FIVE LEVEL TRIAGE

Patients having
Cardiac Arrest,
Cardiac and/or
Respiratory Arrest,
Pulmonary arrest will
LEVE IS THE PATIENT
Anaphylaxis,
Unresponsiveness,
Immediate be placed in the
DYING? Attention Code Bed. Other
L1 Hypoglycemia,
Level 1 patients will
Imminent Childbirth,
be placed in the
Limb Amputations
Treatment Area
Confused, Lethargic,
Disoriented, Severe
Pain, Distress, Active
HIGH RISK
LEVE SITUATION? IS THIS
Chest Pain, Suspected
Coronary Sydrome, 10-15 minutes
All level 2 patients
will be placed to
A PATIENT WHO
L2 SHOULDNT WAIT
Signs of Stroke, Treatment Area.
Immunocompromised
with fever, Suicidal,
Homicidal, Amputations
HOW MANY
RESOURCES? (2 or
more)
Danger Zone Vitals?
CONSIDER VITAL
LEVE SIGNS AS PART OF
Age Pulse
<3mos >155
RR
>50 60 minutes
All level 3 patients
will be placed to
CRITERIA.
L3 TEMPERATURE-
3-8y >160 >40 Treatment Area.
>8y >100 >20
BIRTH TO 6
MONTHS (Consider
upgrading to 2)
HOW MANY
Ankle Sprain, Strept All level 4 patients
LEVE RESOURCES?
(ONE)
Throat, UTI, Migraines
2 hours
will be placed to
with CT Head, Simple Holding/Monitoring
L4 STABLE VITAL
Lacerations, IV/IM Meds area
SIGNS
Patients who can
LEVE HOW MANY
RESOURCES?
Medication Refill, Out-
patient for consultation 4 hours
tolerate sitting
patients will proceed
L5 (NONE) only,
to the waiting area

ER TRIAGE TEAM COMPOSITION

1. Team Leader/Triage Nurse (1)
Overall in-charge of the triage team. Perform quick assessment and brief history taking
to arriving patients and assign appropriate triage levels. Manage ED patient flow.
2. Treatment Nurse (3)
Perform thorough assessment to level 1, 2 and 3 patients. Perform necessary nursing
interventions as needed. Administer Code Blue Protocols to patients having Cardiac
and/or Pulmonary Arrest. Refer patient to the ROD for proper management. Carry-out
doctors order.
3. Monitoring Nurse (1)
Care of patients assigned to Level 4 and Level 5.