"MED"

MODERN EMERGENCY DEPARTMENT

dr. ISKAK GENERAL HOSPITAL TULUNGAGUNG

A. PERSONAL DETAIL
Your name
Dr. Drs. Muhammad Imanuddin, SH, M.Si

Your organisation
Ministry for administrative and bereaucratic reform Republic of Indonesia

Your email address

muhammad.imanuddin@menpan.go.id

Your telephone number

+62 8161494726

Are you currently a public employee involved with the innovation you are
submitting?
No

Do you know the name and/or contact information for a public official invoved
with the innovation?
Yes

Their name
Dr. Bobi Prabowo, Sp.EM

Their organisation
dr. Iskak Tulungagung General Hospital

Their e-mail address

bprabowo28@gmail.com

Their telephone number

+62 8123569223

B. ORGANISATION DETAILS
Country
Indonesia

Level of government
Central
 What is your organisations primary sector/field of activiity?
Please select all that apply
Public administration modernisation and reform

Size of organisation undertaking the innovation

Between 250 and 499

C. DESCRIBING THE INNOVATION

Name of Innovation

"MED" is a Modern Emergency Department

Innovation Website
www.rsudtulungagung.com

Other URL related to the innovation

Video : https://www.youtube.com/watch?v=UKkEmJNY61M&t=17s
Foto
Tulisan Artikel koran

Your innovation launched

2014

1. Short elevator pitch of the innovation

An elevator pitch is a succinct and persuasive sales pitch used to quickly and simply
define something (maximum character: 400)

MED is a modern emergency department. MED divides treatment zone

according to emergency level of patient to shortening the emergency response time
from 11 to 0 minutes. This system has decreased the less than 24 hours mortality rate
from 12.2 to 2.2 . In addition, Tulungagung Emergency Medical Services (TEMS)
provides pre-hospital services and integrate it with non-medical care.

2. Executive summary of the innovation

In your summary, please include on why the innovation was developed, as well as its
objectives and beneficiaries. (character minimum: 2.000 character; character
maximum: 5.000 character)

In Indonesia hospital, the incidence of patients died less than 24 hours after
admission is still high. In 2013 the figure reaches 14.15 (per mile). While at
Emergency Department (ED) of General Hospital dr. Iskak Tulungagung, the figure is
12.2 (per mile). The above situation is worse than National Minimum Service
Standard which is 2 (per mile).

High mortality rate in ED dr. Iskak Tulungagung General Hospital is due to use a
conventional system that causes inaccurate in the sorting of patients in regards to their
critical situation. This condition causes the emergency response time reached 11
minutes that exceeds minimum national service standard (5 minutes).

The high mortality rate is also caused by the lack of pre-hospital services for
emergency patients. In addition, ED dr. Iskak Tulungagung General Hospital does not
yet have an medical emergency facility that meet the adequate standards. This condition
is exacerbated by first aid in the field that does not meet emergency response standards.

MED (Modern Emergency Department) is a system that prioritizes the accuracy and
speed in handling cases of emergency patients. Through the application of this system,
patients will get prompt, appropriate and safe assistance according to the critical level
by using the zone.
Strategy of successful implementation of MED is through pre-hospital service
and zoning. Patients are grouped according to the emergency level so that handling is
more focused and faster. Accuracy and speed in the handling of emergency patients in
the hospital is one of the decisive factors in the recovery of patients, also to avoid
disability and even death.
With MED then the priority of service is not based on arrival order, but is
based on the level of emergency. In this system, patient sorting has been done since the
patient arrives in the ED drop zone (primary triage) using visual examination by senior
nurse. Patients with emergency conditions requiring basic life support are directly
included in the critical zone (red zone). At critical zones the response time is 0 (zero)
minutes and is handled by emergency specialist doctors and nurses who have
certificates of emergency handling capability.
For non-critical patients, MED does the sorting on the secondary triage.
Patients get examinations by doctors and nurses using equipment. If the patient is
critical then it will be inserted into the critical zone (red zone), if semi-critical will be
inserted into the semi-critical space (yellow zone) with a response time of 15 minutes.
Non-emergency patients will be entered into the green zone with response
time 30 minutes. The patients in the green zone area are treated just like outpatient care.
Patient gets examination and treatment.
Furthermore, to accelerate the handling of emergency patients, in 2014 dr.
Iskak Tulungagung General Hospital developed the MED program with the addition of
TEMS (Tulungagung Emergency Medical Services) program. TEMS is a pre-hospital
service that has been integrated with MED. TEMS equipped with competent pre-
hospital care facilities and team in emergency first aid. With these strategy, MED
manages to reduce the mortality rate of emergency patients.

Instagram benefits:
For the Community:
a. Get a faster, easier and safer emergency service according to the critical level.
b. Obtain certainty and follow up on emergency services.
c. Easier to get health care information from patient's home using call center.
d. Can be guided for first aid before pre-hospital care team (PHC) comes.
e. Obtain education and training in emergency assistance for the general public.
f. The decline in less than 24 hours mortality rate
For Officers:
a. Easy to provide services because the zone has been determined based on the level
of emergency.
 b. The officers give the service in accordance with their knowledge and skills since
patients are grouped in each room based on emergency level.
c. The medical officer may know the medical history of the patient before the
patient arrives at the hospital so that they can prepare for the place, advice or
officer before the patient arrives.
d. Officers can provide services from the location, in the ambulance to the hospital,
so that the golden period of patients can be achieved.
For Policy (Hospital management, Local Legislature (DPRD : Dewan Perwakilan
Rakyat Daerah)) :
a. Planning for the development and maintenance and operation of medical and non
medical equipment is easier because this system is more focused and clearer in its
use.
b. Providing wider emergency services to the public.
c. There is availability of complete and regular data that make management easier
and more accurate in policy making and decision process.
d. There is planning stages of health development in Tulungagung District
e. Increased patient visit.

3. How is the innovation different, unique, or more innovative than the status-quo or
whats been tried previously?

If you were inspired by another innovation, please also describe it and how your
innovation is different. (maximum characters: 2.500)

MED is better than conventional emergency service system. Because

Instagram applies System Patient Acuity Category Modification by embracing modern
emergency department. Instagram provides emergency service from pre-hospital on the
spot and continued in the ambulance to the hospital. MED divides the zone according to
the patient's emergency level, ie:
1. Primary triage system
Triage officers perform visual screening without using tools. The examination is
performed by trained nurses who can see the condition of the patient just by
looking at the expression and the state of glance from the patient's condition
(eagle eye). Based on screening it is recommended whether the patient goes
directly to the critical (red zone) or secondary triage area.
2. Triage secondary system
Patients entering secondary triage are examined by the physician to determine the
emergency level based on service/ relief zone needed by the patient, ie green
zone, yellow zone, and red zone.
3. Green zone system
Green zone is an outpatient room in the Emergency Departement.
4. Yellow zone system
Yellow zone is a semi-critical area that is used for patients who need to observe a
maximum of 6 hours or patients who will be hospitalized.
5. Red zone system
Red zone is a critical area, the highest priority requiring immediate intervention
to save lives with a response time of 0 minutes. The emergency services are done
 quick and accurate, led by Emergency specialist doctors and experienced nursing
team and certified emergency officers.
6. Tulungagung Emergency Medical Services (TEMS)
TEMS is a part of MED that provides emergency services since pre-hospital.
TEMS has been integrated with non-medical emergency services (Police, Local
Agency for Disaster Management, Fire Brigade, and disaster-affected social
institutions.

4. Innovation tags
Please select all tags that describe your innovation. We encourage you tp add
additional tags through the additional tags box

Emergency Management

D. DEVELOPING THE INNOVATION

5. Which stage is your innovation currently in?
Diffussing lessons

6. Please describe the status of your innovation today and how is has gotten to this
point in the innovation lifecycle

For example, how the idea for the innovative solution came from, how a course of
action was determined, methods and tools used to implement the project and evaluate
success and failure, and how the innovation is being spread to others. (maximum
characters: 5.000)

To solve the problem of emergency services as mentioned above, dr. Iskak

Tulungagung General Hospital took the initiative to redesign to be MED. MED
prioritizes accuracy, speed and safety in handling cases of emergency patients starting
from pre-hospital care.

Patients have been treated since the incident and are grouped according to the
emergency level so that handling is more focused and faster. Accuracy and speed in
the handling of emergency patients in the hospital is one of the decisive factors in the
recovery of patients, also to avoid disability and even death. Furthermore, to
accelerate the handling of emergency patients, in 2014 dr. Iskak Tulungagung General
Hospital developed the MED program with the addition of TEMS program. Then
based on the idea of Tulungagung Regent, TEMS has developed collaboration with
Police, Local Agency for Disaster Management (BPBD : Badan Penanggulangan
Bencana Daerah), Army Force and Health Department.
Implementation of emergency service by using Patient Acuity Category Modification
system by adopting modern emergency department is done gradually as follows:
 a. 2011 to conduct a comparative study of Emergency Department dr. Iskak
Tulungagung General Hospital service system with Patient Acuity Category
system to Hospital Kualalumpur Malaysia.
b. 2011 to plan restructuring of spatial concept of ED dr. Iskak Tulungagung
General Hospital and prepare budget.
c. 2012 to establish the building ED dr. Iskak Tulungagung General Hospital with
spatial arrangement embrace the system Patient Acuity Category Modification by
embracing modern emergency department.
d. 2013, Emergency Department dr. Iskak Tulungagung General Hospital operates
with Patient Acuity Category Modification system by adopting modern
emergency department. During ED operation, many sophisticated infrastructure
facilities are provided. Human resources experts in emergencies, Emergency
specialists and nurses specializing in emergency medicine are recruited. These are
all to ensure speed in service.
e. 2014 plans to develop integrated pre-hospital services TEMS with relevant
agencies such as police, Local Agency for Disaster Management (BPBD) and
basic health services.
f. 2015 Realization of pre-hospital service development with Tulungagung
Emergency Medical Services system integrated with police, Regional Disaster
Management Agency, Puskesmas as Pre-Hospital Care (PHC).
g. 2016 MED services are enhanced with acute coronary syndrome services and
integrated heart services.
TEMS Networking Flow

A medical emergency or non-medical emergency occurred in community

Community calls phone number +62 355-320119 or dials emergency keypad
Call taker received the information and asked the location of the incident, the type of
incident, the number of victims
Dispatcher find the PHC team closest to the location with GPS, assign PHC to go to
the location and send address and patient data using tablets and radio
communications. If the incident is related to the police or disaster then the data will
be sent to command center Tulungagung Police or Local Agency for Disaster
Management (BPBD)
PHC team arrives in locaton with GPS guidance, provide emergency assistance by
reporting the patient condition to Dispatcher in the form of data, photo and video call
PHC team transports patient to hospital with ambulance, carry out stabilization
inside ambulance, keep update patient data to Dispatcher, prepare officer at hospital
to accept patient referred by PHC team
The Emergency Department officer is ready to accept patients along with the sent
data. The officer speciality is inline with patients situation.

MED establishes a number of progress and evaluation monitoring procedures that

include:
a. Daily, monthly and annual service reports on emergency services.
 b. Public complaints made through complaint number +62355-322609, SMS center with
number +62822323011111, e-mail, suggestion box, complaint directly to the
complaint officer and also through mass media.
c. Make a morning report twice a week to discuss cases that are handled by involving
experts from each of the disciplines related to emergency services.
d. Public Relations Coordination Meeting of the public safety center (PSC) held every
month to discuss problems in the implementation of TEMS.
e. Monitor equipment regularly once a month as a key supporter (ambulance,
GPS, telephone, medical care in ambulances) to ensure the device is functioning
properly.
f. Evaluate the outcome of Minimum Standard Service

To ensure the sustainability of Instagram, Tulungagung Regency Government has

been stipulated Regulation No. 29 of 2015 regarding Integrated Emergency
Management System in Tulungagung Regency. MED program in Dr. Iskak
Tulungagung general hospital has been used as a comparative study of hospitals
throughout Indonesia.

7. To the extent information is avallable, what resources were used?

For example: staff, budget, etc. (maximum characters: 1.000)

Resources used in the implementation of MED innovation include:

1. Financial resources:
a. Credit from Bank Jatim in 2012 worth Rp 13 billion is used for building ED dr.
Iskak Tulungagung General Hospital.
b. State budget (APBN : Anggaran Pendapatan Belanja Negara) 2013 worth Rp 9
billion used for the purchase of medical equipment.
c. Regional Government Budget (APBD : Anggaran Pendapatan Belanja Daerah) of
Tulungagung Regency in 2014 valued at Rp 3.5 billion used for hardware purchase
of the development of ED dr. Iskak Tulungagung General Hospital with TEMS
system.
d. Budget Local community service agency (BLUD : Badan Layanan Umum Daerah)
dr. Iskak Tulungagung General Hospital 2015 worth Rp 900 million used for the
manufacture of software TEMS and ED.

2. Human resources:
a. Emergency specialist doctor, as leader
b. Trained nurses
c. A trained ambulance driver
d. Police officers and staff, Local Agency for Disaster Management (BPBD), Army
force and staff, and primary healty center as network.

E. RESULTS & IMPACT

 8. What results and mission impacts have been observed from the innovation so far?
What results and impacts are exepected?

(maximum characters: 2.000)

The integration of medical emergency services and non medical health has a
positive impact on emergency services in Tulungagung district, among others:
1. Reduced patient death rate of less than 24 hours after admission from 12.2 to
2.2 .
2. Decrease of Dead on Arrival (DOA) accident cause from 12 cases to 6 cases.
3. Reduced number of public complaints against emergency services and ambulance
services.
4. Decrease morbidity of heart disease from 676 cases to 271 cases.
5. Reduced mortality from heart disease from 68 patients to 32 patients.
6. Creation of a safe community for the community of Tulungagung regency.

F. COLLABORATION AND PARTNERSHIPS

9. Please describe the collaboration and partnerships and how it affected the
innovation.

What did each bring to the table and why was it important? (maximum characters:
1.000)

The Tulungagung Regent's decree on the integrated emergency response team was
issued. The team consists of related elements including:
a. Regent Tulungagung as a primary responsible person of the implementation of
Instagram.
b. Dr. Iskak Tulungagung General Hospital as implementer of MED Innovation
program to provide service of pre-hospital emergency, intra hospital and inter
hospital as well as call center controller.
c. The Regional Development Planning Board of Tulungagung Regency to plan,
study and prepare MED budget.
d. Regional Financial Management and Asset Office as budget provider in the
development and operation.
e. Tulungagung District Health Office and primary healt care as Pre-hospital
Team (PHC) in Public Safety Center (PSC).
f. Tulungagung District Police as an integral part of PSC service related to non-
medical emergency.
g. Regional Disaster Management Agency as an integral part of the PSC service
related to the occurrence of disaster or non-medical emergency.

10. Please describe how users, stakeholders, and partners were inovolved during the
innovation process and how this impacted the innovation.
 This may include citizens, government officials, civil society organisations, and
companies. (maximum characters: 1.000)

Parties who have been contributing to MED are:

a. Tulungagung Regent as the initiator of originating idea of ED dr. Iskak
Tulungagung General Hospital development.
b. Dr. Iskak Tulungagung General Hospital that adopts and develop modern
emergency department, including doctors, nurses and all employees.
c. Bank Jatim as a lender in building modern ED dr. Iskak Tulungagung General
Hospital.
d. The Regional Development Planning Board of Tulungagung Regency as the
agency of ED dr. Iskak Tulungagung General Hospital and TEMS development.
e. The Regional Financial Management and Asset Office as a budget provider in the
development and operation of TEMS services.
f. Health Office of Tulungagung and primary healt care as an integral part of pre-
hospital service (PHC) in PSC.
g. Tulungagung District Police as an integral part of PSC service relating to Police or
non-medical emergency.
h. Regional Disaster Management Agency as an integral part of PSC.

G. PROJECT REFLECTIONS

11. What challenger have been encountered? And how, if at all, have those challenges
have been responded to?
(maximum characters: 1.000)

Some obstacles faced during MED implementation in dr. Iskak Tulungagung, among
others:
a. The hight visit of patiens makes inadequate capacity, particularly in the yellow
zone. To overcome this, management added more bed and made a virtual space
(transit space).
b. Tulungagung Emergency Medical Services program with call center +62355
320119 is still not known to everyone over the Regency. Therefore, education,
socialization and promotion through promotion and mass media (printed and online
media) are encouraged to community to use the call center in case health problems
occured.
c. Coordination with PSC and cross-sectoral networks is still not optimal because it is
still relatively a new program.
d. Telecommunication network in Indonesia can not show caller position, so call
center officer must ask caller position and look for MAPS application in call center.

12. What lessons from your experience would you like to share with other?

Please include what worked well and what may have worked less well. (maximum
charaters: 1.000)

MED decreases the less than 24 hours patient death rates. It is possible to
make it lower. The morbidity and mortality rate of heart attack also decreased.The dead
 on arrival (DOA) cases can be lowered. MED that equipped with pre-hospital service
can accelerate the emergency response time in handling both medical and non-medical.
So that people feels safe against the emergence handling.
Pre-hospital services that integrated with Emergency Department are needed
by all regions in order to create a safe community. In both medical and non-medical
emergency situations State must be present to provide services to community.

13. What conditions do you think arenecessary for the success of an innovation such
as this?

For example: supporting infrastructure and services, policy and rules, leadership and
financial resources, and personal values and motivation. (maximum characters: 1.000)

The successful of MED comprises several supportive factors which are:

a. The commitment of the Regional Head
Achievement on cheap and high quality health services required a high commitment
from the head of the region both in the form of policy (Decree of Tulungagung
Regent No. 29 of 2015) and budget support.
b. Assembly at regional support in Regional Government Budget.
c. The importance of cross-sectoral partnerships.
Partnership with Police, Local Agency for Disaster Management, Health Office and
staff are needed for synergy and coordination in the handling of emergency medical,
non-medical and natural disasters.

14. In your opinion, what is the potential for the innovation to be replicated to address
similar or common problems in government?

(maximum characters: 1.000)

This could include replicability of the problem (i.e., widespread public challenges), as
well as replicability of the solution (i.e., the ease at which the solution can be adopted
by others)

To ensure the sustainability of MED and TEMS, The Regent has stipulated a
Regulation No. 29 of 2015 on Integrated Emergency Management System in
Tulungagung Regency. In addition, several steps have been taken as follows:

1. Development of emergency services with Patient Acuity Category System

Modification by adopting modern emergency department and development of pre-
hospital care (PHC)
2. The development of pre-hospital service system (TEMS) that inserted to the
development of ED dr. Iskak Tulungagung General Hospital service with MED.
This program integrated call center service among hospital, service primary healt
 care, police, and disaster management agencies. People that need emergency help
can directly dial call center +62355-320119.

Replication

Emergency Department dr. Iskak Tulungagung General Hospital with Patient Acuity
Category Modification system by adopting modern emergency department is widely
used as comparative study of hospitals all over Indonesia.

15. Is there any other information that you would like to share about the innovation?
(maximum characters: 1.000)

The Instagram innovation program that deals with problems in medical emergency and
non medical emergency has been awarded several times for its achievements such as:
1. Award from Ministry of Administrative Reform and Bureaucracy Reform as TOP
35 innovation of public service in Indonesia.
2. Award from the Ministry of Health.
3. Award from the Ministry of Interior.
4. The first winner of Indonesia Health Care Forum Innovation Award I 2017.

H. QUESTIONNAIRE FEEDBACK & MISCELLANEOUS

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