TRIAGE

Dewi Kartikawati

HISTORY
The formal definition of TRIAGE taken from the French word trier which means to sort into 3 groups The classification of patients originated on the battlefields of World war I

Cont.
The concept of triage has also been applied to disasters Implementation of triage process in ED was initiated in the late 1950s and the early 1960s Triage ialah suatu proses dimana pasien digolongkan menurut tipe dan tingkat kegawatan kondisinya.

Principles Of Triage
1. 2. 3. 4. 5. 6. Immediate & timely Adequate and accurate assessment Assessment based decisions Interventions according to acuity Patient satisfaction Complete documentation

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

Triage Classification
Triage classification based on knowledge, available data and the current situation. Triage classification often used :
Priority 1 or Emergency Priority 2 or Urgent Priority 3 or Non Urgent

Sistem Klasifikasi

Sistem Klasifikasi
Menggunakan nomor, huruf atau tanda

Prioritas 1 atau Emergensi Pasien dgn kondisi mengancam nyawa,

memerlukan evaluasi dan intervensi segera Pasien dibawa ke Ruang Resusitasi Waktu tunggu nol

Triage

Prioritas 2 / Urgent
Pasien dgn penyakit yg akut Mungkin membutuhkan trolley, kursi roda atau jalan kaki Waktu tunggu 30 menit Area Critical care

Triage

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Prioritas 3 / Non Urgent

Pasien yg biasanya dapat berjalan dgn masalah medis yang minimal Luka lama Kondisi yang timbul sudah lama Area Ambulatory / Ruang P 3

Triage

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Prioritas 0 / 4 Kasus kematian

Tdk ada respon pada segala rangsangan Tdk ada respirasi spontan Tdk ada bukti aktivitas jantung Hilangnya respon pupil thd cahaya

Triage

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START METHODE ( SIMPLE TRIAGE & RAPID TREATMENT)

Respiration
None open the airway
Still none deceased Restored immediate

Present
Above 30 immediate Below 30 check perfusion

Cont.
Perfusion Radial pulse absent or capillary refill >2 sec immediate Radial pulse present or capillary refill < 2 sec check mental status

Cont.
Mental status Can not follow simple commands (unconscious or AMS) Immediate Can follow simple commands Delayed

Pengkajian Triage ( Soap System )

Gathers subjective and objective data for quick assessment Enables accurate planning for nursing intervention and immediate management Is a 2 minutes process Is effective for documentation of nursing assessment

WHAT IS SOAP ?
S Subjective Collect data about what the patient is telling you. Objective What are you actually seeing? Parameters Assessment Assess the situation. Plan Establish a plan for the patient.

O -

A -

P -

TRIAGE PROCES
S - SUBJECTIVE Collect subjective data Ask open ended questions e.g. Why did you want to see a doctor? Gather other relevant information Obtain brief one-line statements.

QUESTIONS TO ASK
Chief complaint? Location? Site of pain? Pattern? Radiation? Time of onset? Duration? Frequency? Character, Quality? e.g. ?Colicky

Cont..
Effects to other system and activities e.g. fever (1 week) & now having bleeding PR Effort to treat ? seen by GP/Polyclinic self medicate Past medical history & drug allergy

TRAUMA CASES
Mechanism of injury must be noted. 1. Ask how the patient was injured. 2. Other Questions When did the accident occur? How fast was the car travelling? Where were you sitting? Were you wearing a seat belt? Did you hit the dashboard and were you thrown against another car? Did you lose consciousness?

Pain assesment
Pain is one of the most command complaints. PQRST is a helpful method of evaluating pain. P Provokes / palliates / pattern What precipitated the pain ? What makes it better or worse ? What were you doing when it started ?

Cont.
Q quality Describe the quality of the pain dull,colicky,sharp ? What does it fell like ? R region Where is the exact location of the pain ? Ask patient to point to the area Does the pain spread to anywhere else?

Cont..
S- severity How severe is the pain or symptom? Use rating scale ex.number rating, visual analog scale, Are there any associated symptoms? T - time When did the pain start and how long did it lasts (duration) ?

O - OBJECTIVE
Collect objective data : General Mode of arrival to A&E Level of consciousness; GCS (Trauma Case) Patients general appearance using your senses Vital signs temperature,pulse, respiration & BP

A - ASSESSMENT
Assess and evaluate patient from subjective and objective data collection.

P - PLAN
Establish your priority & direct to appropriate area. Carry out further tests if required ECG Peripheral blood glucose Urine Lab stix/Combur 9; Urine for inspection Institute first aid management: Immobilize fracture Put on cervical collar First aid dressing X-ray

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

Cont
Diagnostic tes ordered Intervention rendered Disposition Reevaluation and changes in condition

Questions & Answers

Triage - Extremity Trauma

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Wassalamualaikum