Prioritization of Multiple Patients Using the ABCDE Approach

Scenario

You receive four new patients during a shift handover:

1. COPD patient on 2 L nasal cannula, now confused.
2. Post-op cholecystectomy patient complaining of severe pain (8/10).
3. Diabetic patient with BG 42 mg/dL, drowsy.
4. Pneumonia patient with SpO₂ 86% on 4 L, frothy sputum.

Question: Who will you assess first and why?

Best Practice Answer

1. Apply the ABCDE framework (verbalize your structure):

   • Airway: Any obstruction/secretions/stridor? Pink frothy sputum suggests fluid in alveoli and potential airway compromise if deterioration continues.
   • Breathing: Patient #4 is severely hypoxic on supplemental O₂ with signs consistent with acute pulmonary edema → first.
   • Circulation: Patient #3 has symptomatic hypoglycemia (BG 42) → second. Untreated, this progresses to seizure/coma.
   • Disability (Neuro): Patient #1’s new confusion in COPD could be hypercapnia; urgent but typically after immediate life-threats. → third.
   • Exposure/Pain: Patient #2 has high pain but no immediate threat to life → fourth.

2. First 10 minutes – structured actions and delegation:

   • Minute 0–3 (Patient #4):
     • Raise HOB, ensure patent airway, reassess SpO₂ and work of breathing.
     • Escalate O₂ per protocol (consider NRB/high-flow), call RT; auscultate for crackles.
     • Prepare for possible IV diuretics/nitrates if ordered; place on continuous cardiac & pulse ox monitoring.
     • Delegate CNA to obtain full set of stat vitals and notify charge nurse you’re managing an unstable patient.
   • Minute 3–6 (Patient #3):
     • If alert and can swallow: give 15 g fast carbs (juice/glucose gel). If altered/NPO: IV D50 per protocol.
     • Set a timer to recheck BG in 15 minutes; ensure meal coverage plan is appropriate.
     • Ask LPN/CNA to remain nearby to observe for improving mentation and report immediately if not.
   • Minute 6–8 (Patient #1):
     • Rapid neuro check (A&O, pupils), ABG or VBG if available; assess for CO₂ retention.
     • Titrate O₂ cautiously to baseline target range; avoid over-oxygenation if chronic CO₂ retainer.
     • Consider provider notification if persistent confusion or ABG derangement.
   • Minute 8–10 (Patient #2):
     • Reassess pain, surgical site, last analgesia, and sedation score.
     • Offer multimodal analgesia (e.g., acetaminophen + regional/PO options) and non-pharm measures (splinting, repositioning).
     • Educate patient on expected post-op course; set expectations for reassessment in 30–60 minutes.

3. SBAR to provider (what you actually say):

   • Situation: “We have a pneumonia patient with SpO₂ 86% on 4 L and pink frothy sputum—acute respiratory compromise; interventions started.”
   • Background: “Hx pneumonia; on 4 L; worsening hypoxia.”
   • Assessment: “Crackles bilaterally, increased WOB; concern for pulmonary edema.”
   • Recommendation: “Request evaluation for diuretics/nitrates, consider CXR, ABG, and escalation of O₂ delivery.”

4. Clinical pitfalls to avoid (interviewers listen for these):

   • Treating pain before airway/oxygenation.
   • Giving high, fixed O₂ to a known CO₂ retainer without monitoring or a goal saturation.
   • Correcting hypoglycemia but forgetting the 15-minute recheck.
   • Failing to delegate vitals/monitoring while you stabilize the most critical patient.

Where/When This Applies in Real Life

• ER triage, rapid response activations, and ICU step-downs where multiple unstable patients compete for attention.
• Change-of-shift handoffs when you must quickly build a safe plan with incomplete information.

Evaluation Focus

• Prioritization rationale grounded in ABCDE and pathophysiology (40%)
• Immediate, guideline-concordant interventions with clear escalation (40%)
• Delegation, communication, and follow-through (rechecks, documentation) (20%)

Tip: Say the quiet parts out loud. In interviews, narrate the algorithm: “Airway first, then breathing…” It proves you’ll be systematic under pressure.