Note from the Director
The Agency for Healthcare Research and Quality (AHRQ) is pleased to bring you the Emergency Severity Index
(ESI): A Triage Tool for Emergency Department Care, Version 4: Implementation Handbook, 2012 Edition. This
edition of the handbook, like the previous edition, covers all details of the Emergency Severity Index—a five-level
emergency department (ED) triage algorithm that provides clinically relevant stratification of patients
into five groups from least to most urgent based on acuity and, unique to ESI, resource needs.
This edition introduces a new section (Chapter 6), developed in response to numerous requests for more
detailed information on using the ESI algorithm with pediatric populations. The section recognizes that the
needs of children in the emergency room differ from the needs of adults, including:
- Different physiological and psychological responses to stressors.
- More susceptibility to a range of conditions, such as viruses, dehydration, or radiation sickness.
- Limited ability to communicate with care providers; thus harder to quickly and accurately assess.
In keeping with our mission to improve the quality, safety, efficiency, and effectiveness of health care for all
Americans, one of AHRQ's areas of emphasis is improved training for the health care workforce. This
handbook will provide invaluable assistance to ED nurses, physicians, and administrators in the
implementation of a comprehensive ESI educational program. In turn, a well-implemented ESI program will
help hospital emergency departments rapidly identify patients in need of immediate attention, better
identify patients who could safely and more efficiently be seen in a fast-track or urgent-care area rather than
in the main ED, and more accurately determine thresholds for diversion of ambulance patients from the ED.
We hope that you find this tool useful in your ongoing efforts to improve the quality of care provided by
your emergency department.
Carolyn M. Clancy, M.D.
Agency for Healthcare Research and Quality
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