situation. This patient is a danger to herself and needs to be placed in a safe environment with a constant observer.
ESI level 5: No resources. The patient will need a history and physical exam and then will be discharged to home with a prescription. An oral dose of his blood pressure medication does not count as a resource.
ESI level 5: No resources. A tetanus booster is not a resource, and neither is cleaning and dressing abrasions.
ESI level 1: Requires immediate lifesaving intervention. The trauma team needs to be in the trauma room and ready to aggressively manage this 21-year-old with a single gunshot wound to the left chest. He will require airway management, fluid resuscitation and, depending on the injury, a chest tube or rapid transport to the operating room.
ESI level 3: Two or more resources. This patient probably has a cellulitis of the hand and will require labs and IV antibiotics. Starting a saline lock is not a resource, but IV antibiotics are a resource.
ESI level 2: High-risk situation. An overdose is a high-risk situation, and wellbutrin overdoses are prone to seizures, hallucinations, and irregular heart rhythms. This patient is suicidal and also needs to be monitored closely for safety.
ESI level 2: High-risk situation. This 48- year-old male is probably showing signs of alcohol withdrawal, a high-risk situation. He is restless, tremulous and tachycardic. In addition he is hypertensive. He is not safe to wait in the waiting room, and should be given your last open bed.
ESI level 3: Two or more resources. Abdominal pain, loss of appetite, and nausea in a 10-year-old who has not had a bowel movement in several days is probably due to constipation. He will need two or more resources—labs, maybe an x-ray, maybe a surgery consult, maybe an enema—but at least two resources.
ESI level 1: Requires immediate lifesaving intervention. This young asthmatic is tiring out and will need immediate lifesaving intervention that will require at a minimum a nurse and physician at the bedside immediately. The decision may be to continue the respiratory treatments and try IV steroids, IV magnesium, and heliox immediately. She may also require rapid sequence intubation.

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Page last reviewed October 2014

Internet Citation: Chapter 10. Competency Cases. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/esi/esi10.html