MODERN TRIAGE IN EDs

By:
Ns. Nana Rochana, S.Kep, MN
 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?
TRIAGE

Pengkajian
cepat
NO
DIAGNOSIS
Prioritas sesuai
kegawatan
klinis
 Sejarah
1. Triage militer
Perang Napoleon (DJ Larrey), perang krimea
(Nikolai Pirogov) & WW I “Salvage triage”
2. Triage sipil (1950s)
Berfokus pada penyelamatan pasien gawat
dan pasien dengan kondisi kritis
3 periode utama: the early civilian period
(1950s-1960s), moral issues-related period
(1970s-1980s), and the lime-light period
(1990s -sekarang)
PERLUKAH MODERN
TRIAGE DI IGD ?
 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 KARS v 2012
Pelayanan pasien darurat  Triage berbasis
bukti

• Standar JCI
Access to Care and Continuity of Care 
Priority assessment and treatment for
emergent and urgent patients
 INTERNATIONAL LITERATURE
TRIAGE SYSTEM
3-level 5-level

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
 The CTAS
Level Kategori Waktu ke Warna
reassessmen
I Resusitasi Berkelanjutan Biru
II Emergen Setiap 15 menit Merah
III Urgen Setiap 30 menit Kuning
IV Kurang urgen Setiap 60 menit Hijau
V Non urgent Setiap 120 menit Putih
Adapted from CAEP (2004)
 The CTAS
Presenting complaints

First order modifiers (VS)

Hemodynamic Blood Level of Respiratory
Temperature
stability pressure consciousness distress

Pain severity
Central vs peripheral Acute vs chronic

Mechanism of injury
High risk Low risk

Other modifiers
Blood glucose level Obstetrical presentation
The ESI
The ESI
 The ATS
Kategori Waktu ke pengkajian dan tindakan Standar penampilan

1 Segera dan simultan 100%

2 Dalam waktu 10 menit, seringkali simultan 80%

3 Dimulai dalam waktu 30 menit 75%

4 Dimulai dalam waktu 60 menit 70%

5 Dimulai dalam waktu 120 menit 70%

Adapted from FitzGerald, et al (2010)

 The Clinical Descriptors of ATS
Category Airway Breathing Circulation Disability
1 Obstructed/ Severe respiratory Severe haemodynamic GCS < 9
partially distress/ absent compromise/ absent
obstructed respiration/ circulation/
hypoventilation uncontrolled
hamorrhage
2 Patent Moderate Moderate GCS 9 - 12
respiratory distress haemodynamic
compromise
3 Patent Mild respiratory Mild haemodynamic GCS > 12
distress compromise
4 Patent No respiratory No haemodynamic Normal GCS
distress compromise
5 Patent No respiratory No haemodynamic Normal GCS
distress compromise

Adapted from Department of Health and Aging (2007)

 The MTS
Level Nama Warna Waktu max

1 Segera Merah 0 menit

2 Sangat urgen Orange 10 menit

3 Urgen Kuning 60 menit

4 Standar Hijau 120 menit

5 Non-urgen Biru 240 menit

Adapted from Mackway-Jones, et al. (2006)
 General discriminators of MTS
• Airway compromise, absent/
Life threat inadequate breathing, shock
• Exsanguinating, uncontrollable major,
and uncontrollable minor
Haemorrhage haemorrhage
• Severe, moderate, and recent pain
Pain
• Currently fitting, altered, history of
Conscious level unconsciousness
• Cold and very hot adult, hot child, hot
Temperature adult, and warmth

• Recent problem
Acuteness
 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?????
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)
EVIDENCE BASED PRACTICE
PERLUKAH MODERN
TRIAGE DI IGD ?

IDEAL TRIAGE
SYSTEM
 THANK YOU
WASSALAMUALAIKUM