Diana Pefbrianti, S.Kep., Ns., M.

Kep
-Minimal dokter ( BTCLS, PPGD )
-Peralatan emergency kit
-Oksigen .
-Long spine board
-Rekam medis.
-Balut bidai -Stabilisasi urgent
-Selimut. -Minimal dokter ( BTCLS, PPGD )
-payung -Peralatan emergency kit.
-Balut bidai. -Non emergency collecting
-Oksigen . -Minimal perawat ( BTCLS,
-Long spine board PPGD )
-Rekam medis. -Rekam medis
-Selimut, payung -Peralatan rawat luka minor
- Air minum.- Death body collective
-Selimut. - DVI tim
- Kantong mayat
- Rekam medis.
 Purpose of ED triage: To prioritize incoming
patients and to identify those who cannot
wait to be seen
 Three most common types of triage systems:
 Traffic director
 Spot-check
 Comprehensive triage
 The emergency staff triages each patient and
determines the priority of care based on
physical, developmental and psychosocial
needs as well as factors influencing access to
health care and patient flow through the
emergency care system.
 Urgency refers to the need for time-critical
intervention – it is not synonymous with
severity
 Triage assessment is not necessarily intended
to make a diagnosis
 Patients triaged to lower acuity categories
may be safe to wait longer for assessment
and treatment but may still require hospital
admission
 “Who should be seen first?”
 “How long can everybody wait?”
 ESI triage is a rapid sorting into five groups
with clinically meaningful differences in
projected resource needs and therefore,
associated operational needs.
 Use of the ESI for this rapid sorting can lead
to improved flow of patients through the ED.
 A Yes
Patient dying? 1

No

B
Yes
Shouldn’t wait? 2
No

How many resources? C Consider

None One Many

D No
Vital signs 3
5 4
 Does the patient require immediate life-
saving intervention?
 Aimed at securing the ABC’s

 Does the patient require an immediate

airway, medication, or other hemodynamic
intervention? (IV, supplemental O2, monitor,
ECG or labs DO NOT count)
 Does the patient meet any of the following
criteria:
 Already intubated
 Apneic and pulseless
 Severe respiratory distress
 Acute mental status changes, or unresponsive
 Cardiac arrest/ Respiratory arrest
 Critically injured trauma patient who presents
unresponsive
 Overdose with a respiratory rate of 6
 Severe respiratory distress with agonal or
gasping type respirations.
 Severe bradycardia or tachycardia with signs
of hypoperfusion
 Hypotension with signs of hypoperfusion
 Trauma patient who requires immediate
crystalloid and colloid resuscitation
 Chest pain, pale, diaphoretic, blood pressure
palpatory
 Weak and dizzy, heart rate < 50
 Anaphylactic reaction
 Unresponsive with strong odor of ETOH
 Hypoglycemia with a change in mental status
 Is this a high risk situation?
 patient you would put in your last open bed
 Is the patient confused, lethargic or
disoriented?
 Is the patient in severe pain or distress?
 determined by clinical observation and/or patient
rating of greater than or equal to 7 on 0-10 pain
scale
System Examples/diagnosis
Abdomen Abdominal pain in the elderly,
Gastrointestinal bleeding
Cardiac Chest pain
Acute arterial occlusion
History of angioplasty with
chest pain
Pericardial effusion
Infective endocardititis
General Immunocompromised patients
Oncology patients
Genitourinary Testicular torsion
Acute renal failure
Signs/symptoms
Severe pain or unstable vital signs;
Tachycardia, vomiting blood or
bright red blood per rectum
Constant or intermittent
Absence of distal pulse
Stable vital signs
Chest pain and dyspnea
History of drug use
May or may not have fever
Sudden onset of testicular pain;
Unable to be dialyzed
System Examples/diagnosis Signs/symptoms
Gynecological Ectopic pregnancy (+ )pregnant, severe lower
quadrant pain
Spontaneous abortion Bleeding and tachycardia even
with stable blood pressure
Neurologic Rule out meningitis Headache, fever, lethargy
History of multiple CVD Motor or speech deficits
Stroke Severe headache with
mental status changes, high
blood pressure
Respiratory Severe asthma Severe shortness of breath
Spontaneous pneumothorax Sudden dyspnea
Trauma Motor vehicle crash with transient History of head trauma
loss of consciousness
Blunt and Penetrating Trauma
 A Yes
Patient dying? 1

No

B
Yes
Shouldn’t wait? 2
No

How many resources? C Consider

None One Many

D No
Vital signs 3
5 4
 What is typically done for the patient who
presents to the emergency department with
this common complaint?
 Resources can be hospital services, tests,
procedures, consults or interventions that are
above and beyond the physician history and
physical, or very simple emergency
department interventions such as applying a
bandage.
RESOURCES
Labs (blood, urine)
ECG, X-rays, CT-MRI-ultrasound
angiography
IV fluids (hydration)
IV, IM or nebulized medications
Specialty consultation
Simple procedure = 1
(laceration repair, Foley cath)
Complex procedure = 2
(conscious sedation)
NOT RESOURCES
History & physical
(including pelvic)
Point-of-care testing
Saline or heplock
PO medications
Phone call to PCP
Simple wound care (dressings, recheck)
Crutches, splints, slings
ESI Patient Presentation Interventions Resources
Level
5 Healthy 52-year-old male ran out Needs an exam and None
of blood pressure medication prescription
yesterday; BP 150/92
4 Healthy 19-year-old with sore Needs an exam, CBC and Lab tests
throat and fever possibly throat culture, (throat culture
prescriptions and CBC)
4 Healthy 29-year-old female with a Needs an exam, urine, Lab (Urinalysis,
urinary tract infection, denies and urine C&S, preg test, Urine C&S,
vaginal discharge and prescriptions Pregnancy
test)
3 A 22-year-old male with right Needs an exam, lab 2 or more
lower quadrant abdominal pain studies, IV fluid,
since early this morning (+) abdominal CT, and
nausea, no appetite perhaps surgical consult
 Before assigning a patient to ESI level 3, the
staff needs to look at the patient's vital signs
and decide whether they are outside the
accepted parameters
 Danger zone vital signs:
 Adults(>8 years old) = Pulse <50 or >100
RR <10 or >30
BP <90/60
SaO2 <80%
 A Yes
Patient dying? 1

No

B
Yes
Shouldn’t wait? 2
No

How many resources? C Consider

None One Many

D No
Vital signs 3
5 4
 PATIENT SHOULD BE
LEVELS AREA ASSIGNED SEEN BY PROVIDER
WITHIN
1 - Resuscitation Resuscitation Area 0 minutes
2 - Emergent Critical Beds 10 minutes
3 - Urgent Acute Beds 30 minutes
4 - Semi-urgent Acute or Primary Care 60 minutes
5 - Nonurgent Primary Care 120 minutes
 A 44-year-old female is retching continuously
into a large basin as her son wheels her into
the triage area. Her son tells you that his
diabetic mother has been vomiting for the
past 5 hours and now it is “just this yellow
stuff.” “She hasn't eaten or taken her insulin,”
he tells you. No known drug allergies (NKDA).
VS: BP 148/70, P 126, RR 24
 “I have this infection in my cuticle,” reports a
26-year-old healthy female. “It started
hurting 2 days ago and today I noticed the
pus.” The patient has a small paronychia on
her right 2nd finger. NKDA, T 37.8° F, RR 14,
HR 62, BP 108/70
 “My mother is just not acting herself,” reports
the daughter of a 72-year-old female. “She is
sleeping more than usual and complains that
it hurts to pee.” VS: T 100.8° F, HR 98, RR 22,
BP 122/80. The patient responds to verbal
stimuli but is disoriented to time and place
 A 76-year-old male is brought to the ED because of
severe abdominal pain. He tells you “it feels like
someone is ripping me apart.” The pain began about
30 minutes prior to admission and he rates the
intensity as 10/10. He has hypertension for which he
takes a diuretic. No allergies. The patient is sitting in
a wheelchair moaning in pain. His skin is cool and
diaphoretic. VS: HR 122, BP 88/68, RR 24, SpO2 94%
 A 68-year-old female presents to the ED with her
right arm in a sling. She was walking out to the
mailbox and slipped on the ice. “I put my arm out to
break my fall. I was lucky I didn't hit my head.” Right
arm with good circulation, sensation, and
movement, obvious deformity noted. medications:
ibuprofen, NKDA. Vital signs within normal limits.
She rates her pain as 6/10.
 Review of all negative outcomes which
occurred due to a mis-triage
 Measurement of time from patient arrival to
being seen by a physician for each ESI triage
category
 Measurement of length of stay for each ESI
triage category
 Measurement of admission rates for each ESI
triage category