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EMERGENCY

TRIAGE
Benny Arief Sulistyanto, MSN
Tujuan
• Mendefinisikan Triage
• Mendefinisikan sistem Triage
• Identifikasi berbagai sistem triage
• Fungsi sistem triage
Triage
• Dari Bahasa Perancis “Tier” yang berarti “To Sort”
atau mensortir.
• Tujuan triase BUKAN untuk mengurangi waktu
tunggu pasien!!!
• Tujuan triage di ER adalah untuk memanfaatkan
staf medis dan perawat yang ada sebaik mungkin
dan untuk memutuskan mana pasien yang harus
segera ditangani dan pasien yang dapat menunggu
(ditunda penanganannya).
INTRODUCTION
• TRIAGE is the preliminary clinical assessment of
patients entering an emergency department (Wuerz,
2001).
• The central purpose of all triage methods is clinical
prioritization in the setting of constrained resources,
so that patients with major emergencies are treated
before those with more minor complaints (Wuerz, 2001).
• Inappropriate triage assignment can result in patient
delays and lead to increased costs for the
department (Ng et al., 2010)
TIPE TRIAGE
• Three level

• Four level

• Five level
Literature Review
• There are several triage systems model are in
widespread use:
• 3-category level model
Eg. Simple Triage and Rapid Treatment (START)
• 4-category level model
Eg. Taiwan triage system (TTS); Italian four-level
emergency triage system
• 5-category level model
Eg:
• Emergency Severity Index (ESI);
• Manchester Triage System (MTS);
• Canadian Triage and Acuity Scale (CTAS)
• Australasian Triage Scale (ATS);

(Chi & Huang, 2006; Farrohknia et al., 2011; Parenti, et al, 2014
Reed, et al, 2014)
TRIAGE SYSTEM

(Gilboy N, et. al., 2003)


START TRIAGE

COLOR CODE CATHEGORY TIME

RED IMMIDIATE/ < 10 Minutes


EMERGENCY
Yellow Urgent < 30 Minutes

Green Non Urgent > 2 Hours

Black Decease -
EVIDENCE BASED

(Reed, et al, 2014)


5-category level model
• There is some evidence that a five-level triage
system is more effective than a three-level triage
system.
(Travers, et. al., 2002)
• Five-level triage systems are valid and reliable
methods for assessment of the severity of incoming
patients’ conditions by nursing staff in the
emergency department.
(Christ, et. al., 2010)
EVIDENCE BASED
ESI
Algorithm

(Eitel, et al., 2003)


Key concepts
• Acuity level change

• Choose higher acuity when in doubt

• Discontinue assessment and transport the patient


immediately to the treatment area if immediate
care is needed. Do not delay treatment to finish the
assessment
Reassessment in triage
• Level 1 =Continuous
• Level 2 = every 15 min
• Level 3 = every 60 min
• Level 4 = every 60 to 90 min
• Level 5 = every 2 hours
Triage process
• Establish priorities

• Scientific method

• Importance of time
Nursing process in triage
• Assessment time

• Vital signs

• Pain scale

• Nursing diagnosis
Key Concept
• Never assume the accident caused the presenting
condition. The presenting condition may have
caused the accident.
Interview methods
• Open ended
• Close ended
• Communication style
• Use of five sense
• attitude
How do I triage?
• Across the room
• General appearance
• ABCD
• Subjective and objective (AMPLE)
• Focused assessment
• Pains scale (PQRST)
Triage decision
• Step1- visual
• Step 2- chief complaints
• Step3- focused assessment
• Step 4- pose hypothesis
• Step 5- determine acuity
• Step 6- reassess the acuity
Remember That:
Effective triage gets the patient
• To the right place.
• At the right time.
• With the right care provider.
TERIMA KASIH
Wanita 30 tahun
1 jam yang lalu ketika menjemur baju jatuh berdiri setinggi 3 m,
datang ke rumah sakit
dengan keluhan nyeri pada punggung dan kaki kanan sehingga tak dapat berjalan.
Pasien sadar sejak jatuh sampai rumah sakit.

Laki-laki 60 tahun,
Ketika berjalan ditabrak truk dari samping dibawa ke RS dalam keadaan
Tidak sadar, GCS 7 Pupil anisokor dan sedikit midriasis,
ada jejas didada dan di pelvic
Trumatic amputasi setinggi paha kanan, tensi 90/palp, nadi 116 x/ menit

Laki 26 tahun datang ke rumah sakit karena


ditusuk dada sebelah kanan ketika berkelahi dengan temannya,
kejadian sejak 30 menit sebelum masuk rumah sakit.
Saat ini penderita mengeluh sesak dan rasa nyeri sekali bila bernafas,
kepala pusing dan berputar, kaki terasa dingin.

Ketiga penderita ini datang secara hampir bersamaan di IGD Rumah Sakit,
anda sebagai seorang petugas lakukan apa yang harus anda lakukan.
PRIORITAS PENANGANAN

BREATH
BLOOD
BRAIN
BOWEL
BLEADE
R
BONE

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