EVIDENCE BASE TRIAGE IN EDs

LATAR BELAKANG
IGD  pintu pertama pemberian pelayanan terhadap cedera
mayor dan kondisi kegawatan yang mengancam nyawa

TETAPIpasien non gawat darurat datang ke

IGD

Sistem manajemen
pasien gawat darurat

TRIAGE
 Apa itu Triage?

• “Triage”  bahasa perancis “trier” ….?????

• “suatu sistem untuk mengkaji dan

memprioritaskan pasien di IGD sesuai dengan
kondisi klinis dan tepat waktu” (Mackway-Jones,
Marsden, and Windle, 2006)
Apa itu Triage?

NO
DIAGNOSIS
 Sistem triage yang efektif dan efisien
1. Mengurangi kepadatan IGD
2. Mengurangi waktu tunggu pasien
3. Meningkatkan pengkajian pasien
4. Meningkatkan patient flow
5. Meningkatkan kepuasan pasien
6. Meningkatkan patient outcomes
7. Meningkatkan patient safety
8. Mengontrol infeksi
(Augustyn, Ehlers, & Hattingh, 2009; Bruijns, et al., 2008;
Chan & Chau, 2005; Coughlan & Corry, 2007; Göransson
& von Rosen, 2010; Woolwich, 2000)
 TUNTUTAN AKREDITASI
• Standar akreditasi SNARS 2018, STANDAR
PELAYANAN BERFOKUS PASIEN (AKSES KE RUMAH SAKIT
DAN KONTINUITAS PELAYANAN)
Elemen penilaian ARK 1.1
 Triage berbasis bukti, Pelaksanaan, staf terlatih
menggunakan kriteria, pasien dengan kebutuhan mendesak
diprioritaskan.
• Standar JCI
Access to Care and Continuity of Care  Priority assessment
and treatment for emergent and urgent patients
 INTERNATIONAL LITERATURE
TRIAGE SYSTEM

Reliabilitas cukup – moderate Reliabilitas cukup – sangat baik

(kappa 0.347 to kappa 0.53 ) (kappa 0.25 to kappa 0.89 )
(Travers, et al., 2002; Wuerz, (Fernandes, et al., 2005a)
et al., 1998)

LEBIH
DIREKOMENDASIKAN
 5-LEVEL TRIAGE SYSTEM

• The CTAS (Canadian Triage and Acuity

Scale)
• The ESI (Emergency Severity Index)
• The MTS (Manchester Triage System)
• The ATS (Australasian Triage Scale)
 VALIDITAS DAN RELIABILITAS
VALIDITAS RELIABILITAS
Good validity: Good Reliabilities :
ATS CTAS
ESI ESI
CTAS
Moderate Reliabilities:
Moderate Validity: ATS
MTS MTS
 4-level Triage System

• The HAPT system (Hillerød Acute Process

Triage)
• The TTS (Taiwan Triage Scale)
The HAPT
 The TTS
Level Discriminants Action
Level I 22 chief complaints/ Immediate
condition; 2 vital sign management
criteria
Level II 13 chief complaints; 2 vital 10 minutes
sign criteria
Level III 8 chief complaints; 1 vital 30 minutes
sign criterion
Level IV No chief complaints; no VS Delayed treatment/
criteria outpatients
Adapted from Ng, et al. (2010)
 3-level Triage System

• ETAT (Emergency Triage Assessment and

Treatment)
 ETAT
Kategori Warna Tindakan yang diperlukan

Kasus kegawatan Merah Memerlukan tindakan

kegawat daruratan segera
Kasus prioritas Kuning Memerlukan pengkajian dan
tindakan yang cepat
Kasus non urgen Hijau Dapat menunggu giliran
Adapted from WHO (2005)
Indonesian triage system?????
TRIAGE PRE HOSPITAL
------------------------

17 / 19
Category Criteria Color
1 Emergency or life-threatening condition Red
requiring emergent care
2 Less serious condition requiring Yellow
emergent care
3 Non emergency condition and can wait Green
for treatment
4 Dead Black
Ministry of Health The Republic of Indonesia (1999)
START Adult Triage
Able to walk ? Yes
MINOR Secondary Triage

No

No Spontaneous
Spontaneous
Position airway IMMEDIATE
breathing
breathing
APNEA

EXPECTANT
Triage Categories
Yes

EXPECTANT Black Triage Tag Color

> 30 • Victim unlikely to survive given severity of injuries,

Respiratory Rate IMMEDIATE level of available care, or both
• Palliative care and pain relief should be provided

IMMEDIATE Red Triage Tag Color

Radial pulse absent • Victim can be helped by immediate intervention and

Perfusion IMMEDIATE transport
Or capillary refill > 2 sec • Requires medical attention within minutes for survival
(up to 60)
Radial pulse Or capillary • Includes compromises to patient’s Airway, Breathing,
present refill < 2 sec Circulation.
Doesn’t obey DELAYED Yellow Triage Tag Color
Mental commands
IMMEDIATE
Status • Victim’s transport can be delayed
• Includes serious and potentially life-threatening
injuries, but status not expected to deteriorate
Obeys commands significantly over several hours.

DELAYED MINOR Green Triage Tag Color

• Victim with relatively minor injuries

• Status unlikely to deteriorate over days
• May be able to assist in own care : “Walking
Wounded”
19 / 19
JumpSTART Pediatric Multiple Casualty Incident
Triage
Able to walk ? Yes
MINOR Secondary Triage

No

No
Spontaneous breathing Spontaneous
Position airway IMMEDIATE
breathing
APNEA

Palpable pulse? No
EXPECTANT

APNEA
Yes 5 rescue breaths EXPECTANT

Spontaneous breathing
Triage Categories
IMMEDIATE
EXPECTANT Black Triage Tag Color
• Victim unlikely to survive given severity of injuries, level of
available care, or both
• Palliative care and pain relief should be provided
< 15 or > 45
Respiratory Rate IMMEDIATE
IMMEDIATE Red Triage Tag Color
• Victim can be helped by immediate intervention and transport
• Requires medical attention within minutes for survival (up to 60)
• Includes compromises to patient’s Airway, Breathing, Circulation.
15 - 45

Palpable Pulse? No
IMMEDIATE DELAYED Yellow Triage Tag Color
• Victim’s transport can be delayed
• Includes serious and potentially life-threatening injuries, but status
not expected to deteriorate significantly over several hours.
Yes
MINOR Green Triage Tag Color
Inappropriate “P”
• Victim with relatively minor injuries
Neurological (e.g.,posturing) or “U” • Status unlikely to deteriorate over days
IMMEDIATE
Assessment • May be able to assist in own care : “Walking Wounded”
(AVPU)

“A” , “V” or Appropriate “P” Neurological Assessment

(e.g., withdrawal from painful stimulus) A P
Responds to Painful
Alert Stimuli
DELAYED Responds to Verbal Unresponsive to Noxious 20 / 19
V Stimuli U Stimuli
 THANK YOU
WASSALAMUALAIKU
M