| 4. In which ways is the initiative creative and innovative?
Instagram is better than conventional emergency service because of implementation of Patient Acuity Category System modified with modern emergency department by dividing zones based on the level of patients’ acuity as follow:
1. Primer triage system
Triage medical personnel have visual screening without any tools. The examination looking for the condition of the patient only from patients’ expression and condition of the patient (eagle eye). Based on the result of screening, patient is recommended to be taken into critical area (red zone) or secondary triage.
2. Secondary triage system
Patient gets triage examination by a doctor to decide the level of acuity based on the zone of service needed by the patient.
3. Green zone system
Green zone is used as an outpatient care room in emergency department.
4. Yellow zone system
It is used for patient who needs no more than 6 hours observation or for hospitalized patient.
5. Red zone system
Prepared for highest priority who needs quick intervention to safe the patient with 0 (zero) minute response time. Emergency service is done by an emergency specialist and qualified as well as certified medical personnel team.
6. Tulungagung Emergency Medical Services/TEMS
Pre-hosppital service which is integrated with Instagram.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Instagram is conducted by team of emergency department Dr. Iskak Tulungagung general hospital that consists of emergency specialist, doctor and nurses. Instagram is also supported by team of Tulungagung Emergency Medical Services/TEMS that consists of hospital PHC team, Public health service PHC team, BPBD team, Police team, and fire station team.
Instagram serves emergency patient in Tulungagung Regency and some other surrounding regencies such as Blitar, Trenggalek and Pacitan. Meanwhile, TEMS serves patients in every single part of Tulungagung.
| 6. How was the strategy implemented and what resources were mobilized?
The success of instagram and TEMS are supported by the commitment of the Regent of Tulungagung and all integrated institutions to complete the needed facilities as follow:
1. Financial Resources
a. 13 Billion Rupiah Credit from Bank Jatim in 2012 was used to build the emergency department with patient acuity category system modified with modern emergency department.
b. The Indonesian Budget (APBN) in 2013 in the amount of 9 Billion rupiah is used to purchase both medical equipment and doctors’ equipment.
c. Tulungagung regional budget in 2014 in the amount of 3.5 Billion Rupiah is used for developing the emergency department with pre-hospital service and Tulungagung emergency medical service and purchasing the hardware.
d. Public Service Agency Dr. Iskak Tulungagung general hospital in 2015 in the amount of 900 million rupiah is used to build the software of Tulungagung Emergency Medical service and the operational budget of emergency department.
2. Human Resources
Both human resources’ knowledge and skill are prepared well through practices in handling emergency. Human resources involves in Instagram are:
a. Emergency specialist doctor as a leader
b. Skillful and qualified nurse
c. Skillful ambulance driver
Police officers and staff, Regional Disaster Mitigation Agency, Kodim and staff, and also health department and public health services as the networking.
The significance of developing Instagram and TEMS for community are as follow:
a. Getting more quickly emergency service, easier and safer according to the level of acuity.
b. Getting certainty and follow up treatment for emergency service.
c. Getting easier information in health service from home by dealing call center.
d. Getting guidance to have first aid before the pre hospital care (PHC) arrives.
e. Getting education and practice in emergency first aid for public community.
f. Decreasing the number of death less than 24 hours.
The implementation of emergency service using patient acuity category system modified with modern emergency department is done in some phases as follow:
a. In 2011, Dr. Iskak Tulungagung general hospital held comparative study about emergency unit service system by using patient acuity category system in Hospital Kuala Lumpur Malaysia.
b. In 2011, Dr. Iskak Tulungagung general hospital planned the concept of emergency room spatial and the budget.
c. In 2012, Dr. Iskak Tulungagung general hospital started to build the emergency unit with the design of spatial was based on the patient acuity category system modified with modern emergency department.
d. In 2013, Dr. Iskak Tulungagung general hospital started the operational of the emergency by implementing patient acuity category system modified with modern emergency department. In the operation of emergency unit, there were many sophisticated facilities provided, expert human resources in emergency field, emergency specialist doctor, and skillful nurses in emergency problems. Those are for the guarantee of the rapidity service.
e. In 2014, Dr. Iskak Tulungagung general hospital planned the development of integrated pre-hospital services (Tulungagung Emergency Medical Service/TEMS) with some linked institutions such as Police, Regional Disaster Mitigation Agency and Basic Health Service.
f. In 2015, it was the realization of pre-hospital service with Tulungagung Emergency medical Service System which is integrated with police, Regional Disaster Mitigation Agency, Public health service or Puskesmas as pre hospital care (PHC)
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Stakeholders who have contributed in developing Instagram and TEMS are:
a. The Regent of Tulungagung as an initiator in developing emergency department by adapting Patient Acuity Category system modified with modern emergency department.
b. Dr. Iskak Tulungagung general hospital as the doer of the emergency unit by adapting Patient Acuity Category system modified with modern emergency department program. This involves doctor, nurses and all staffs.
c. Bank Jatim as the creditor in developing emergency unit by adapting Patient Acuity Category system modified with modern emergency department.
d. Regional Development Agency of Tulungagungas the planner of the development of emergency unit by adapting Patient Acuity Category system modified with modern emergency department.
e. Tulungagung Financial Planner as the funder in the development and operation of emergency unit by adapting Patient Acuity Category system modified with modern emergency department program.
f. Health department of Tulungaung and the staffs (puskesmas / public health service) as an integral part for the service of pre hospital care (PHC) in Public Safety Center (PSC).
g. Tulungagung Police Officer as an integral part of the Public Safety Center (PSC) dealing with police and non-medical emergency case.
h. Tulungagung Disaster Mitigation Agency (Badan Penanggulangan Bencana Daerah) as an integral part of Public Safety Center (PSC) dealing with disaster and non-medical emergency case.
i. Public community who are able to access the health, medical emergency and non-medical emergency services.
| 8. What were the most successful outputs and why was the initiative effective?
The most successful outputs that supports the development of instagram are:
a. Building the emergency department with Patient Acuity Category system modified with modern emergency department (instagram).
Its service becomes easier to be accessed and the service of emergency can be done more quickly with 0 (zero) response time for red zone. As a result, the number of death and disability can be reduced.
b. Classifying the patient based on the level of acuity.
This is able to ease and speed up the service in emergency unit. Moreover, it can reduce the complaints from community about discrimination in service based on the arrival.
c. Pre-hospital service with Tulungagung Emergency Medical System (TEMS).
It is able to make the emergency service closer to the community through call center so the treatment can be done earlier. With early service, the golden period to handle patient can be done to reduce the number of death and disability.
d. TEMS Ambulances
Special emergency ambulance equipped with emergency tools and professional team comes to the scene and gives certain treatment in the scene. In the ambulance, the golden period can be achieved and able to reduce the number of death or disability.
e. Call center system
It consists of informational technology software and supported hardware. Call center system covers the manual of handling emergency. It can give the direct instruction for the first aid while waiting for PHC team arrives in the location. Radio communication is used to have additional communication when telephone communication cannot be used because of the lack of signal. GPS device is used to know the location so the PHC team can quickly come to give the first aid. This system has already been integrated with police and Tulungagung Disaster Mitigation Agency. Good coordination in handling cases can be divided into medical emergency case helped by hospital PHC team or public health service (puskesmas) and non medical emergency handled by police or Regional Disaster Mitigation Agency. Those three institutions is PHC team of Tulungagung Emergency Medical Service (TEMS). This aims at creating safe community to reach Tulungagung Ayem tentrem Mulyo Lan Tinoto.
| 9. What were the main obstacles encountered and how were they overcome?
Some of obstacles encountered in the implementation of Instagram in Dr. Iskak Tulungagung general hospital are as follow:
a. Over capacity caused by high number of patients especially in yellow zone. Some efforts has been done by adding extra bed and build virtual room as a transit spot.
b. Tulungagung Emergency Medical Services program with 0355-320119 as call center has not been known yet by community. To overcome this problem, Dr. Iskak Tulungagung general hospital holds socialization, education, and advertisement through radio, television, newspaper and online media. It is hoped that community can take the advantages from call center when they get health problems.
c. As a new program, the coordination with public safety center (PSC) networks and across the sectors has not been done maximally. Therefore, regular meetings are held to discuss problems and alternative solutions for the sake of the program can run smoothly.