Emergency Department

Triage System
Ns. Risna Yekti Mumpuni, M. Kep.
 Definition
• It’s the process by which patients are
classified according to the type and
urgency of their conditions to get the
– Right patient to the
– Right place at the
– Right time with the
– Right care provider
 Konsep Triage
• Tujuan utama untuk mengidentifikasi kondisi
yang mengancam nyawa
• Tujuan kedua untuk memprioritaskan pasien
berdasarkan keakutannya
• Pengkategorian mungkin ditentukan sewaktu-
waktu
• Jika ragu, pilih prioritas yang lebih tinggi untuk
menghindari penurunan triage
 Principles Of Triage
1. Immediate & timely
2. Adequate and accurate assessment
3. Assessment based decisions
4. Interventions according to acuity
5. Patient satisfaction
6. Complete documentation
 Category of triage
• In hospital triage

• Multi casualty disaster triage

 START
Simple Triage and Rapid Treatment
• Digunakan pada kondisi bencana atau
multi casualty incident
• Menggunakan parameter respirasi, nadi
radialis, dan CRT
Noji
Nojiet
etal,
al,NEJM
NEJM
Triage Severity Rating Systems
 Emergency Severity Index
• Definition

• Advantages

• disadvantages
E SI Is patient dying ?
M EN
E VD
Yes No
R EE
G RX Level I Level II, III, IV, V

E I Can patient wait ?

N T
C Y Yes No
Y
Level III, IV, V Level II

How many resources ?

 TWO ONE NON

Level III Level IV Level V
 What are resources ?
Resources Not resources
• Labs • HX and physical exam.
• ECG-X-rays C-T MRI •Point of care testing
• IV Fluids /hydration • Saline or Hep lock
• IV /IM Medication • PO. Medication
• Specialty consult • Simple wound care
(dressing check /recheck)
crutches ,splints,slings.
• Simple procedure
• Complex procedure
 Reassessment in triage
• Level 1 =Continuous
• Level 2 = every 15 min
• Level 3 = every 60 min
• Level 4 = every 60 to 90 min
• Level 5 = every 2 hours
 Key concepts

• Acuity level change

• Choose higher acuity when in doubt

 Basic triage components
• Across the room assessment

• Triage history

• Physical assessment

• Triage decision
 Guidelines For
Triaging An Injury
Mechanism Of Injury Triage Questions
Motor vehicle collision Speed of the vehicle; direction of impact; patient position
within the vehicle; use of restraints; airbag
deployment; ejection; rollover; fatalities; ambulatory at
the scene; entrapment or prolonged extrication

Penetrating injury Type of object (knife, bullet, impaled object); left in place,
removed, broken off
Fall From how high; landed on which body part(s); what kind
of landing surface; why the patient fell
Motorcycle crash Impact speed; helmet use; other protective clothing;
thrown, skidded, pinned, or run over; position of patient
relative to the motorcycle
Bicycle crash Helmet use; collided with a vehicle or object; thrown or
run over; impact speed; landed on which body parts
 Key concept
• Discontinue assessment and transport the
patient immediately to the treatment area if
immediate care is needed. Do not delay
treatment to finish the assessment
 Triage process
• Establish priorities

• Scientific method

• Importance of time
 Nursing process in triage
• Assessment time

• Vital signs

• Pain scale

• Nursing diagnosis
 Key Concept
• Never assume the accident caused the
presenting condition. The presenting
condition may have caused the accident.
 Interview methods
• Open ended
• Close ended
• Communication style
• Use of five sense
• attitude
 How do I triage?
• Across the room
• General appearance
• Abcd
• Subjective and objective (AMPLE)
• Focused assessment
• Pains scale (Pqrst)
 Across-the-room
Assessment
Observe
• Airway patency
• Respiratory rate, obvious distress, use of oxygen devices
• Signs of external bleeding
• Level of consciousness: interacting, unconscious, crying,
moaning
• Signs of pain: grimacing, holding, guarding
• Skin color and condition
• Chronic illness: cancer, chronic obstructive pulmonary
disease, neuromuscular disorders
• Deformities
Observe (cont’d)
• Body habitus: cachectic, morbidly obese
• Activity: ability to ambulate, balance, bear weight
• General behavior: agitated, angry, flat affect
• Presence of splints, dressings, casts, medical
equipment
• Clothing: clean, appropriate
• Listen
– Abnormal airway sounds
– Speech pattern, tone of voice, language
– Interactions with others
• Smell
– Stool, urine, vomit, ketones, alcohol
– Poor hygiene, cigarettes, infection, chemicals
 Triage decision
• Step1- visual
• Step 2- chief complaints
• Step3- focused assessment
• Step 4- pose hypothesis
• Step 5- determine acuity
• Step 6- reassess the acuity
 Remember That:

Effective triage gets the patient

• To the right place.
• At the right time.
• With the right care provider.
 Triage Documentation
• Goals of documentation:
– To support the triage dicision
– To communicate essential information to
subsequent care providers
– To meet medical legal requirements
 What must be documented ???
• Time patient was triaged ?
• Chief complaint & associated symtoms
• Past medical history
• Allergies
• Vital signs
• Subjective & objective assesment
• Acuity category
• Diagnostic tes ordered
• Intervention rendered
• Disposotion
• Reevaluation and changes in condition
 1 Individual Assignment
st

• FOCUSED PHYSICAL ASSESSMENT AT

TRIAGE  Major Body System

• Analisis salah satu sistem triage