TRIAGE

PowerPlugs: Templates

EMERGENCY
EMERGENCY is something that difficult to
predict (Unpredictable). Usually involve a
variety of situations that require to have
decision in a situation involving
multidisciplinary team members

Input

Emergency Dept Flow

Patient arrives
to ED

Emergency Care
Seriously ill from the
community and
referral sources

Triage and
room placement
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care

Safety Net
Care
Vulnerable
populations
Access
barrier

Output

Throughput

Ambulance
diversions

Ambulatory
Care System
Left
without
being seen
Transfer to
outside
facility

Demand
for ED
care

Diagnostic
evaluation and
treatment

ED boarding of
inpatients

Patient
Disposition

Admit to
hospital

Impact of throughput times on

ED capacity
5 Rooms

5 Rooms

5 Rooms

ED
Through
put:4
hours

ED
Through
put:3
hours

ED
Through
put:2
hours

ED
Capacity
: 30/day

ED
Capacity:
40/day

ED
Capacity:
60/day10

BIMC Triage Flow

Patient arrives to ED

Triage and
room placement

1
Resus
Room

3
Treatment
room

Fast Track
Reception for
Regristration

Consult
Room

Definition
Triage system: The process by which a
clinician assesses a patients clinical
urgency
Triage: A triage system is the basic
structure in which all incoming patients are
categorized into groups using a standard
urgency rating scale or structure.

DEFINITIONS cont.
Re-triage: Clinical status is a dynamic state for all patients. If clinical
status changes in a way that will impact upon the triage category, or
if additional information becomes available that will influence
urgency, then re-triage must occur.
When a patient is re-triaged, the initial triage code and any
subsequent triage code must be documented. The reason for retriaging must also be documented.
Urgency: Urgency is determined according to the patients clinical
condition and is used to determine the speed of intervention that is
necessary to achieve an optimal outcome. Urgency is independent
of the severity or complexity of an illness or injury. For example,
patients may be triaged to a lower urgency rating because it is safe
for them to wait for an emergency assessment, even though they
may still eventually require a hospital admission for their condition or
have significant morbidity and attendant mortality

PURPOSE OF TRIAGE
To ensure that patients are treated in the order
of their clinical urgency.
To ensure that treatment is appropriate and
timely.
To allocate the patient to the most appropriate
assessment and treatment area.
To optimize the safety and the efficiency of
hospital-based emergency services
To ensure equity of access to health services
across the population.

EMERGENCY TRIAGE SCALE

Overview of the triage system can be evaluated based on the following
four criteria :
Utility
The scale should be relatively easy to understand and easy to apply by nurses and
ER doctors.
Validities
The scale must be designed to measure the clinical urgency as opponents of the
severity or complexity of illness or some other aspect of the presentation on
emergency dept.
Reliability
The triage scale application must be independent of the nurse or doctor who
performs the role, they must be consistent. 'Inter-rater reliability is a term used to
statistically measure the agreement reached by two or more assessors using the
same scale.
Safety
Triage decisions must be accordance to clinical criteria of objective and must
optimize time for medical intervention. In addition, the triage scale must be sensitive
enough to identify the patient's problems.

EMERGENCY TRIAGE SCALE

Internationally, five-tier triage scales have been shown to
be valid and reliable methods for categorizing people
who are seeking assessment and treatment in hospital
EDs
ATS Category Treatment Acuity
(Maximum waiting time)
1

Immediate

10 Minute

30 Minute

60 Minute

120 Minute

Note: ATS = AustralAsian Triage System

EMERGENCY TRIAGE SCALE

cont
ATS Category 1 - Immediate simultaneous assessment and treatment
Immediately Life-Threatening Condition
Conditions that are threats to life (or imminent risk of deterioration) and
require immediate aggressive intervention

ATS Category 2 - Assessment and treatment within 10 minutes (often

simultaneously)
Imminently Life threatening
The patient's condition is serious enough or deteriorating so rapidly that there is the
potential of threat to life,or organ system failure, if not treated within ten minutes of
arrival or
Important time-critical treatment
The potential for time-critical treatment (e.g. thrombolysis, antidote) to make a
significant effect on clinical outcome depends on treatment commencing within a few
minutes of the patient's arrival in the ED or
Very severe pain
Humane practice mandates the relief of very severe pain (7-10 on a 0-10 scale) or
distress within 10 minutes

 ATS Category 3 - Assessment and treatment start within 30 mins

Potentially Life-Threatening
The patient's condition may progress to life or limb threatening, or may lead
to significant morbidity, if assessment and treatment are not commenced
within thirty minutes of arrival or
Situational Urgency
There is potential for adverse outcome if time-critical treatment is not
commenced within thirty minutes or Humane practice mandates the relief of
severe pain (5-6 on a 0-10 scale), discomfort or distress within thirty
minutes

 ATS Category 4 - Assessment and treatment start within 60 mins

Potentially serious
The patient's condition may deteriorate, or adverse outcome may result, if
assessment and treatment is not commenced within one hour of arrival in
ED. Symptoms moderate or prolonged or
Situational Urgency
There is potential for adverse outcome if time-critical treatment is not
commenced within hour or
Significant complexity or Severity
Likely to require complex work-up and consultation and/or inpatient
management or Humane practice mandates the relief of pain (< 4 on a 0-10
scale), discomfort or distress within one hour

 ATS Category 5 - Assessment and treatment start within 120

mins
Less Urgent
The patient's condition is chronic or minor enough that symptoms or
clinical outcome will not be significantly affected if assessment and
treatment are delayed up to two hours from arrival or
Clinico-administrative problems
Results review, medical certificates, prescriptions only

Summary of adult physiological predictor for ATS

Level 1

Level 2

Level 3

Level 4

Level 5

Airway

Obstructed/Partial
obstructed

Patent

Patent

Patent

Patent

Breathing

Severe respiratory
distress/Absent
respiratory/Hypove
ntilation

Moderate
respiratory
distress

Mild Respiratory
distress

No respiratory
distress

No respiratory
distress

Circulation

Severe
haemodynamic
compromise/absent
circulation/uncontrol
led hemorrhage

Moderate
haemodynamic
compromise

Mild Haedynamic
compromise

No Haedynamic
distress

No Haedynamic
distress

GCS <9

GCS 9-12

GCS > 12

Normal GCS

Normal GCS

7-10 (on a 0-10

scale)

5-6 (on a 0-10

scale)

4 (on a 0-10
scale)

No pain

Disability

Pain Scale

Example Case
ATS 1
Cardiac arrest
Respiratory arrest
Immediate risk to airway impending arrest
Respiratory rate <10/min
Extreme respiratory distress
BP< 80 (adult) or severely
shocked child/infant
Unresponsive or responds to
pain only (GCS < 9)
Ongoing/prolonged seizure

ATS 3
Severe hypertension
Moderately severe blood loss
Moderate shortness of breath
SpO2 90 - 95%
Post Seizure (now alert)
Any fever if immunosuppressed,
e.g. oncology patient, steroid Rx
Persistent vomiting
Dehydration
Head injury with short LOC - now
alert
Severe pain - any cause - requiring
analgesia
Chest pain likely non-cardiac and
moderate severity

ATS 2
ATS 4
Mild hemorrhage
Foreign body aspiration, no
respiratory distress
Chest injury without rib pain or
respiratory distress
Difficulty swallowing, no respiratory
distress
Minor head injury, no loss of
consciousness
Moderate pain, some risk features
Vomiting or diarrhea without
dehydration
Eye inflammation or foreign body normal vision
Minor limb trauma - sprained ankle,
possible fracture, uncomplicated
laceration requiring investigation or
intervention - Normal vital signs,
low/moderate pain
Swollen "hot" joint
Non-specific abdominal pain

Airway risk - severe stridor or

drooling with distress
Severe asthma/Severe
COPD/Severe SOB
Chest Pain Cardiac origin
HR<50 or >150 (adult)
Hypotension with haemodynamic
effects
Severe blood loss
Drowsy, decreased responsiveness
any cause (GCS< 13)
Acute hemiparesis/dysphasia
Fever with signs of lethargy
Severe localised trauma - major
fracture, amputation

ATS 5
Minimal pain with no high risk
features (1-2 on a 0-10 scale)
Low-risk history and now
asymptomatic
Minor symptoms of existing stable
illness
Minor symptoms of low-risk
conditions
Minor wounds - small abrasions,
minor lacerations (not requiring
sutures)
Follow up
Immunization only

Algorithm
Patient dying
yes

no

Shouldnt wait

yes

no

2
How many resources ?
None

one

many

abnormal

Vital signs
normal

PEDIATRIC TRIAGE

CLINICAL PARAMETERS
Hewsonet al, 1990 significant clinical features may predict serious
illness in children.
Decrease of oral intake (<1/2 the normal intake in the 24 hours)
Difficulty breathing / respiratory problems
Replacement diapers <4x for 24 hours
Decrease of activity
Look weak and sleepy
Looks pale and hot
High fever in children aged <3 months.

PHYSIOLOGICAL APPROACH AS A BASIS FOR DECISION OF

TRIAGE
GENERAL APPEARANCE
Assessment general appearance? Why???
AIRWAY
Airway evaluation? Evaluation of airway obstruction?
BREATHING
The ability of Baby and children's to tolerate respiratory disorders is very bad
Increased work of breathing
indicator of serious illness in infants.

PHYSIOLOGICAL APPROACH AS A BASIS FOR

DECISION OF TRIAGE cont
CIRCULATION
hypotension is signs of hemodynamic disturbances that
was late to get treatment in infants and children
Initial assessment of circulation must depend on the
general appearance of patient's, pulse, CRT
Pale in infants are significant findings as indicators of
serious illness
CRT is indicator of central perfusion and cardiovascular
function
Level of dehydration is important things to assess the
circulation status

TABEL PENGKAJIAN TINGKAT DEHIDRASI

Tingkat Keparahan

Sign

Mild

Moderate

Severe

Kondisi umum

thirsty,
Restlessness,
agitation

thirsty,
Restlessness,
irritability /
Offended

Withdraw,
somnolence /
drowsiness, coma,
rapid breathing

Pulse rate

Normal

Rapid and weak

Rapid and weak

Crown

Normal

Cekung

Sangat Cekung

eye

Normal

Cowong

Sangat cowong

Tear

yes

None

None

mucous membrane dryish

Dry

Dry

Skin turgor

Normal

Decrease

Decrease

Urine

Normal

Reduced,
concentrated

Nothing in a few
hours

Decrease of BW

4-5%

6-9 %

> 10 %

PHYSIOLOGICAL APPROACH AS A BASIS FOR DECISION OF

TRIAGE cont

DISABILITY
Immediate assessment if any abnormalities of
consciousness
Decreased level of consciousness sign of
oxygenation / circulation disruption .
Decreased activity indicator of serious illness
in infants and children
AVPU scale is a method to assess the level of
consciousness of patients in triage.
Do not be underestimated complaints from the
parents.

PPD

Airway

Category 1
Immediate
Obstructed

Category 2
Emergency
Within 10 minutes
Patent

Category 3
Urgent
within 30 minutes
Patent

Category 4
Semi-urgent
Within 60 minutes

Category 5
Non-urgent
Within 120 minutes

Patent

Patent

Respiration present

Respiration present

Partially obstructed with severe Partially obstructed with

Partially obstructed with
respiratory distress
moderate respiratory distress mildrespiratory distress
Breathing

Absent respiration or
hypoventilation

Respiration present

Respiration present

Severe respiratory distress, e.g. Moderate respiratory distress,

e.g.

moderate use of
accessory muscles

severe use of accessory

muscles

moderate retraction

severe retraction

skin pale

acute cyanosis

Mild respiratory distress, e.g. No respiratory distress, e.g.

mild use of accessory

no use of accessory
muscles
muscles

No respiratory distress, e.g.

no use of accessory
muscles

mild retraction

skin pink

Circulation
s/s dehydration *

Absent circulation
Severe bradycardia, e.g. HR
<60 in an infant

Circulation present

Circulation present

Circulation present

Circulation
s/s dehydration *

Moderate haemodynamic
Severe haemodynamic
compromise, e.g.
compromise, e.g.

absent peripheral pulses

weak/thready brachial
pulse

skin pale, cold, moist,

skin pale, cool

mottled

Mild haemodynamic
compromise, e.g.

palpable peripheral
pulses

No haemodynamic
compromise, e.g.

palpable peripheral
pulses

No haemodynamic
compromise, e.g.

palpable peripheral
pulses

skin pale, warm

significant tachycardia

moderate tachycardia

mild tachycardia

capillary refill >4 secs

capillary refill 2-4 secs

Circulation
s/s dehydration *

Uncontrolled haemorrhage

Circulation present

> s/s dehydration

3-6 s/s dehydration

no retraction

skin pale, warm

<3 s/s dehydration

no retraction

skin pale, warm

No s/s dehydration

PPD

Disability

Category 1
Immediate

GCS <8

Category 2
Emergency
Within 10 minutes

Category 3
Urgent
within 30 minutes

GCS 9-12
GCS >13
Severe decrease in activity, Moderate decrease in
e.g.
activity, e.g.

lethargy

no eye contact

decreased musle
tone

Severe pain, e.g.

patient/parents
report severe pain

skin pale, cool

alteration in vital
signs

requests analgesia

Severe neurovascular
compormise, e.g.
pulseless
cold
nil sensation
nil movement
capillary refill

eye contact wihen

disturbed

Category 4
Semi-urgent
Within 60 minutes

Category 5
Non-urgent
Within 120
minutes

Normal GCS or no acute

change to usual GCS
Mild decrease in activity,
e.g.

quiet but eye contact

Normal GCS or no
acute change to usual
GCS
No alteration in activity,
e.g.

playing

interacts with
parents

Moderate pain, e.g.

patient/parents
Mild pain, e.g.
patient/parents
report moderate pain
report mild pain

skin pale, warm

skin pink, warm

alteration in vital

no alteration in vital
signs
signs

requests analgesia

requests analgesia
Moderate neurovascular
Mild neurovascular
compormise, e.g.

pulse present
compormise, e.g.

pulse present

cool

normal/ sensation

sensation

normal/ movement

movement
normal capillary

capillary refill
refill

smiling

No or mild pain, e.g.

patient/parents
report mild pain

skin pink, warm

no alteration in
vital signs

declines
analgesia

No neurovascular
compormise

MENTAL HEALTH
TRIAGE

Prinsip Dasar Mental Health

Triage
Asssesment to determine URGENCY not
DIAGNOSIS
Maintain our safety and others
Seek help ASAP ----Pasien bertambah
aggresif
Tidak semua pasien dengan prilaku
gelisah dan agresif adalah pasien jiwa

Mental Health In ED
Aggression, self
harm ,
substance
abuse

Cognitive
dysfunction,
physical disability

Emergency
Department

Symptomatic
problems:
Hallucination, delusion
Social problems: job,
relationship, financial

The ABCs of Mental Health

Assessment
A = Appearance, Affect
B = Behavior
C = Conversation and mood

A = Appearance

Wajah pasien
Pakaian yg digunakan
TubuhGizi (malnutrisi ??, dehidrasi? )
Nampak ada bekas cidera?
Pasien nampak intoxicated ?
Nampak tegang? Lemas, gelisah

Sikap / Affect / Mood

Bagaimana gambaran Emosi
pasien(datar, tearful, cemas, stres)
Emosinya berubah secara cepat ?
Emosinya tidak sesuai dengan apa yang
dibicarakan oleh pasien
Pasien nampak bahagia berlebihan

B = Behaviors (tingkah laku)

Bagaimana perilaku pasien ????
Tertidur
Gelisah
Hiperventilasi
Tremor?
Disorientasi
Perilaku yang aneh, yg tidak bisa
diprediksi

Bagaimana Reaksi Pasien???

Pasien marah-marah, tidak kooperatif,
curiga, menarik diri, ketakutan
Pasien berespon terhadap suara yg tidak
ada, object yg tidak terlihat
Apakah pasien menolak untuk berbicara?
Apakah Pasien nampak fokus?

C = Conversation and mood

Bahasa yang digunakan apa? Perlu interpreter??
Percakapan dg pasien cepat, berulang-ulang, lambat,
diam
Pasien berbicara keras, lemah atau tidak berbicara
Bicaranya jelas atau kacau
Berbicara sambil marah, berbahasa yg jorok/kasar?
Pasien menghentikan bicaranya krn mendengar suara
Apakah mereka tahu hari, waktu dan bagaimana mereka
sampai ke ED

Mood
Bagaimana gambaran mood pasien??
Sedih, depresi
Marah dan sensitive
Cemas, ketakutan
Gembira
Tidak bisa berhenti menangis
Apakah pasien mengatakan mau mati,
bunuh diri

Mental Health Triage Tools

Triage
Code

Description

Presentation
(Observed)

Presentation
(Reported)

1-immidiate

Definitedanger to self & other

Violentbehavior and patient Possession

of weapon, self destruction, extreme
agitation, restlessness, disoriented
behavior

Verbal command to do harm

to self or others
Recent violent behavior

2-emergency
10 min

Probablerisk of danger to
self , other
Pt. physically restrain

Extreme agitation/restlesness
Physically/verballyagresive
Confused/unable to cooperate
Hallucinations/delusions/paranoia
Requires restrain
High risk to escape

Attempt at self harm/threat of

self harm
Threat of harm to others
Unableto wait safely

3 urgent
30 minutes

Possible danger to self or

other

agitation/restlesness
Intrusive bbehaviour,confuse,
ambivalence, not likely to wait

Suicidal ideation
Situational crisis

4-semi urgent
60 minutes

Semiurgent mental health

problem
Under observation and/or no
immediate risk to self or
others

No agitation/restlessness
Irritable without aggression
Cooperative
Give coherent history

Preexstingmental health
Symptoms of anxiety or
depression without suicidal
ideation
Willing to wait

5 non urgent
Within 120 min

No danger to self or other

Cooperative,communicativeand able to
engage in developing mngtplan
Able to discuss concerns, compliant with
instructions

Known ptwith chronic

psychotic symptoms
Pre existingnon acute
mental disorder, financial,
social problems

TRIAGE IN PREGNANCY

Key Word
1. Semuawanitausiasuburharusdianggaphamilsampaiterb
uktisebaliknya.
2. Penilaianyang
urgensiharusdilakukanbaikpadaibudanjanin
3. Peningkatantekanandarahmerupakantandaperburukand
anmemerlukanpenanganansegera.
4. Wanitahamilmempunyairisikoperdarahanotak,trombosis
otak,radangparuberat,aritmiaatrium,trombosisvena
danembolus.
5. Presentasimungkintermasukkekhawatirantentangperke
mbangankehamilan.

AIRWAY
Potensi Gangguan jalan nafas
Wanita hamil sulit diintubasi;
Ukuran pasien ,posisi pasien, kebutuhan obat induksi berbeda karena
perubahan fisiologis kardiovaskuler.
BREATHING
Progesteron dianggap bertanggung jawab dalam mempengaruhi kepekaan
pusat pernafasan
Wanita hamil umumnya mengalami peningkatan vaskularisasi hidung dan
jalan nafas dan edema mukosa. Ini menyajikan sebagai peningkatan
keluhan tentang hidung tersumbat.

CIRCULATION
Kehamilan digambarkan sebagai kondisi
hiperdinamik dan perubahan fisiologis
terjadi pada awal kehamilan 6-8 minggu.
Progesteron menyebabkan vasodilatasi l
dan estrogen berkontribusi pada 40-50
persen peningkatan volume darah.

 Hal hal penting yang perlu diperhatikan:

Wanita hamil sering mengalami jantung berdebar selama
kehamilan, yang biasanya karena hiperdinamik aliran darah.
volume aliran arah yang tinggi dan dinamis adalah diperkirakan
berkontribusipada peningkatan resikopen arahan otak (terutama
perdarahan sub-arakhnoid (SAH)) pada kehamilan.
Setiap wanita hamil > 20 minggu kehamilan harus berbaring pada
posisi miring lateral kiri (ganjal dibawah pinggulkanan ibu, atau
miringkan seluruh tempat tidur jika pemberiangan jalan merupakan
kontraindikasi).
Embolus paru relatif sering terjadi selama kehamilan karena
perubahan dalam sistem koagulasi yang berhubungan dengan
kehamilan.

Dalam kasus trauma, semua kriteria trauma harus diperhatikan.

Pertimbangan termasuk trauma pada plasenta, uterus atau janin, terutama
pada trimester ketiga ketika janin sedang tumbuh. Tanda-tanda vital ibu
mungkin dapat tetap stabil bahkan ketika kehilangan seper tiga dari
volume darah.
Perlakuan awal yang terbai kuntuk janin adalah resusitasi optimum dari ibu.

Kondisi Umum Yang sering di

temukan dalam ED

Wanita Hamil sering datang keUGD dengan keluhan pendarahan vagina. Penyebab
umum termasuk berbagai jenis keguguran (yaitu terancam, tak terelakkan, lengkap,
tidak lengkap dan septik).
Pengetahuan tentang volume dan perdarahan warna per vagina (PV) akan
membantu perawatTriage menentukan kategori urgensi kasus.
Kehilangan darah merah terang biasanya menunjukkan perdarahan aktif, sedangkan
kehilangan darah merah kecoklatan biasanya terjadi sudah lama.
Nyeri Bahu dapat menjadi indikasi perdarahan kehamilan ektopik.
Diagnosis pertama dan utama untuk wanita dengan usia subur, yang datang dengan
keluhan perdarahan pervagina setelah prosedur sterilisasi, adalah suatu kehamilan
ektopik dan Penuaan
Nyeri abdomen merupakan gejala yang paling umum dari pecahnya kehamilan
ektopik.Kehamilan ektopik yang tidak pecah umumnya hadir dengan pendarahan
(pada umumnya berwarna coklat).

 Masalah yang terjadi dari 20 minggu dan seterusnya

Wanita hamil pada umur kehamilan 20 minggu kehamilan akan mengalami
kondisi obstetri berikut:
perdarahan antepartum
Preeklamsia (termasuk eklampsia)
pecah membran dan kelahiran yang pre term
Hipertensi(> 140/90) adalah tanda penting terutama untuk memperingatkan
PerawatTriage pada masalah yang lebih serius. Adanya gejala-gejala
terkait preeklampsia berat menandakan perlunya penilaia nmedis yang
mendesak. Antaralain:
Sakitkepala
GangguanVisual
Nyeriepigastrium
nyerikuadrankanan(kuadrankananatas) atas
. Edema Non-dependen.

Ancaman Penting untuk keselamatan janin

Perubahan dalam saturasi oksigen pada ibu memiliki relevansi
langsung pada kesejahteraan janin. Penurunan kecil oksigenasi ibu
sangat berdampak pada oksigenasi janin karena pergeseran kiri
dalam kurva disosiasioxy haemoglobint erkait dengan hemoglobin
janin. Pertimbangkan pengukuran saturasi oksigen ditriase pada
semua wanita hamil.
Perubahan Mayor pada tekanan darah (baik tinggi atau rendah) tidak
ditoleransi oleh janin.

PROCEDURE

All assessments, interventions and its results as well as the ATS category
need to be documented by the triage nurse on the Triage Form.
On arrival assess the patient. Balance the need for speed against the need to
be thorough.
Before the patient has registered with admin
Introduce yourself to the patient and your role as triage nurse, e.g.
Good morning Mr/Mrs/Miss patients name or Sir/Mam/Miss if
unknown name. I am (your name) and I am the triage nurse this
morning
Ask the patient for their complaint. If pt already have registered him/herself in admin then read at the form/file first what his/her complain
may be but do also ask them directly. (May only be applicable to Kuta
staff)
Be discrete and try to talk privately to the patient. e.g. Excuse me,
may I know what is your complaint / why you seek health care / why
you like to see a doctor today? (You may need to explain that you
need this information in order to make sure the priority of the patients
who has to see a doctor first.)

PROCEDURE

cont

On arrival assess the patient. Balance the need for speed against the
need to be thorough. - cont
Before/After the patient has registered at the admin - cont
Actively ask for any pain or other discomfort. If yes, Location?
Number on a 0-10 scale? e.g. Do you feel any pain right
now?
Continue with any follow up questions that may be needed to
clarify the patients ATS category. See ATS categories what to
look for.
Simultaneously, Look at the patient to get an impression of
his/her general status, e.g. cannot stand/walk, shortness of
breath, pale, in pain or distress etc.

PROCEDURE cont
Measure vital signs at triage if required to estimate urgency, and if
time permits, otherwise have a nurse to perform it before patient
sees a doctor.
The triage nurse may do this by him-/herself or delegate it to another nurse
who must report the result back to the triage nurse ASAP.

Determine the clinical urgency of the patient based on emergency

triage category
Notify doctor on call of patient's arrival and ATS category as
required
Take any patient identified as ATS Category 1 or 2 into the
appropriate assessment and treatment area immediately.
Handover briefly to NOD/DOD so they can Meet any immediate care
needs.

PROCEDURE
Document details of the triage assessment on the Triage Form.
Include at least the following details:
Name and DOB of the Patient
Date and time of assessment
Name of triage nurse
Chief presenting problem(s)
Limited, relevant history
Relevant assessment findings
Initial triage category allocated
Any diagnostic, first aid or treatment measures initiated.
Ensure continuous reassessment of patients who remain waiting. Retriage a patient if:
His/her condition changes while they are waiting for treatment
Additional relevant information becomes available that impacts on
the patient's urgency

PROCEDURE Cont (Path way of triage)

1!ye

1)Pt present for triage: safety hazard are considered above all
2) Assess: chief complaint, general
appearance, A, B, C, D,E, limited
history, co-morbidities

3) Differentiate predictors of poor

outcome from other data collected
during the triage assessment

4) Identify patients who have evidence

of or are at high risk of physiological
instability

yes

2) Quick evaluation: is
pt stable
no
5) Assign an appropriate ATS
category in response
to clinical assessment data

6) Allocate staff to patient,

including brief handover to
allocated staff member/s

7) ED model of care proceeds

Assessment technique for safe

triage
Assessment of environmental hazards
This is the first step to safe practice at triage. As part of
maintaining a safe environment, the Triage Nurse must ensure
that equipment for basic life support (bag-valve mask and
oxygen supply) is available at triage. Likewise, equipment which
complies with standard precautions is required. At the beginning
of each shift, the Triage Nurse should conduct a basic safety
and environment check of the work area to optimize
environmental and patient safety.

Assessment technique for safe

triage
General appearance
Observation of the patients appearance and behavior
when they arrive tells us much about the patients
physiological and psychological status. Take particular
notice of the following:
Observe the patients mobility as they approach the
reception area. Is it normal or restricted? If it is
restricted, in what way?
Ask yourself the question Does this patient look
sick?
Observe how the patient is behaving.

Assessment technique for safe

triage
Airway
Always check the airway for patency, and consider cervical
spine precautions where indicated
Breathing
Assessment of breathing includes determination of respiratory
rate and work of breathing. It is important to detect
hypoxaemia. This can be detected using pulse oximetry.

Assessment technique for safe

triage
Circulation
Assessment of circulation includes determining heart rate,
pulse and pulse characteristics, skin indicators, oral intake and
output.
It is important that hypotension be detected during the triage
assessment to facilitate early and aggressive intervention.
If not possible to measure blood pressure at triage, other indicators of
haemodynamic status should be considered, including peripheral
pulses, skin status, conscious state and alterations in heart rate.
Patients with evidence of haemodynamic compromise (hypotension,
severe hypertension, tachycardia or bradycardia) during the triage
assessment should be put in a high triage category, e.g. 1, 2 or 3.

Assessment technique for safe

triage
Disability

This assessment includes determining AVPU. GCS and/or activity level,

assessing for loss of consciousness, and pain assessment. Altered level of
consciousness is an important indicator of risk for serious illness or injury. Patients
with conscious-state abnormalities should be allocated to a high triage category.

A = Alert
V = Responds to voice
P = Responds to pain
Purposefully
Non-purposefully
Withdrawal/flexor response
Extensor response
U = Unresponsive

Triage Decision

'Under-triage' di mana pasien menerima kode triage yang lebih rendah dari tingkat mereka yang
sebenarnya (sebagaimana ditentukan oleh indikator klinis dan fisiologis ). Keputusan ini memiliki
potensi untuk menghasilkan waktu tunggu yang berkepanjangan terhadap intervensi medis dan
risiko hasil yang buruk.
Kode triage benar (atau diharapkan) sesuai keputusan triage (Correct (or expected) triage
decision ' di mana pasien menerima kode triage yang sesuai dengan tingkat urgensi pasien
(sebagaimana ditentukan oleh indikator klinis dan fisiologis ). Keputusan ini mengoptimalkan
waktu untuk intervensi medis pasien dan mengurangi risiko hasil yang merugikan.
Over triage, di mana pasien menerima kode triage yang lebih tinggi dari tingkat
urgensi sebenarnya mereka. Keputusan ini memiliki potensi untuk menghasilkan waktu
tunggu yang singkat untuk memperoleh intervensi medis, akan tetapi, akan berdampak buruk
bagi pasien lain yang menunggu di IGD karena mereka harus menunggu lebih lama.