Triage

Triase • Kata Triase (Triage) berasal dari Bahasa

Prancis:

Trier : memilah
• Proses pemilahan pasien secara cepat
saat tiba di rumah sakit.
• Selama masa pandemi, perlu memilah
pasien yang terduga Covid-19
• Triase Covid-19 tidak menggantikan
proses triase yang telah dijalankan
Sumber:
selama ini.
Standard Operating Procedure (SOP) for Triage of Suspected COVID-19 Patients in non-US Healthcare Settings: Early
Identification and Prevention of Transmission during Triage. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-
settings/sop-triage-prevent-transmission.html
• Kegawatdaruratan Non Pandemi
• Isolasi / non-isolasi
Pandemi • Kegawatdaruratan
• Isolasi / non-isolasi
• Kewaspadaan

Triase
Proses Triase
• Pisahkan jalan masuk pasien gejala ISPA
• Pertahankan jarak >1 meter
• Berikan masker pada pasien
• Gunakan pertanyaan sederhana
berdasarkan definisi kasus WHO/Kemkes
• Tempatkan pasien terduga/ terkonfirmasi
Covid-19 pada single-person room
• Pasien terduga dan pasien terkonfirmasi
tidak boleh digabung.
Sumber: CDC (2020); Dadashzadeh, A, et al (2020); WHO (May 2020);
Burhan et al (2020)
 r.iiTiilCenters for Disease Control and Prevention
~ CDC 24/7: Saving Lives. Protecting People™

Coronavrius Disease 2019 (COVID-19)

StandardOperatingProcedure(SOP) for Triage of Triase dibedakan

SuspectedCOVID-19 Patients in non-US Healthcare menjadi dua jenis, yaitu:
Settings: Early Identification and Prevention of 1. Widespread
Transmission during Triage community
Updated May 28, 2020

transmission
Summary of Changes
2. No or limited
• Edits to clarify how healthcare workers can protect themselves during triage
• Update to triage algorithm to allow for fever (>38°() OR history of fever
community
transmission
This document is provided by CDC for use in non-US healthcare settings.

Sumber:
Standard Operating Procedure (SOP) for Triage of Suspected COVID-19 Patients in non-US Healthcare Settings: Early
Identification and Prevention of Transmission during Triage. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-
settings/sop-triage-prevent-transmission.html
 Triage of patients with suspected COVID-19 infection
(widespread community transmission)
Identify signs and symptoms of respiratory infection:
• Fever (>38°C) or history of fever* No Continue with usual
-And- triage, assessment and
• At least 1 sign or symptom of respiratory disease (e.g., care
cough or shortness of breath)
Yes Sumber:
Standard Operating Procedure (SOP) for
Place medical mask on patient Triage of Suspected COVID-19 Patients in non-
US Healthcare Settings: Early Identification and
Prevention of Transmission during Triage.
Yes
Separate from the rest of the patients:
• Place the patient in a single-person room with the door closed or in other designated area
• Ensure healthcare personnel (HCP) caring for the patient adhere to Standard, Contact, and Droplet Precautions
• Only essential HCP with designated roles should enter the room and wear appropriate personal protective
equipment
Inform
• Notify the hospital infection control program and other appropriate staff
*Elderly people may not develop fever, but new-onset of cough or worsening respiratory symptoms
Triage of patients with suspected COVID-19 infection (no or limited community transmission)
Identify signs and symptoms of respiratory infection:
• Fever (>38°C)* or history of fever No
-And- Continue with usual triage,
• At least 1 sign or symptom of respiratory disease (e.g., cough or assessment and care
shortness of breath)
Yes
Place medical mask on patient
Identify Travel and Direct Exposure History:
• Has the patient traveled or resided in another country where COVID- No
19 is spreading during the 14 days prior to symptom onset? Continue with usual triage,
- or - assessment and care
• Has the patient had contact** with an individual with confirmed
COVID-19 during the 14 days prior to symptom onset?
Yes
Separate from the rest of the patients:
• Place the patient in a single-person room with the door closed or in other designated area
• Ensure healthcare personnel (HCP) caring for the patient adhere to Standard, Contact, and Droplet Precautions
• Only essential HCP with designated roles should enter the room and wear appropriate personal protective
equipment
Inform: Notify the hospital infection control program and other appropriate staff
Triase IGD Normal
PEMERIKSAAN RESUSITASI MERAH KUNING HIJAU
0 menit 5 menit 30 menit 60 menit
JALAN NAPAS o Sumbatan o Bebas o Bebas o Bebas
o Ancaman
PERNAPASAN o Henti napas o Takipnea o Normal o Frek. napas
o Bradipnea o Mengi o Mengi normal
o Sianosis
SIRKULASI o Henti jantung o Nadi lemah o Nadi kuat o Nadi kuat
o Nadi tidak o Bradikardia o Akral hangat o Akral hangat
teraba o Takikardia o Takikardia o Frek. nadi
o Akral dingin o Pucat o CRT <2 detik normal
o Akral dingin o CRT <2 detik
o CRT >2 detik
o Nyeri dada
KESADARAN o GCS <9 o GCS 9 - 12 o GCS >12 o GCS normal
o Kejang o Gelisah o Apatis o Kompos mentis
o Tidak respon o Hemiparesis o Somnolen
Adult physiological predictors for the ATS
Dimodifikasi dari: Australian Government (2009). Emergency Triage Education Kit
Tantangan Triase Pada Pandemi Covid-19
• Proses secepat & setepat mungkin Rate of Symptoms Seen with COVID-19 Cases.

Symptom Rate
• Minimalkan undertriage dan overtriage
Fever 82.2 %
• Jumlah pasien asimptomatik dan gejala Cough
Fatigue
61.7 %
44.0 %
non-ISPA yang berkunjung ke IGD Dyspnea 41.0 %
Anorexia 40.0 %
semakin meningkat Productive Sputum 27.7 %
Myalgia 22.7 %
• Tingkatkan kewaspadaan (terutama Sore Throat 15.1 %
optimalkan pre-triase dan kepatuhan APD) Nausea 9.4 %
Dizziness 9.4 %
• Tugaskan perawat yang qualified Diarrhea 8.4 %
Headache 6.7%
• Kategori triase harus didasarkan pada Vomiting
Abdominal Pain
3.6%
2.2 %
kriteria yang jelas
Sumber: Siordia (2020)
• Hindari ‘personel burden’
 Tantangan Triase Pada Pandemi Covid-19 (Lanjutan)

• COVID-19-free ward”
• Pisahkan alur pasien terduga/terkonfirmasi Covid-19
• Dedikasikan area/gedung tertentu untuk skrining Covid-19 dan
poliklinik untuk pasien Covid-19 yang asimptomatik atau gejala
ringan yang terpisah dengan gedung RS
Keputusan Skirining Covid-19

Melanjutkan ke pelayanan yang

Hijau diharapkan di Gedung RS

Melanjutkan ke pelayanan poli di

Kuning area khusus di luar Gedung RS

Ruang tunggu Skrining Merah IGD Isolasi

Early Warning
Score System
Covid-19
EWS Pada Covid-19 (Lanjutan)

Distribusi Usia Pasien

COVID-19 pada Kelompok
Ringan dan Kelompok Berat

Sumber:
Yang, P., Wang, P., Song, Y., Zhang, A., Yuan, G., & Cui, Y.
(2020). A retrospective study on the epidemiological
characteristics and establishment of early warning system of
severe COVID-19 patients. Journal of Medica
Virology, doi:http://dx.doi.org/10.1002/jmv.26022.
EWS Pada Covid-19 (Lanjutan)

• EWS berbasis
parameter fisiologis
dapat membantu
deteksi dini perburukan
pasien Covid-19.
• Modifikasi EWS dengan
penambahan parameter
usia (>65 tahun).

Sumber:
Liao, X., Wang, B. & Kang, Y. Novel coronavirus infection during the 2019–2020 epidemic: preparing intensive care units—the experience in
Sichuan Province, China. Intensive Care Med 46, 357–360 (2020). https://doi.org/10.1007/s00134-020-05954-2
Kasus
Seorang laki-laki berusia 72 tahun dirawat di
ruang isolasi IGD dengan keluhan napas
terasa berat. Demam, mialgia, sakit kepala,
dan diare disangkal. Hasil pengkajian: RR 14
x/menit, SpO2 97% dengan terpasang
oksigen NRM 15 L/menit, HR 80 x/menit,
TD 118/77 mmHg, suhu 36,8 C. SpO2 saat
datang di IGD 88%.
Hasil pemeriksaan lab: GDS 170 mg/dL, kreatinin 4.06 mg/dL, limfosit 10.5%
(normal 20-40%). Hasil rontgen: opasitas perihilar bilateral. Pasien masuk ICU
sekitar 12 jam sejak tiba di IGD karena kondisinya terus memburuk dan dua hari
kemudian diketahui hasil pemeriksaan swab SARS-Cov-2 positif.
 Kasus (Lanjutan)

Parameter Hasil Skor • Kategori Orange (Sedang)

Usia 72 3
• Monitor tiap 1-2 jam
Frekuensi napas 14 0
Saturasi oksigen 97 0
• Perawat memberitahukan dokter
Suplementasi oksigen Ya 2
untuk melakukan evaluasi ulang
TDS 118 0 • Pertahankan terapi, atau
Frekuensi jantung 80 0 sesuaikan rencana terapi, atau
Kesadaran Alert 0 konsutasi Tim Reaksi Cepat
Suhu 38,8 1
Total 6
Emergency
Management
Covid-19
Emergency Management

Sumbatan jalan napas, Airway

A Wheezing, Stridor Management

Takipnea, sianosis,
B ronkhi, SpO2 <90%
Oxygen Therapy

Takikardia, hipotensi,
Shock
C Nadi lemah, CRT>2 detik,
Prevention
Akral dingin, Pucat
Airway Management
• Monitor pola napas (frekuensi, kedalaman, usaha napas)
• Monitor sekret (jumlah, warna, bau, konsistensi)
• Monitor kemampuan batuk efektif
• Berikan minum hangat untuk memberikan efek ekspektorasi pada jalan napas
• Lakukan penghisapan lendir kurang dari 15 detik, jika perlu
• Anjurkan asupan cairan 2000 ml/hari jika tidak kontraindikasi, untuk
meningkatkan aktivitas silia mengeluarkan sekret dan kondisi dehidrasi dapat
meningkatkan viskositas sekret
• Ajarkan teknik batuk efektif untuk memfasilitasi pengeluaran sekret
• Kolaborasi bronkodilator dan/atau mukolitik, jika perlu
Sumber:
Beeching, et al (2020); PPNI (2017)
Oxygen Therapy
• Monitor saturasi oksigen. Waspadai ‘silent hypoxia’
• Terapi oksigen dimulai dengan 5 L/menit via nasal kanul
• Titrasi dengan target SpO2 ≥90% (pasien tidak hamil) atau
SpO2 ≥ 92%-95% (pasien hamil)
• Target SpO2 ≥94% selama proses resusitasi
• Terapkan kewaspadaan kontak saat memegang alat-alat
penghantar oksigen (nasal kanul, simple mask, RM, NRM)
• Oxygen delivery dapat ditingkatkan dengan pemberian oksigen
via NRM dan prone positioning

Sumber: Beeching, N. J., Fletcher, T. E., & Fowler, R. (2020). Coronavirus disease 2019 (COVID-19) -
symptoms, diagnosis and treatment. BMJ Best Practice.
Prone Positioning PTP Blood
flow

s
upine 1>0slllon

Ventral .tfvoolu$
.
Ventr.1 Ilung
.
. .
(overd}s tended)

+++

Oor1il lunt.1 Dor'NI atveolu1

(oollo-)

Prone position

oo,ul alveolus
Oorat1l luno (dccre.1ed ooll.,pac)

t
Vffllr.11 luno Ventr.tl .itveolut
(dccrco.5ed ovc1'distcn(10n)

Sumber Gambar: PTP : Transpulmonary Pressure

Intensive Care Society’s Guidance For: Prone Positioning in Adult Critical Sumber Gambar: Maholtra & Kacmarek (2020). Prone ventilation for adult
Care, 2019. patients with acute respiratory distress syndrome. https://www.uptodate.com
Kasus
Seorang laki-laki berusia 37 tahun diantar ke
IGD dengan diagnosis Covid-19. Riwayat batuk,
mialgia dan demam selama 7 hari. Hasil CT 4 Mei 2020
Scan: tampak konsolidasi pada sekitar 50% Variabel
08:00 18:00
parenkim paru. Pasien takikardia dan takipnea,
lalu diberi oksigen via NRM 10 L/menit. RR (x/menit) 28 22
Pasien terus mengeluh sesak, RR 28 kali/menit, HR (x/menit) 100 85
SpO2 94%. Pasien diberikan posisi pronasi
(tengkurap) selama yang pasien bisa. Setelah 8 SpO2 (%) 94 96
jam, terjadi perbaikan gejala yang signifikan, RR O2 via NRM (L/menit) 10 -
dan HR membaik. Rasio PaO2/FiO2 juga
membaik dan kebutuhan suplementasi oksigen O2 via NK (L/menit) - 3
juga semakin turun.
Setelah dua hari, pasien mendapat oksigen via PaO2/FiO2 198 238
nasal kanul. Tidak ada keluhan dispnea lagi dan
kondisi klinis pasien terus membaik.
Shock Prevention
• Monitor status kardiopulmonal (HR, pulsasi, TD, MAP)
• Monitor status oksigenasi (oksimetri nadi, AGD)
• Monitor status cairan (intake-output, turgor kulit, CRT)
• Monitor tingkat kesadaran
• Pasang jalur IV
• Pasang kateter urine
• Batasi resusitasi cairan terutama pada pasien edema paru
• Kolaborasi cairan IV kristaloid 30 mL/kg BB jika terjadi syok
• Kolaborasi pemberian antibiotik dalam waktu 1 jam

Sumber: Beeching et al (2020); SIKI (2017);

Life Support for
Covid-19
Penyesuaian Algoritma RJP pada Pasien Terduga atau
Terkonfirmasi Covid-19
• Minimalkan keterpaparan penolong
• Gunakan APD lengkap
• Batasi personil penolong
• Gunakan perangkat RJP mekanis
• Komunikasikan status Covid-19 kepada
setiap penolong baru
• Prioritaskan oksigenasi dan ventilasi
• Gunakan HEPA filter
• Intubasi segera (jika memungkinkan)
• Hentikan kompresi dada saat intubasi
• Sebelum intubasi, gunakan BVM dengan
seal yang rapat
• Jika intubasi terlambat, pertimbangkan
supraglottic airway

Sumber:
https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463
Referensi
Beeching, N. J., Fletcher, T. E., & Fowler, R. (2020). Coronavirus
disease 2019 (COVID-19) - symptoms, diagnosis and
treatment. BMJ Best Practice.
Burhan, E., Susanto, A. D., Nasution, S. A., et al (2020). Protokol
Tatalaksana Covid-19. Jakarta: PDPI, PERKI, PAPDI, PERDATIN,
IDAI.
CDC (2020). Standard Operating Procedure (SOP) for Triage of
Suspected COVID-19 Patients in non-US Healthcare Settings:
Early Identification and Prevention of Transmission during Triage.
Dadashzadeh, A, et al (2020). Triage guidelines for emergency
department patients with COVID-19. J Res Clin Med, 8, 12.
Geng, S., Mei, Q., Zhu, C., Yang, T., Yang, Y., Fang, X., & Pan, A.
(2020). High flow nasal cannula is a good treatment option for
COVID-19. Heart & lung : the journal of critical care, S0147-
9563(20)30113-8.
Hugo et al (2012). Humidified High Flow Nasal Oxygen During
Respiratory Failure in the Emergency Department: Feasibility and
Efficacy. Respiratory Care, 57 (11) 1873-1878.
Referensi (Lanjutan)
Li G, Fan Y, Lai Y, Han T, Li Z, Zhou P, et al (2020). Coronavirus
infections and immune responses. J Med Virol, 92(4):424-32.
Liao, X., Wang, B. & Kang, Y. Novel coronavirus infection during the
2019–2020 epidemic: preparing intensive care units—the
experience in Sichuan Province, China. Intensive Care
Med 46, 357–360 (2020).
Maholtra & Kacmarek (2020). Prone ventilation for adult patients with
acute respiratory distress syndrome. https://www.uptodate.com
PPNI (2017). Standar Intervensi Keperawatan Indonesia. Jakarta: DPP-
PPNI.
Sztajnbok, et al (2020). Prone positioning to improve oxygenation and
relieve respiratory symptoms in awake, spontaneously breathing
non-intubated patients with COVID-19 pneumonia. Respiratory
Medicine Case Reports, 30, 101096.