TRIAGE

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
 Emergency Dept Flow
Input
Ambulance Throughput Output
diversions

Patient arrives Ambulatory

Emergency Care Care System
Seriously ill from the to ED
community and
referral sources Left
without
being seen
Triage and
room placement
Unscheduled Transfer to
Urgent Care Demand outside
Lack of available for ED facility
ambulatory care care
Desire for
Patient
immediate care Diagnostic Disposition
evaluation and
treatment

Safety Net
Care
Vulnerable ED boarding of Admit to
populations
Access inpatients hospital
barrier
Impact of throughput times on
ED capacity
5 Rooms 5 Rooms 5 Rooms

ED ED ED
Through Through Through
put:4 put:3 put:2
hours hours hours

ED ED ED
Capacity Capacity: Capacity:
: 30/day 40/day 60/day10
 BIMC Triage Flow
Patient arrives to ED

Triage and
room placement

1 2 3 4 5

Resus Treatment Fast Track

Room room
Reception for
Regristration
Consult
Room
 Definition
Triage system: The process by which a
clinician assesses a patient’s 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 re-
triaging must also be documented.
 Urgency: Urgency is determined according to the patient’s 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.
 EMERGENCY TRIAGE SCALE
Overview of the triage system can be evaluated based on the following
four criteria :
 Utility
The scale should be relatively easy to understand and easy to apply by nurses and
ER doctors.
 Validities
The scale must be designed to measure the clinical urgency as opponents of the
severity or complexity of illness or some other aspect of the presentation on
emergency dept.
 Reliability
The triage scale application must be independent of the nurse or doctor who
performs the role, they must be consistent. 'Inter-rater reliability is a term used to
statistically measure the agreement reached by two or more assessors using the
same scale.
 Safety
Triage decisions must be accordance to clinical criteria of objective and must
optimize time for medical intervention. In addition, the triage scale must be sensitive
enough to identify the patient's problems.
 EMERGENCY TRIAGE SCALE
Internationally, five-tier triage scales have been shown to
be valid and reliable methods for categorizing people
who are seeking assessment and treatment in hospital
EDs
ATS Category Treatment Acuity
(Maximum waiting time)
1 Immediate
2 10 Minute
3 30 Minute
4 60 Minute
5 120 Minute
Note: ATS = AustralAsian Triage System
 EMERGENCY TRIAGE SCALE
cont
 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 .
 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 (7-10 on a 0-10 scale) or
distress within 10 minutes
 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 pain (5-6 on a 0-10 scale), discomfort or distress within thirty
minutes
 ATS Category 4 - Assessment and treatment start within 60 mins
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 pain (< 4 on a 0-10
scale), discomfort or distress within one hour
 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
 Summary of adult physiological predictor for ATS

Level 1 Level 2 Level 3 Level 4 Level 5

Airway Obstructed/Partial Patent Patent Patent Patent

obstructed

Breathing Severe respiratory Moderate Mild Respiratory No respiratory No respiratory

distress/Absent respiratory distress distress distress
respiratory/Hypove distress
ntilation

Circulation Severe Moderate Mild Haedynamic No Haedynamic No Haedynamic

haemodynamic haemodynamic compromise distress distress
compromise/absent compromise
circulation/uncontrol
led hemorrhage
Disability GCS <9 GCS 9-12 GCS > 12 Normal GCS Normal GCS

Pain Scale ? 7-10 (on a 0-10 5-6 (on a 0-10 ≤ 4 (on a 0-10 No pain
scale) scale) scale)

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
Example Case
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 2
•Airway risk - severe stridor or
drooling with distress
•Severe asthma/Severe
COPD/Severe SOB
•Chest Pain Cardiac origin
•HR<50 or >150 (adult)
•Hypotension with haemodynamic
effects
•Severe blood loss
•Drowsy, decreased responsiveness
any cause (GCS< 13)
•Acute hemiparesis/dysphasia
•Fever with signs of lethargy
•Severe localised trauma - major
fracture, amputation
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 1
yes
no

Shouldn’t wait
yes
no

2
How many resources ?

None one many

abnormal
5 4 Vital signs
normal

3
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.
 PHYSIOLOGICAL APPROACH AS A BASIS FOR DECISION OF
TRIAGE

GENERAL APPEARANCE
Assessment general appearance? Why???
AIRWAY
Airway evaluation? Evaluation of airway obstruction?
BREATHING
The ability of Baby and children's to tolerate respiratory disorders is very bad
Increased work of breathing indicator of serious illness in infants.
 PHYSIOLOGICAL APPROACH AS A BASIS FOR
DECISION OF TRIAGE cont’

CIRCULATION
• hypotension is signs of hemodynamic disturbances that
was late to get treatment in infants and children
• Initial assessment of circulation must depend on the
general appearance of patient's, pulse, CRT
• Pale in infants are significant findings as indicators of
serious illness
• CRT is indicator of central perfusion and cardiovascular
function
• Level of dehydration is important things to assess the
circulation status
 TABEL PENGKAJIAN TINGKAT DEHIDRASI

Tingkat Keparahan
Sign Mild Moderate Severe
Kondisi umum thirsty, thirsty, Withdraw,
Restlessness, Restlessness, somnolence /
agitation irritability / drowsiness, coma,
Offended rapid breathing
Pulse rate Normal Rapid and weak Rapid and weak
Crown Normal Cekung Sangat Cekung
eye Normal Cowong Sangat cowong
Tear yes None None
mucous membrane dryish Dry Dry
Skin turgor Normal Decrease Decrease
Urine Normal Reduced, Nothing in a few
concentrated hours
Decrease of BW 4-5% 6-9 % > 10 %
 PHYSIOLOGICAL APPROACH AS A BASIS FOR DECISION OF
TRIAGE cont’

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
parent’s.
 PPD Category 1 Category 2 Category 3 Category 4 Category 5
Immediate Emergency Urgent Semi-urgent Non-urgent
Within 10 minutes within 30 minutes Within 60 minutes Within 120 minutes
Airway Obstructed Patent Patent Patent Patent

Partially obstructed with severe Partially obstructed with Partially obstructed with
respiratory distress moderate respiratory distress mildrespiratory distress
Breathing Absent respiration or Respiration present Respiration present Respiration present Respiration present
hypoventilation
Severe respiratory distress, e.g. Moderate respiratory distress, Mild respiratory distress, e.g. No respiratory distress, e.g. No respiratory distress, e.g.
e.g.  mild use of accessory  no use of accessory  no use of accessory
 moderate use of muscles muscles muscles
 severe use of accessory accessory muscles
muscles  mild retraction  no retraction  no retraction
 moderate retraction
 severe retraction  skin pink
 skin pale
 acute cyanosis
Circulation Absent circulation Circulation present Circulation present Circulation present Circulation present
s/s dehydration * Severe bradycardia, e.g. HR
<60 in an infant
Circulation Severe haemodynamic Moderate haemodynamic Mild haemodynamic No haemodynamic No haemodynamic
s/s dehydration * compromise, e.g. compromise, e.g. compromise, e.g. compromise, e.g. compromise, e.g.
 absent peripheral pulses  weak/thready brachial  palpable peripheral  palpable peripheral  palpable peripheral
pulse pulses pulses pulses
 skin pale, cold, moist,
mottled  skin pale, cool  skin pale, warm  skin pale, warm  skin pale, warm

 significant tachycardia  moderate tachycardia  mild tachycardia

 capillary refill >4 secs  capillary refill 2-4 secs

Circulation Uncontrolled haemorrhage > s/s dehydration 3-6 s/s dehydration <3 s/s dehydration No s/s dehydration
s/s dehydration *
 PPD Category 1 Category 2 Category 3 Category 4 Category 5
Immediate Emergency Urgent Semi-urgent Non-urgent
Within 10 minutes within 30 minutes Within 60 minutes Within 120
minutes
Disability GCS <8 GCS 9-12 GCS >13 Normal GCS or no acute Normal GCS or no
Severe decrease in activity, Moderate decrease in change to usual GCS acute change to usual
e.g. activity, e.g. Mild decrease in activity, GCS
 lethargy e.g. No alteration in activity,
 quiet but eye contact e.g.
 no eye contact  eye contact wihen  playing
disturbed  interacts with
 decreased musle parents  smiling
tone Moderate pain, e.g.
 patient/parents Mild pain, e.g. No or mild pain, e.g.
Severe pain, e.g. report moderate pain  patient/parents  patient/parents
 patient/parents report mild pain report mild pain
report severe pain  skin pale, warm
 skin pink, warm  skin pink, warm
 skin pale, cool  alteration in vital
signs  no alteration in vital  no alteration in
 alteration in vital signs vital signs
signs  requests analgesia
 requests analgesia  declines
 requests analgesia Moderate neurovascular analgesia
compormise, e.g. Mild neurovascular
Severe neurovascular  pulse present compormise, e.g. No neurovascular
compormise, e.g.  pulse present compormise
pulseless  cool
 normal/↓ sensation
cold  sensation
 normal/↓ movement
nil sensation  movement
 normal capillary
nil movement  ↓ capillary refill refill

↓ capillary refill
MENTAL HEALTH
TRIAGE
 Prinsip Dasar Mental Health
Triage
Asssesment to determine URGENCY not
DIAGNOSIS
Maintain our safety and others
Seek help ASAP ----Pasien bertambah
aggresif
Tidak semua pasien dengan prilaku
gelisah dan agresif adalah pasien jiwa
 Mental Health In ED

Aggression, self Symptomatic

harm , problems:
Hallucination, delusion
substance Social problems: job,
abuse Cognitive relationship, financial
dysfunction,
physical disability

Emergency
Department
 The ABCs of Mental Health
Assessment
A = Appearance, Affect
B = Behavior
C = Conversation and mood
 A = Appearance
• Wajah pasien
• Pakaian yg digunakan
• Tubuh Gizi (malnutrisi ??, dehidrasi? )
• Nampak ada bekas cidera?
• Pasien nampak intoxicated ?
• Nampak tegang? Lemas, gelisah
 Sikap / Affect / Mood
Bagaimana gambaran Emosi
pasien(datar, tearful, cemas, stres)
Emosinya berubah secara cepat ?
Emosinya tidak sesuai dengan apa yang
dibicarakan oleh pasien
Pasien nampak bahagia berlebihan
 B = Behaviors (tingkah laku)
Bagaimana perilaku pasien ????
Tertidur
Gelisah
Hiperventilasi
Tremor?
Disorientasi
Perilaku yang aneh, yg tidak bisa
diprediksi
 Bagaimana Reaksi Pasien???
• Pasien marah-marah, tidak kooperatif,
curiga, menarik diri, ketakutan
• Pasien berespon terhadap suara yg tidak
ada, object yg tidak terlihat
• Apakah pasien menolak untuk berbicara?
• Apakah Pasien nampak fokus?
 C = Conversation and mood
 Bahasa yang digunakan apa? Perlu interpreter??
 Percakapan dg pasien cepat, berulang-ulang, lambat,
diam
 Pasien berbicara keras, lemah atau tidak berbicara
 Bicaranya jelas atau kacau
 Berbicara sambil marah, berbahasa yg jorok/kasar?
 Pasien menghentikan bicaranya krn mendengar suara
 Apakah mereka tahu hari, waktu dan bagaimana mereka
sampai ke ED
 Mood
Bagaimana gambaran mood pasien??
Sedih, depresi
Marah dan sensitive
Cemas, ketakutan
Gembira
Tidak bisa berhenti menangis
Apakah pasien mengatakan mau mati,
bunuh diri
 Mental Health Triage Tools
Triage Description Presentation Presentation
Code (Observed) (Reported)
1-immidiate Definitedanger to self & other Violentbehavior and patient Possession Verbal command to do harm
of weapon, self destruction, extreme to self or others
agitation, restlessness, disoriented Recent violent behavior
behavior

2-emergency Probablerisk of danger to Extreme agitation/restlesness Attempt at self harm/threat of

10 min self , other Physically/verballyagresive self harm
Pt. physically restrain Confused/unable to cooperate Threat of harm to others
Hallucinations/delusions/paranoia Unableto wait safely
Requires restrain
High risk to escape
3 –urgent Possible danger to self or agitation/restlesness Suicidal ideation
30 minutes other Intrusive bbehaviour,confuse, Situational crisis
ambivalence, not likely to wait

4-semi urgent Semiurgent mental health No agitation/restlessness Preexstingmental health

60 minutes problem Irritable without aggression Symptoms of anxiety or
Under observation and/or no Cooperative depression without suicidal
immediate risk to self or Give coherent history ideation
others Willing to wait

5 –non urgent No danger to self or other Cooperative,communicativeand able to Known ptwith chronic
Within 120 min engage in developing mngtplan psychotic symptoms
Able to discuss concerns, compliant with Pre –existingnon acute
instructions mental disorder, financial,
social problems
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.
• Hal –hal penting yang perlu diperhatikan:
• Wanita hamil sering mengalami jantung berdebar selama
kehamilan, yang biasanya karena hiperdinamik aliran darah.
• volume aliran arah yang tinggi dan dinamis adalah diperkirakan
berkontribusipada peningkatan resikopen arahan otak (terutama
perdarahan sub-arakhnoid (SAH)) pada kehamilan.
• Setiap wanita hamil > 20 minggu kehamilan harus berbaring pada
posisi miring lateral kiri (ganjal dibawah pinggulkanan ibu, atau
miringkan seluruh tempat tidur jika pemberiangan jalan merupakan
kontraindikasi).
• Embolus paru relatif sering terjadi selama kehamilan karena
perubahan dalam sistem koagulasi yang berhubungan dengan
kehamilan.
• Dalam kasus trauma, semua kriteria trauma harus diperhatikan.
Pertimbangan termasuk trauma pada plasenta, uterus atau janin, terutama
pada trimester ketiga ketika janin sedang tumbuh. Tanda-tanda vital ibu
mungkin dapat tetap stabil bahkan ketika kehilangan seper tiga dari
volume darah.
• Perlakuan awal yang terbai kuntuk janin adalah resusitasi optimum dari ibu.
 Kondisi Umum Yang sering di
temukan dalam ED
• 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).
• Masalah yang terjadi dari 20 minggu dan seterusnya
Wanita hamil pada umur kehamilan 20 minggu kehamilan akan mengalami
kondisi obstetri berikut:
• perdarahan antepartum
• Preeklamsia (termasuk eklampsia)
• pecah membran dan kelahiran yang pre term
Hipertensi(> 140/90) adalah tanda penting terutama untuk memperingatkan
PerawatTriage pada masalah yang lebih serius. Adanya gejala-gejala
terkait preeklampsia berat menandakan perlunya penilaia nmedis yang
mendesak. Antaralain:
• Sakitkepala
• GangguanVisual
• Nyeriepigastrium
• nyerikuadrankanan(kuadrankananatas) atas
. Edema Non-dependen.
 Ancaman Penting untuk keselamatan janin

• Perubahan dalam saturasi oksigen pada ibu memiliki relevansi

langsung pada kesejahteraan janin. Penurunan kecil oksigenasi ibu
sangat berdampak pada oksigenasi janin karena pergeseran kiri
dalam kurva disosiasioxy haemoglobint erkait dengan hemoglobin
janin. Pertimbangkan pengukuran saturasi oksigen ditriase pada
semua wanita hamil.

Perubahan Mayor pada tekanan darah (baik tinggi atau rendah) tidak
ditoleransi oleh janin.
 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 patient’s 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.
• Determine the clinical urgency of the patient based on emergency
triage category
• Notify doctor on call of patient's arrival and ATS category as
required
• Take any patient identified as ATS Category 1 or 2 into the
appropriate assessment and treatment area immediately.
• Handover briefly to NOD/DOD so they can Meet any immediate care
needs.
 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. Re-
triage 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
 PROCEDURE Cont (Path way of triage)
1!ye
1)Pt present for triage: safety hazard are considered above all

2) Assess: chief complaint, general yes 2) Quick evaluation: is

appearance, A, B, C, D,E, limited pt stable
history, co-morbidities
no

5) Assign an appropriate ATS

3) Differentiate predictors of poor category in response
outcome from other data collected to clinical assessment data
during the triage assessment

6) Allocate staff to patient,

4) Identify patients who have evidence including brief handover to
of or are at high risk of physiological allocated staff member/s
instability

7) ED model of care proceeds

 Assessment technique for safe
triage
 Assessment of environmental hazards
This is the first step to safe practice at triage. As part of
maintaining a safe environment, the Triage Nurse must ensure
that equipment for basic life support (bag-valve mask and
oxygen supply) is available at triage. Likewise, equipment which
complies with standard precautions is required. At the beginning
of each shift, the Triage Nurse should conduct a basic safety
and environment check of the work area to optimize
environmental and patient safety.
Assessment technique for safe
triage
 General appearance
Observation of the patient’s appearance and behavior
when they arrive tells us much about the patient’s
physiological and psychological status. Take particular
notice of the following:
– Observe the patient’s mobility as they approach the
reception area. Is it normal or restricted? If it is
restricted, in what way?
– Ask yourself the question ‘Does this patient look
sick?’
– Observe how the patient is behaving.
Assessment technique for safe
triage
 Airway
Always check the airway for patency, and consider cervical
spine precautions where indicated
 Breathing
Assessment of breathing includes determination of respiratory
rate and work of breathing. It is important to detect
hypoxaemia. This can be detected using pulse oximetry.
 Assessment technique for safe
triage
 Circulation
Assessment of circulation includes determining heart rate,
pulse and pulse characteristics, skin indicators, oral intake and
output.
It is important that hypotension be detected during the triage
assessment to facilitate early and aggressive intervention.
If not possible to measure blood pressure at triage, other indicators of
haemodynamic status should be considered, including peripheral
pulses, skin status, conscious state and alterations in heart rate.
Patients with evidence of haemodynamic compromise (hypotension,
severe hypertension, tachycardia or bradycardia) during the triage
assessment should be put in a high triage category, e.g. 1, 2 or 3.
 Assessment technique for safe
triage
 Disability
• This assessment includes determining AVPU. GCS and/or activity level,
assessing for loss of consciousness, and pain assessment. Altered level of
consciousness is an important indicator of risk for serious illness or injury. Patients
with conscious-state abnormalities should be allocated to a high triage category.

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.