TRIAGE

Ade Winata
RS Martha Friska Brayan
2016
Adalah cara pemilihan penderita
berdasarkan kebutuhan terapi
dan sumber daya yang tersedia. TRIAGE

Terapi didasar pada kebutuhan

ABC
.

Berlaku juga untuk penilaian

penderita dilapangan dan
dirumah sakit yang akan dituju
Obyektif

• Menjelaskan aturan dan cara dari triage

• Indentifikasi proses dari triage
Tujuan

• Mendapatkan hasil yang sebaik mungkin

pada kondisi jumlah pasien besar dengan
sarana terbatas
 Dasar - Dasar Triage

• Derajat cedera
• Jumlah yang cedera
• Sarana dan kemampuan
• Kemungkinan bertahan hidup

• Sehari-hari >< korban masal

TRIAGE

• Penilaian tanda vital dan kondisi

• Penilaian tindakan yang diperlukan
• Penilaian harapan hidup
• Penilaian kemampuan medis
• Prioritas penanganan definitif
• Pemberian label
TRIAGE

• Penentuan prioritas akan menekan

- morbiditas
- mortalitas
- kecacatan
• Siapa yang melakukan ?
• Elemen apa saja yang dipertimbangkan ?
• Pertama datang – pertama dilayani ?
Prosedur Triage

• Triage dulu sebelum pengobatan

• Jangan lebih dari 60 detik tiap pasien
• Tentukan fasilitas terbaik untuk
penanganan
- di ruang emergensi
- di lapangan
Sehari-hari/pasien satu

Penting untuk mengatur supaya alur pasien

baik terutama pada kondisi ruang terbatas
Prioritas pasien untuk menekan morbiditas
dan mortalitas
Tiga kategori
- emergency
- urgent
- non urgent
Emergency

Trauma berat
Akut MCI
Sumbatan jalan nafas
Tension pneumothorax
Flail chest
Shock hipovolemic derajat III - IV
Luka bakar dengan trauma inhalasi
Urgent
Cedera tulang belakang
Patah tulang terbuka
Trauma capitis tertutup
Luka bakar
Apendiksi Akut

Akan terjadi peningkatan resiko

jika tidak ditangani dalam beberapa jam
Non Urgent

• Luka lecet
• Luka memar
• Fraktur extremitas atas
• Demam
• Keluhan-keluhan lain
Triage  waktu emas

• Batasan waktu untuk mendapat pelayanan

• Jam pertama : morbiditas 
mortalitas 
 Konsep Awal Triage
• Zaman Napoleon
• Baron Dominique Jean Larrey (1766-1842)
seorang dokter bedah
• Tangani pasien yang paling mendesak
• Bukan berdasarkan yang duluan datang
• 1846, John wilson. Dokter bedah
 Latar Belakang
Dr. Baron Dominique JL (1766-1842)
:memberikan tindakan tidak berdasarkan
urutan
PD I :dipisahkan dipusat pengumpulan korban
dan dibawa langsung ke fasilitas yang sesuai
PD II : membedakan yang dengan luka ringan
agar dapat kembali bertempur
Akhir 1950 an:mulai dikembangkan sistem
triage
 Pengertian
• Gawat adalah suatu keadaan yang mengancam
nyawa dan kecacatan yang memerlukan
penanganan dengan cepat dan tepat
• Darurat adalah suatu keadaan yang tidak
mengancamnyawa tetapi memerlukan penangan
cepat dan tepat seperti gawat
• Gawat darurat adalah suatu keadaan yang
mengancam jiwa disebabkan oleh gangguan ABC
( Airway/jalan nafas, Breathing/pernafasan,
Circulation/sirkulasi) jika tidak dapat ditolong
segera maka dapat meninggal/cacat
 Prinsip Triage
1. Segera dan tepat waktu (<60”)
2. Pengkajian adekuat dan akurat
3. Keputusan dibuat berdasarkan pengkajian.
4. Intervensi sesuai kekuatan kondisi
5. Tercapainya kepuasan pasien
Triage Management Flow

Hitam Kuning

Area Triage
penerimaan
Merah Hijau
8 May 2018
 Klasifikasi
1. Prioritas I ( merah) :mengancam jiwa,perlu
resusitasi dan tindakan segera dan mempunyai
kesempatan hidup yang besar
2. Prioritas II (kuning) :potensi mengancam nyawa
atau fungsi vital bila tidak segera ditangani
dalam waktu singkat.
3. Prioritas III (hijau) : perlu penanganan seperti
pelayanan biasa, tidak perlu segera.
4. Priorotas 0 (hitam)kemungkinan untuk hidup
sangat kecil, luka sangat parah
 The Australasian Triage Scale:
Descriptors for Categories
Key points
• The most urgent clinical feature identified
determines the ATS category.
• Once a high-risk feature is identified, a
response commensurate with the urgency of
that feature should be initiated.
 Primary triage decisions

Objective data: Subjective data:

1. Chief complaint;
1. Primary survey; and 2. Precipitating event /
2. Physiological data. onset of symptoms;
3. Mechanism of injury;
4. Time of onset of
symptoms / event;
and
5. Relevant past history
 Category 1 Category 2 Category 3 Category 4 Category 5
Immediate 10 minutes 30 minutes 60 minutes 120 minutes

Obstructed/
Airway partially Patent Patent Patent Patent
obstructed

Severe respiratory
Moderate
distress/absent Mild respiratory No respiratory No respiratory
Breathing respiration/
respiratory
distress distress distress
distress
hypoventilation

Severe
haemodynamic
Moderate Mild
compromise/ No haemodynamic No haemodynamic
Circulation absent circulation
haemodynamic haemodynamic
compromise compromise
compromise compromise
Uncontrolled
haemorrhage

Disability GCS <9 GCS 9–12 GCS >12 Normal GCS Normal GCS

Risk factors for serious illness/injury – age, high risk history, high risk mechanism of injury, cardiac risk factors, effects
of drugs or alcohol, rash and alterations in body temperature – should be considered in the light of history of events
and physiological data. Multiple risk factors = increased risk of serious injury/illness. Presence of one or more risk
factors may result in allocation to a triage category of higher acuity.
 Triage Category Severe pain Moderate pain Mild pain Mild pain

Category 1

Category 2 • patient reports

severe pain
• skin pale, cool
• severe alteration in
vital signs
• requests analgesia

Category 3 • patient reports moderate

pain
• skin pale, warm
• Moderation
• alteration in vital signs
• requests analgesia

Category 4 • patient reports mild

pain
• skin pale / pink,
warm
• mild alteration in vital
signs
• requests analges

Category 5 • patient reports mild

pain
• skin pale / pink,
warm
• no alteration in vital
signs
• declines analgesia
 ATS Category 1
• Immediate simultaneous assessment and treatment
• Immediately Life-Threatening Condition
• Conditions that are threats to life (or imminent risk of
deterioration) and require immediate aggressive intervention.
• Clinical Descriptors (indicative only)
• ! 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
! IV overdose and unresponsive or hypoventilation
! Severe behavioural disorder with immediate threat of
dangerous violence
 ATS Category 2
• Assessment and treatment within 10 minutes (often simultaneously)
Imminently Life threatening
• The patient's condition is serious enough or deteriorating so rapidly that
there is the potential of threat to life, or organ system failure, if not
treated within ten minutes of arrival. or
Important time-critical treatment
• The potential for time-critical treatment (e.g. thrombolysis, antidote) to
make a significant effect on clinical outcome depends on treatment
commencing within a few minutes of the patient's arrival in the ED or
Very severe pain
• Humane practice mandates the relief of very severe pain or distress within
10 minutes
Clinical Descriptors Category 2 (indicative only)
• Airway risk - severe stridor or drooling with distress
• Severe respiratory distress
• Circulatory compromise
– Clammy or mottled skin, poor perfusion - HR<50 or >150 (adult)
– Hypotension with haemodynamic effects - Severe blood loss
– Chest pain of likely cardiac nature
• Very severe pain - any cause
• BSL < 2 mmol/l
• Drowsy, decreased responsiveness any cause (GCS< 13)
• Acute hemiparesis/dysphasia
• Fever with signs of lethargy (any age)
• Acid or alkali splash to eye - requiring irrigation
• Major multi trauma (requiring rapid organised team response)
• Severe localised trauma - major fracture, amputation
• High-risk history:
– Significant sedative or other toxic ingestion
– Significant/dangerous envenomation
– Severe pain suggesting PE, AAA or ectopic pregnancy
• Behavioural/Psychiatric:
– violent or aggressive
– immediate threat to self or others - requires or has required restraint - severe agitation or
aggression
 ATS Category 3
• Assessment and treatment start within 30 mins
Potentially Life-Threatening
• The patient's condition may progress to life or limb threatening, or may lead to
significant morbidity, if assessment and treatment are not commenced within
thirty minutes of arrival. or
Situational Urgency
• There is potential for adverse outcome if time-critical treatment is not commenced
within thirty minutes or Humane practice mandates the relief of severe discomfort
or distress within thirty minutes
• Clinical Descriptors (indicative only)
– Severe hypertension
– Moderately severe blood loss - any cause
– Moderate shortness of breath
• SAO2 90 – 95%
• BSL >16 mmol/l
• Seizure (now alert)
• Any fever if immunosuppressed eg oncology patient, steroid Rx ! Persistent vomiting
• Dehydration
• Head injury with short LOC- now alert
 ATS Category 3
– Moderately severe pain - any cause - requiring analgesia
– Chest pain likely non-cardiac and mod severity
– Abdominal pain without high risk features - mod severe or patient
age >65 years
– Moderate limb injury - deformity, severe laceration, crush
– Limb - altered sensation, acutely absent pulse
– Trauma - high-risk history with no other high-risk features
– Stable neonate
– Child at risk
– Behavioural/Psychiatric:
– very distressed, risk of self-harm
– acutely psychotic or thought disordered
– situational crisis, deliberate self harm
– agitated / withdrawn / potentially aggressive
 ATS Category 4
Assessment and treatment start within 60 mins
Potentially Life-Threatening
• The patient's condition may progress to life or limb threatening, or may lead to significant
morbidity, if assessment and treatment are not commenced within thirty minutes of arrival.
or
Situational Urgency
• There is potential for adverse outcome if time-critical treatment is not commenced within
thirty minutes or
• Humane practice mandates the relief of severe discomfort or distress within thirty minutes
Potentially serious
• The patient's condition may deteriorate, or adverse outcome may result, if assessment and
treatment is not commenced within one hour of arrival in ED. Symptoms moderate or
prolonged. or
Situational Urgency
• There is potential for adverse outcome if time-critical treatment is not commenced within
hour or Significant complexity or Severity
Likely to require complex work-up and consultation and/or inpatient management or
Humane practice mandates the relief of discomfort or distress within one hour
 ATS Category 4
• Clinical Descriptors (indicative only)
– Mild haemorrhage
– 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 diarrhoea 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
– Tight cast, no neurovascular impairment
– Swollen "hot" joint
– Non-specific abdominal pain
– Behavioural/Psychiatric:
• Semi-urgent mental health problem
• Under observation and/or no immediate risk to self or others
 ATS Category 5
Assessment and treatment start within 120 mins
Less Urgent
• The patient's condition is chronic or minor enough that symptoms or clinical outcome will not
be significantly affected if assessment and treatment are delayed up to two hours from
arrival or
Clinico-administrative problems
Results review, medical certificates, prescriptions only
• Clinical Descriptors (indicative only)
– Minimal pain with no high risk features
– 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)
– Scheduled revisit eg wound review, complex dressings
– Immunisation only
– Behavioural/Psychiatric:
– Known patient with chronic symptoms - Social crisis, clinically well patient
 Risk factors for serious illness or injury
Adult
Age>65
Mechanism of injury e.g. Cardiac risk factors, eg.
- penetrating injury - smoker
- fall > 5m - diabetes
- MCA>60kph - family Hx
- MBA / cyclist > 30 kph - ↑ cholesterol
- pedestrian
- ↑BP
- ejection / rollover
- Obesity
- prolonged extrication (> 30 minutes)
- Hx AMI / ischaemic heart disease
- death of same car occupant
- Other vascular disease
5
- explosion

Co morbidities, e.g. Victims of violence, eg.

• respiratory disease
• cardiovascular disease
- domestic violence
• renal disease - sexual assault
• carcinoma - neglect
• diabetes
substance abuse
• immuno-compromised
• complex medical problems
Historical variables, e.g. events preceding presentation to Other, eg.
ED - rash
- apnoeic episode - actual / potential effects of drugs / alcohol
- seizure activity - chemical exposure
- intermittent altered conscious state - envenomation
- collapse - immersion
- alteration in body temperature
 Primary triage decision

“expected” triage decision

• The allocation of a triage category that is
appropriate to the patient’s presenting
problem.
• The patient will be seen by a doctor within a
suitable time frame and should have a positive
health outcome.
 “over triage” decision
• The allocation of a triage category of a higher
acuity than indicated by the patient’s
physiological status and risk factors.
• This results in the patient’s waiting time until
medical intervention being shorter.
• Although this is not detrimental to the patient
in question, the effect of inappropriate
allocation of resources has the potential to
adversely affect other patients.
 “under triage” decision
• The allocation of a triage category of a lower
acuity than indicated by the patient’s
physiological status and risk factors.
• This prolongs the patient’s waiting time until
medical intervention and there is potential for
patients to deteriorate whilst waiting or be
subjected to prolonged pain or suffering.
• These factors increase the risk of an adverse
patient outcome.
 Secondary triage
• Decisions relate to the initiation of
interventions in order to :
– expedite emergency care and
– promote patient comfort
 The aim
• Provide basic life support as required;
• Expedite definitive management within the
emergency department
• Promote patientcomfort
• Maximise patient satisfaction with emergency
care
 1. Patient presents for triage
Safety hazards are considered above all

2. Quick evaluation
2. Assess the following: Is the patient stable
• Chief complaint
• General appearance
• Airway
• Breathing
• Circulation
• Disability

NO
3. Differentiate predictors of
poor outcome from other data
collected during the triage
assessment

4. Identify patients who 5. Assign an appropriate ATS

have evidence of or are category in response to clinical
at high risk of assessment data member/s
physiological instability

6. Allocate staff to patient

including brief handover to 7. ED model of care proceeds
allocated staff member/s
 CASE
I

8 May 2018
 Wanita 30 tahun
1 jam yang lalu ketika menjemur baju jatuh berdiri setinggi 3 m,
datang ke rumah sakit
dengan keluhan nyeri pada punggung dan kaki kanan sehingga tak dapat berjalan.
Pasien sadar sejak jatuh sampai rumah sakit.

Laki-laki 60 tahun,
Ketika berjalan ditabrak truk dari samping dibawa ke RS dalam keadaan
Tidak sadar, GCS 7 Pupil anisokor dan sedikit midriasis,
ada jejas didada dan di pelvic
Trumatic amputasi setinggi paha kanan, tensi 90/palp, nadi 116 x/ menit

Laki 26 tahun datang ke rumah sakit karena

ditusuk dada sebelah kanan ketika berkelahi dengan temannya,
kejadian sejak 30 menit sebelum masuk rumah sakit.
Saat ini penderita mengeluh sesak dan rasa nyeri sekali bila bernafas,
kepala pusing dan berputar, kaki terasa dingin.

Ketiga penderita ini datang secara hampir bersamaan di IGD Rumah Sakit,
anda sebagai seorang petugas lakukan apa yang harus anda lakukan.
Kunci dari keberhasilan

• Latihan dan evaluasi secara rutin

• Kebijakan akreditasi untuk RS