Professional Documents
Culture Documents
PowerPlugs: Templates
EMERGENCY
EMERGENCY is something that difficult to
predict (Unpredictable). Usually involve a
variety of situations that require to have
decision in a situation involving
multidisciplinary team members
Input
Patient arrives
to ED
Emergency Care
Seriously ill from the
community and
referral sources
Triage and
room placement
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net
Care
Vulnerable
populations
Access
barrier
Output
Throughput
Ambulance
diversions
Ambulatory
Care System
Left
without
being seen
Transfer to
outside
facility
Demand
for ED
care
Diagnostic
evaluation and
treatment
ED boarding of
inpatients
Patient
Disposition
Admit to
hospital
5 Rooms
5 Rooms
ED
Through
put:4
hours
ED
Through
put:3
hours
ED
Through
put:2
hours
ED
Capacity
: 30/day
ED
Capacity:
40/day
ED
Capacity:
60/day10
Triage and
room placement
1
Resus
Room
3
Treatment
room
Fast Track
Reception for
Regristration
Consult
Room
Definition
Triage system: The process by which a
clinician assesses a patients clinical
urgency
Triage: A triage system is the basic
structure in which all incoming patients are
categorized into groups using a standard
urgency rating scale or structure.
DEFINITIONS cont.
Re-triage: Clinical status is a dynamic state for all patients. If clinical
status changes in a way that will impact upon the triage category, or
if additional information becomes available that will influence
urgency, then re-triage must occur.
When a patient is re-triaged, the initial triage code and any
subsequent triage code must be documented. The reason for retriaging must also be documented.
Urgency: Urgency is determined according to the patients clinical
condition and is used to determine the speed of intervention that is
necessary to achieve an optimal outcome. Urgency is independent
of the severity or complexity of an illness or injury. For example,
patients may be triaged to a lower urgency rating because it is safe
for them to wait for an emergency assessment, even though they
may still eventually require a hospital admission for their condition or
have significant morbidity and attendant mortality
PURPOSE OF TRIAGE
To ensure that patients are treated in the order
of their clinical urgency.
To ensure that treatment is appropriate and
timely.
To allocate the patient to the most appropriate
assessment and treatment area.
To optimize the safety and the efficiency of
hospital-based emergency services
To ensure equity of access to health services
across the population.
Immediate
10 Minute
30 Minute
60 Minute
120 Minute
Level 2
Level 3
Level 4
Level 5
Airway
Obstructed/Partial
obstructed
Patent
Patent
Patent
Patent
Breathing
Severe respiratory
distress/Absent
respiratory/Hypove
ntilation
Moderate
respiratory
distress
Mild Respiratory
distress
No respiratory
distress
No respiratory
distress
Circulation
Severe
haemodynamic
compromise/absent
circulation/uncontrol
led hemorrhage
Moderate
haemodynamic
compromise
Mild Haedynamic
compromise
No Haedynamic
distress
No Haedynamic
distress
GCS <9
GCS 9-12
GCS > 12
Normal GCS
Normal GCS
4 (on a 0-10
scale)
No pain
Disability
Pain Scale
Example Case
ATS 1
Cardiac arrest
Respiratory arrest
Immediate risk to airway impending arrest
Respiratory rate <10/min
Extreme respiratory distress
BP< 80 (adult) or severely
shocked child/infant
Unresponsive or responds to
pain only (GCS < 9)
Ongoing/prolonged seizure
ATS 3
Severe hypertension
Moderately severe blood loss
Moderate shortness of breath
SpO2 90 - 95%
Post Seizure (now alert)
Any fever if immunosuppressed,
e.g. oncology patient, steroid Rx
Persistent vomiting
Dehydration
Head injury with short LOC - now
alert
Severe pain - any cause - requiring
analgesia
Chest pain likely non-cardiac and
moderate severity
ATS 2
ATS 4
Mild hemorrhage
Foreign body aspiration, no
respiratory distress
Chest injury without rib pain or
respiratory distress
Difficulty swallowing, no respiratory
distress
Minor head injury, no loss of
consciousness
Moderate pain, some risk features
Vomiting or diarrhea without
dehydration
Eye inflammation or foreign body normal vision
Minor limb trauma - sprained ankle,
possible fracture, uncomplicated
laceration requiring investigation or
intervention - Normal vital signs,
low/moderate pain
Swollen "hot" joint
Non-specific abdominal pain
ATS 5
Minimal pain with no high risk
features (1-2 on a 0-10 scale)
Low-risk history and now
asymptomatic
Minor symptoms of existing stable
illness
Minor symptoms of low-risk
conditions
Minor wounds - small abrasions,
minor lacerations (not requiring
sutures)
Follow up
Immunization only
Algorithm
Patient dying
yes
no
Shouldnt wait
yes
no
2
How many resources ?
None
one
many
abnormal
Vital signs
normal
PEDIATRIC TRIAGE
CLINICAL PARAMETERS
Hewsonet al, 1990 significant clinical features may predict serious
illness in children.
Decrease of oral intake (<1/2 the normal intake in the 24 hours)
Difficulty breathing / respiratory problems
Replacement diapers <4x for 24 hours
Decrease of activity
Look weak and sleepy
Looks pale and hot
High fever in children aged <3 months.
Sign
Mild
Moderate
Severe
Kondisi umum
thirsty,
Restlessness,
agitation
thirsty,
Restlessness,
irritability /
Offended
Withdraw,
somnolence /
drowsiness, coma,
rapid breathing
Pulse rate
Normal
Crown
Normal
Cekung
Sangat Cekung
eye
Normal
Cowong
Sangat cowong
Tear
yes
None
None
Dry
Dry
Skin turgor
Normal
Decrease
Decrease
Urine
Normal
Reduced,
concentrated
Nothing in a few
hours
Decrease of BW
4-5%
6-9 %
> 10 %
DISABILITY
Immediate assessment if any abnormalities of
consciousness
Decreased level of consciousness sign of
oxygenation / circulation disruption .
Decreased activity indicator of serious illness
in infants and children
AVPU scale is a method to assess the level of
consciousness of patients in triage.
Do not be underestimated complaints from the
parents.
PPD
Airway
Category 1
Immediate
Obstructed
Category 2
Emergency
Within 10 minutes
Patent
Category 3
Urgent
within 30 minutes
Patent
Category 4
Semi-urgent
Within 60 minutes
Category 5
Non-urgent
Within 120 minutes
Patent
Patent
Respiration present
Respiration present
Absent respiration or
hypoventilation
Respiration present
Respiration present
moderate use of
accessory muscles
moderate retraction
severe retraction
skin pale
acute cyanosis
no use of accessory
muscles
mild retraction
skin pink
Circulation
s/s dehydration *
Absent circulation
Severe bradycardia, e.g. HR
<60 in an infant
Circulation present
Circulation present
Circulation present
Circulation
s/s dehydration *
Moderate haemodynamic
Severe haemodynamic
compromise, e.g.
compromise, e.g.
Mild haemodynamic
compromise, e.g.
palpable peripheral
pulses
No haemodynamic
compromise, e.g.
palpable peripheral
pulses
No haemodynamic
compromise, e.g.
palpable peripheral
pulses
significant tachycardia
moderate tachycardia
mild tachycardia
Circulation
s/s dehydration *
Uncontrolled haemorrhage
Circulation present
no retraction
no retraction
No s/s dehydration
PPD
Disability
Category 1
Immediate
GCS <8
Category 2
Emergency
Within 10 minutes
Category 3
Urgent
within 30 minutes
GCS 9-12
GCS >13
Severe decrease in activity, Moderate decrease in
e.g.
activity, e.g.
lethargy
no eye contact
decreased musle
tone
patient/parents
report severe pain
alteration in vital
signs
requests analgesia
Severe neurovascular
compormise, e.g.
pulseless
cold
nil sensation
nil movement
capillary refill
Category 4
Semi-urgent
Within 60 minutes
Category 5
Non-urgent
Within 120
minutes
Normal GCS or no
acute change to usual
GCS
No alteration in activity,
e.g.
playing
interacts with
parents
patient/parents
Mild pain, e.g.
patient/parents
report moderate pain
report mild pain
alteration in vital
no alteration in vital
signs
signs
requests analgesia
requests analgesia
Moderate neurovascular
Mild neurovascular
compormise, e.g.
pulse present
compormise, e.g.
pulse present
cool
normal/ sensation
sensation
normal/ movement
movement
normal capillary
capillary refill
refill
smiling
patient/parents
report mild pain
no alteration in
vital signs
declines
analgesia
No neurovascular
compormise
MENTAL HEALTH
TRIAGE
Mental Health In ED
Aggression, self
harm ,
substance
abuse
Cognitive
dysfunction,
physical disability
Emergency
Department
Symptomatic
problems:
Hallucination, delusion
Social problems: job,
relationship, financial
A = Appearance
Wajah pasien
Pakaian yg digunakan
TubuhGizi (malnutrisi ??, dehidrasi? )
Nampak ada bekas cidera?
Pasien nampak intoxicated ?
Nampak tegang? Lemas, gelisah
Mood
Bagaimana gambaran mood pasien??
Sedih, depresi
Marah dan sensitive
Cemas, ketakutan
Gembira
Tidak bisa berhenti menangis
Apakah pasien mengatakan mau mati,
bunuh diri
Description
Presentation
(Observed)
Presentation
(Reported)
1-immidiate
2-emergency
10 min
Probablerisk of danger to
self , other
Pt. physically restrain
Extreme agitation/restlesness
Physically/verballyagresive
Confused/unable to cooperate
Hallucinations/delusions/paranoia
Requires restrain
High risk to escape
3 urgent
30 minutes
agitation/restlesness
Intrusive bbehaviour,confuse,
ambivalence, not likely to wait
Suicidal ideation
Situational crisis
4-semi urgent
60 minutes
No agitation/restlessness
Irritable without aggression
Cooperative
Give coherent history
Preexstingmental health
Symptoms of anxiety or
depression without suicidal
ideation
Willing to wait
5 non urgent
Within 120 min
Cooperative,communicativeand able to
engage in developing mngtplan
Able to discuss concerns, compliant with
instructions
TRIAGE IN PREGNANCY
Key Word
1. Semuawanitausiasuburharusdianggaphamilsampaiterb
uktisebaliknya.
2. Penilaianyang
urgensiharusdilakukanbaikpadaibudanjanin
3. Peningkatantekanandarahmerupakantandaperburukand
anmemerlukanpenanganansegera.
4. Wanitahamilmempunyairisikoperdarahanotak,trombosis
otak,radangparuberat,aritmiaatrium,trombosisvena
danembolus.
5. Presentasimungkintermasukkekhawatirantentangperke
mbangankehamilan.
AIRWAY
Potensi Gangguan jalan nafas
Wanita hamil sulit diintubasi;
Ukuran pasien ,posisi pasien, kebutuhan obat induksi berbeda karena
perubahan fisiologis kardiovaskuler.
BREATHING
Progesteron dianggap bertanggung jawab dalam mempengaruhi kepekaan
pusat pernafasan
Wanita hamil umumnya mengalami peningkatan vaskularisasi hidung dan
jalan nafas dan edema mukosa. Ini menyajikan sebagai peningkatan
keluhan tentang hidung tersumbat.
CIRCULATION
Kehamilan digambarkan sebagai kondisi
hiperdinamik dan perubahan fisiologis
terjadi pada awal kehamilan 6-8 minggu.
Progesteron menyebabkan vasodilatasi l
dan estrogen berkontribusi pada 40-50
persen peningkatan volume darah.
Wanita Hamil sering datang keUGD dengan keluhan pendarahan vagina. Penyebab
umum termasuk berbagai jenis keguguran (yaitu terancam, tak terelakkan, lengkap,
tidak lengkap dan septik).
Pengetahuan tentang volume dan perdarahan warna per vagina (PV) akan
membantu perawatTriage menentukan kategori urgensi kasus.
Kehilangan darah merah terang biasanya menunjukkan perdarahan aktif, sedangkan
kehilangan darah merah kecoklatan biasanya terjadi sudah lama.
Nyeri Bahu dapat menjadi indikasi perdarahan kehamilan ektopik.
Diagnosis pertama dan utama untuk wanita dengan usia subur, yang datang dengan
keluhan perdarahan pervagina setelah prosedur sterilisasi, adalah suatu kehamilan
ektopik dan Penuaan
Nyeri abdomen merupakan gejala yang paling umum dari pecahnya kehamilan
ektopik.Kehamilan ektopik yang tidak pecah umumnya hadir dengan pendarahan
(pada umumnya berwarna coklat).
PROCEDURE
All assessments, interventions and its results as well as the ATS category
need to be documented by the triage nurse on the Triage Form.
On arrival assess the patient. Balance the need for speed against the need to
be thorough.
Before the patient has registered with admin
Introduce yourself to the patient and your role as triage nurse, e.g.
Good morning Mr/Mrs/Miss patients name or Sir/Mam/Miss if
unknown name. I am (your name) and I am the triage nurse this
morning
Ask the patient for their complaint. If pt already have registered him/herself in admin then read at the form/file first what his/her complain
may be but do also ask them directly. (May only be applicable to Kuta
staff)
Be discrete and try to talk privately to the patient. e.g. Excuse me,
may I know what is your complaint / why you seek health care / why
you like to see a doctor today? (You may need to explain that you
need this information in order to make sure the priority of the patients
who has to see a doctor first.)
PROCEDURE
cont
On arrival assess the patient. Balance the need for speed against the
need to be thorough. - cont
Before/After the patient has registered at the admin - cont
Actively ask for any pain or other discomfort. If yes, Location?
Number on a 0-10 scale? e.g. Do you feel any pain right
now?
Continue with any follow up questions that may be needed to
clarify the patients ATS category. See ATS categories what to
look for.
Simultaneously, Look at the patient to get an impression of
his/her general status, e.g. cannot stand/walk, shortness of
breath, pale, in pain or distress etc.
PROCEDURE cont
Measure vital signs at triage if required to estimate urgency, and if
time permits, otherwise have a nurse to perform it before patient
sees a doctor.
The triage nurse may do this by him-/herself or delegate it to another nurse
who must report the result back to the triage nurse ASAP.
PROCEDURE
Document details of the triage assessment on the Triage Form.
Include at least the following details:
Name and DOB of the Patient
Date and time of assessment
Name of triage nurse
Chief presenting problem(s)
Limited, relevant history
Relevant assessment findings
Initial triage category allocated
Any diagnostic, first aid or treatment measures initiated.
Ensure continuous reassessment of patients who remain waiting. Retriage a patient if:
His/her condition changes while they are waiting for treatment
Additional relevant information becomes available that impacts on
the patient's urgency
1)Pt present for triage: safety hazard are considered above all
2) Assess: chief complaint, general
appearance, A, B, C, D,E, limited
history, co-morbidities
yes
2) Quick evaluation: is
pt stable
no
5) Assign an appropriate ATS
category in response
to clinical assessment data
A = Alert
V = Responds to voice
P = Responds to pain
Purposefully
Non-purposefully
Withdrawal/flexor response
Extensor response
U = Unresponsive
Triage Decision
'Under-triage' di mana pasien menerima kode triage yang lebih rendah dari tingkat mereka yang
sebenarnya (sebagaimana ditentukan oleh indikator klinis dan fisiologis ). Keputusan ini memiliki
potensi untuk menghasilkan waktu tunggu yang berkepanjangan terhadap intervensi medis dan
risiko hasil yang buruk.
Kode triage benar (atau diharapkan) sesuai keputusan triage (Correct (or expected) triage
decision ' di mana pasien menerima kode triage yang sesuai dengan tingkat urgensi pasien
(sebagaimana ditentukan oleh indikator klinis dan fisiologis ). Keputusan ini mengoptimalkan
waktu untuk intervensi medis pasien dan mengurangi risiko hasil yang merugikan.
Over triage, di mana pasien menerima kode triage yang lebih tinggi dari tingkat
urgensi sebenarnya mereka. Keputusan ini memiliki potensi untuk menghasilkan waktu
tunggu yang singkat untuk memperoleh intervensi medis, akan tetapi, akan berdampak buruk
bagi pasien lain yang menunggu di IGD karena mereka harus menunggu lebih lama.