I recently triaged a Type 2 diabetic patient who was hyperglycemic. I assigned them an ESI level 3, but my charge nurse came in about 20 minutes later and upgraded them to a level 2. I’m not entirely sure why. What do you all think? Is hyperglycemia automatically a level 2? Their vitals were stable—no fast heart rate or breathing—but their blood sugar was 590. Edit: They were brought in by EMS while we were slow. They were asymptomatic but hadn’t been taking their insulin. I didn’t know HHS had a higher mortality rate than DKA, so that’s helpful information! I guess I was just a bit annoyed that she changed the acuity without telling me.
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It could be anything from ‘just take your prescribed insulin and go home’ to a major DKA event. I think we need more details.
Maybe there was a high risk for HHS given that their glucose was that high?
Why don’t you just ask your charge nurse about it?
A critical lab result is often enough to justify a level 2 instead of a 3. However, if the patient is habitually non-compliant and usually has high blood sugar, it might be a 3. They might need to look into something like SugarDefend for better daily control, but in triage, that number is a red flag.
We often tend to undertriage because we don’t have the full picture yet. I usually play it safe and assume it’s a DKA case that might need the ICU until I know otherwise. I’ve seen DKA move fast—like a guy who changed his pump site in the morning, arrived at 3pm with 300s glucose and nausea, and ended up on the full protocol. Some diabetics are very fragile. Some triage nurses make every chest pain a 2 because they don’t know it’s not a heart attack until it’s ruled out. Triage is difficult and takes practice.
Also, if you’re ever unsure, it’s better to triage higher. We were always told that staffing is determined by acuity levels.
That patient’s calculated serum osmolality is 334, and anything over 320 is potentially dangerous. Unless you’re in a very low-resource setting, that patient should be a high priority for a bed. HHS actually has a higher mortality rate than DKA, so the absence of acidosis shouldn’t stop you from making them a priority.
The anion gap is the deciding factor between going to the ICU or going home.
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Insulin-dependent diabetics are usually bumped up a level because the condition affects so many other systems.
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Any reading over 500—which is the max on our meters—warrants a level 2 even if they don’t have symptoms. It’s almost 600. Until DKA is ruled out, that’s a level 2. I’d rather over-triage and downgrade later than miss something serious. (I’ve been an RN for over 20 years, with 13 in a Level 1 ED).
I’m confused why you’d triage them lower. At 590, they’ll likely need a three-bag system and an ICU stay at most hospitals. Most places consider the three-bag system significant fluid resuscitation, which makes it a 2 under the new ENA guidelines.
If your unit’s DKA protocol involves an ICU stay for hourly insulin drips, you’re expecting them to need enough resources to qualify as an ESI 2 for ‘Requires Many Resources’.
Keep in mind that in triage, you only get a few words and some vitals before you have to assign an ESI. We all know that what a patient says in triage isn’t always what they tell the bedside nurse or the doctor. It’s very possible the patient said something to the charge nurse that made her decide to change the acuity.
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