Beruflich Dokumente
Kultur Dokumente
(Gurney, 2003)
3-level Triage Scale
Time frame for
Level Term treatment/ Examples
reassessment
Cardiac chest
1 Emergency (Red) Immediate/Constant
pain
Abdominal Pain;
2 Urgent (Yellow) < 2 hours/30 min
Open #
Rash; Vaginal
3 Non-urgent (Green) > 2 hours/1-2 hours
discharge
Forensik/
Hitam
Km Jenazah
R. Resus.
Merah ICU
Orange
ICCU
PICU/ Perina
Admini- ReTriase / R. OK
Pasien UGD
R. Tindak / Monitor
strasi Triase RS
IW
Kuning Kebidanan
Hijau Pulang
R. Tunggu
Canada Triage & Acuity Scale (CTAS)
Level Term Time framework Examples
Immediate to RN;
2 Emergency Overdose; domestic abuse
< 15 min to Dr.
Vomiting/diarrhoea < 2 y; Acute
3 Urgent < 30 min
psychosis
2 Emergency 10 min 80
3 Urgent 30 min 75
Less urgent
4 60 min 70
(semi-urgent)
1 Immediate Red 0
3 Urgent Yellow 60
no
High risk situation?
Or yes
Confused/lethargic/disoriented?
Or
Severe pain/distress
no
2
How many different things are needed?
x-ray-lab test-injection-prosedure-consult
-----------------------------------
None One Many
HR > 90 bpm
5 4 Or
RR > 20 bpm
Or
36 > T > 38
---------- yes
(If done)
SpO2 < 90%
PEFR < 200 L/min
no
3
Reference
Curtis, K., Ramsden, C., & Friendship, J., (Eds). (2007). Emergency and trauma nursing. Philadelphia:
Mosby.
FitzGerald, G., Jelinek, G., Scott, D., & Gerdtz, M. (2010). Emergency department triage revisited.
Emergency Medicine Journal, 27, 86-92. doi: 10.1136/emj.2009.077081.
Fry, M., & Burr, G. (2002). Review of the triage literature: Past, present, future? Australian Emergency
Nursing Journal, 5(2), 33-38
Gurney, D. (2003). Comparing triage decisions for the same patients with a five-level and a three-level
triage scale: A quick exercise for nurses orienting to triage. Journal of Emergency Nursing, 29(2), 191-
192. doi: 10.1067/men.2003.76.
Travers, D. A., Waller, A. E., Bowling, M., Flowers, D., & Tintinalli, J. (2002). Five-level triage system more
effective than three-level in tertiary emergency department. Journal of Emergency Medicine, 28, 395-
400. doi: 10.1067/men.2002.127184.
Wuerz, R. C., Milne, L. W., Eitel, D. R., Travers, D., & Gilboy, N. (2000). Reliability and validity of a new
five-level triage instrument. Academic Emergency Medicine, 7, 236-242.
Zimmermann, P. G. (2001). The case for a universal, valid, reliable 5-tier triage acuity scale for US
emergency departments. Journal of Emergency Medicine, 27, 246-254. doi: 10.1067/men.2001.115284.