3.  Does the patient require immediate life saving intervention?  Airway Obstructed or partially obstructed Unable to protect their own airway  Breathing Apneic Intubated prehospital Severe respiratory distress SpO2 less than 90%

4.  Cont.  Circulation Pulseless or concerned about rate, rhythm or quality  Drugs Hemodynamic interventions Immediate IV medications to correct hemodynamic instability

5.  Does this patient have an acute mental status change that requires immediate life saving intervention?  Hypoglycemia needs glucose  Heroin OD needs narcan  Subarachnoid bleed needs airway protection  Is this patient a P or U on the AVPU scale

6.  Cardiac or respiratory arrest  Overdose with a RR of 8  Severe respiratory distress  Acute SOA with SpO2 < 90%  Anaphylactic shock  Critically injured trauma patient  Chest pain, pale, diaphoretic  Chest palpitations, HR 180+  Unresponsive with strong odor of alcohol  Severe stroke needs airway protection

7.  Airway and breathing  Intubation  Surgical airway  CPAP, BiPAP  Bag valve mask  Defibrillation  External pacing  Chest needle decompression  Hemodynamics  Significant IV fluid resuscitation  Blood administration  IV medications Vasopressors  Control of major bleeding

8. Immediate Life-saving Interventions Life-saving Not life-saving Airway breathing BVM ventilation Intubation Surgical airway Emergent CPAP Emergency BiPAP Oxygen administration  Nasal cannula  Non-rebreather Electrical Therapy Defibrillation Emergent cardioversion External pacing Cardiac Monitor Procedures Chest needle decompression Pericardiocentesis Open thoracotomy Intraoseous access Diagnostic tests  ECG  Labs  Ultrasound  FAST (focused abdominal scan for trauma) Hemodynamics Significant IV fluid resuscitation Blood administration Control of major bleeding IV access Saline lock for medications MedicationsNaloxoneD50DopamineAtropineAdenocardASA IV nitroglycerin AntibioticsHeparin Pain medications Respiratory treatments with beta agonists

9.  Is this a high risk situation?  Is this patient confused, lethargic or disoriented?  Is this patient in severe pain or distress?  The triage nurse obtains pertinent subjective and objective information to quickly answer these questions

11.  Determination is based on a brief patient interview, gross observations, “sixth sense”  Do not require a full set of vital signs  Unsafe for the patient to wait  Suggestive of a condition that could easily deteriorate  Symptoms of a condition that’s treatment is time sensitive  Potential for major life or organ threat

12.  Episodes of chest pain, denies other symptoms, known cardiac history  R/O PE  Newborn with a fever  Rule out ectopic pregnancy  Neutropenia with a fever  Suicidal/homicidal

13.  Is there an acute change in level of consciousness?  Is this situation where the brain is structurally or chemically compromised?

14.  New onset of confusion in an elderly patient  30 y.o. with a known brain tumor whose wife reports that he is confused  Adolescent found confused and disoriented

15.  Is the patient currently in Pain?  Pain intensity rating  Chief complaint  PMH, medications  VS, physical assessment findings  Assign ESI level 2 if and only if:  Self reported 7/10 or greater  AND RN cannot intervene AND they require immediate intervention Does this patient need your last bed?

16.  ? Kidney stone  Severe flank pain, vomiting  Burn victim  Burns to both arms  Oncology patient  Possible dislocated shoulder  Rates pain 10+, diaphoretic, tearful  ? Compartment syndrome

17.  Sexual assault victim  Combative patient  Homicidal/suicidal patient  Bipolar patient who is manic  Acute grief reaction  Known alcohol use with head injury

18. How many resources None 5 One 4 2 or more 3

19.  Determined by the experienced ED RN at triage  Based on the standard of care  Independent of type of hospital, location, physician on duty, acuity of the department

20. Resources:  Labs  ECG  X-ray  CT, MRI  IV fluids  IV, IM meds & nebs  Specialty Consult  Simple procedure=1 (lac repair, foley cath) Complex procedure=2 (conscious sedation) Not Resources:  History and Physical  Pelvic  Point of care testing  Saline or heplock  PO medications  Tetanus shot  Prescription refills  Phone call to PCP  Simple wound care  Crutches, gel splints, slings

21.  No Resources  Examples -Healthy 10y.o. with “poison ivy” -Healthy 52y.o. Who ran out of his BP med recently -22y.o. involved in an MVC 2 days ago, just wants to get checked -46y.o. with a cold

22.  Stable, can safely wait for hours to be seen  Care by mid-level providers in a fast track or urgent care setting  Requires a physical exam and one resource

23.  Examples: -Healthy 19y.o. with a sore throat and fever -Healthy 29y.o. with a UTI, denies abdominal pain -Healthy 43y.o. with a stubbed toe -Healthy 12y.o. with a minor thumb laceration

24.  30-40% of patients seen in the ED  Need 2 or more resources  Require in-depth evaluation  Long length of stay  Before assigning a patient to ESI level 3 the nurse must consider the patients vital signs

26.  ESI level 3  Fractured ankle  Abdominal pain  Most migraines  ESI level 4  Sprained ankle  Abscess  ESI level 5  Toothache