ENSURE HEALTY FOR SOCIETY THROUGH MODERN EMERGENCY SERVICES IN DR. ISKAK TULUNGAGUNG GENERAL HOSPITA
Dr. Iskak Tulungagung General Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In Indonesia, the number of death patient less than 24 hours is still high. In 2013, this number reached 14.15‰ (per mile). Meanwhile, in the emergency department of RSUD dr. Iskak Tulungagung, it reached 12.2‰ (per mile). This situation is far from being the national minimum standard of service that is 2‰ (per mile). The cause of the high number of death in emergency unit of dr. Iskak Tulungagung general hospital is caused by conventional classifying system that makes the complexity of the classification based on the level of acuity. This condition makes the response time in the emergency department achieved 11 minutes and it is over the national minimum standard of service that is 5 minutes. This high number of death is also caused by the lack of pre-hospital service for emergency patient. Moreover, emergency department of Dr. Iskak Tulungagung general hospital has not had the standard quality hospital equipment used for helping emergency patient. This condition is worsen by the first aid of field emergency service that does not meet the standard of emergency service. Besides, the conventional classification of the patients creates the complaints from the patients and their families who do not understand the importance of classifying the patient based on the level of acuity. Before the implementation of the innovation, patients just understand about who comes earlier will be served earlier too. This misunderstanding increased the number of complaints in emergency department services. It reached 37 complaints in 2012 and 25 complaints in 2013. The condition of these services cannot be ignored. It needs solutions and innovations in services, considering that this situation promotes the disadvantages for the patient with high level of acuity. Beside those problems, Dr. Iskak Tulungagung general hospital is the only state hospital belongs to Tulungagung Regency which is classified into type B non-educational that becomes a referral hospital for emergency service from several health service facilities in Tulungagung that includes 7 private hospitals, 3 special hospital, 12 inpatient public health service and 19 outpatient public health service. Moreover, RSUD dr. Iskak is also a regional referral hospital for other regent such as Blitar, Trenggalek and Pacitan. Based on the problems of emergency services and considering the importance of the existence of Dr. Iskak Tulungagung general hospital as well for emergency services in the surroundings, Dr. Iskak Tulungagung general hospital made an innovation in the integration of emergency service that covered pre-hospital service and intra-hospital service and also integrated by well informational system, communication and coordination. The target of this program is Tulungagung Regency community and surroundings that suffer from emergency condition and use the facility of integrated emergency services.

B. Strategic Approach

 2. What was the solution?
As a solution of the problems, Dr. Iskak Tulungagung general hospital has developed modern emergency installation (Instalasi Gawat darurat Modern or ‘Instagram’). Instagram is a system of Patient Acuity Category based emergency service modified by modern emergency department. This system is supported by modern health equipment for emergency service and integrated with standard pre-hospital service (Tulungagung Emergency Medical Services/TEMS) and connected directly with public health service, police station, fire station, and Tulungagung Disaster Mitigation Agency.

 3. How did the initiative solve the problem and improve people’s lives?
This instagram is a system that has priority in the appropriateness and rapidity in handling patients’ emergency cases. Through implementation of this system, patient will get rapid, appropriate and safe help based on the classification of the acuity by using zone. The successful strategy in the implementation of Modern Emergency Installation (Instagram) is from its classification of zone. Patients are classified based on the level of acuity so that the service is more focus and quick. Appropriateness and rapidity in handling the emergency patient in the hospital is one of the deciding factor in the patients’ recovery and to avoid disability and even death. By implementing instagram, the priority of service is no longer based on the attendance of the patient but the level of acuity. The classification of the patient is done since he/she is in the emergency unit drop zone (triage primer) by using visual checking of senior nurse. Patient with high level of acuity and need basic life help is put in the critical zone or red zone. In the red zone, the response time is 0 (zero) minute and handled by emergency specialist and nurse that holds the certificate of handling emergency patient. In emergency department, the acuity of patients are treated until it is stable and then they are disposed based on the expertise unit to the intensive room. For patients who need supporting checking such as laboratory and radiology, they are ready in emergency unit. Moreover, if it is needed emergency surgery, it can be done in the second floor emergency unit. There are two emergency surgery rooms. For non-critical patient, instagram does the classification in secondary triage. Patient gets an examination from doctor and nurse by using some equipment. If it is found that the patient is classified into acuity patient, patients will be put in the red zone. If it is found that the patient is semi-critical, he or she is put into yellow zone with 15 minutes response time. In yellow zone the patient gets an appropriate examination and service with his/her case and it is completed with supporting checking to support the diagnosis. For about 2 hours, the diagnosis must be valid and the patient can be taken into the ward. Meanwhile, for non-acuity patient will be dropped into green zone with 30 minutes response time. Service for the patient in green zone is same as the service in polyclinic. Patient gets an examination and medication. If the patient needs observation, maximally for 6 hours, the patient must be given a decision to be hospitalized or not. In line with the community needs in rapidity of emergency service that is informed in community complaints service and mass media about the differences of giving service in emergency department, Dr. Iskak Tulungagung general hospital made a plan and feasibility study to develop integrated emergency unit which already finished and officially opened in 2013. To support the emergency service, professional human resources are needed. To improve the human resources quality, in 2014, Dr. Iskak Tulungagung general hospital sent some medical personnel and nurses in Kuala Lumpur Malaysia for about a month to learn more pre-hospital service through emergency medical service. Then, to speed up the patients’ emergency service, in 2014, Dr. Iskak Tulungagung general hospital developed an ‘instagram’ program with additional Tulungagung Emergency Medical Service (TEMS) program. TEMS is a pre-hospital service that is already integrated with Instagram. TEMS which is completed with equipment, facilities and competent pre-hospital care teams in giving first aid in emergency case. Implementing various strategies, Instagram is successful in decreasing the number of death in emergency patient.

C. Execution and Implementation

 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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Main significances for the community from the implementation of Instagram and TEMS are as follow: a. Community gets a more safety, quick, and easier emergency service according to the level of acuity. b. Community gets certainty and follow up treatment in emergency service. c. Community easily gets information about health service since in the patients’ house by using call center. d. Community can be guided to give first aid before pre-hospital care (PHC) team arrived. e. Community gets education and emergency training. f. The number of death less than 24 hours can be decreased. Besides positive effect for community, there are some other significances of Instagram and TEMS for related sectors as follow: Medical personnel: a. Getting easy to give service because there has been zone classification based on the level of acuity. b. Having appropriate knowledge and skill in serving the patients because they have been categorized into each rooms based on the level of acuity. c. Knowing the patients’ health records before they come to the hospital so that all facilities can be prepared before the patients arrived. d. Giving treatment earlier since in the place of accident then continued into ambulance until arriving in the hospital. In this case, the golden period of the patient can be reached. Policies makers (hospital management, regional government, and Regional House of Representatives): a. Plan for the development and maintenance and operational as well for medical and non-medical equipment are easier because the implementation of the system is more focus and obvious. b. Give wider emergency service to the community. c. Have complete and regular data to be used in making policy and decision easier and more appropriate. d. Plan for the next steps in developing health sector in Tulungagung.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Those are shows the difference in emergency service before and after the implementation of Instagram and TEMS. 1. Response Time Before Innovation (before 2013) 11 mimutes After Innovation (after 2014) 0 minutes 2. Patients’ categorization Before Innovation (before 2013) There was no category After Innovation (after 2014) Categorized into zones (green, yellow, red) 3. Number of Complaints Before Innovation (before 2013) 37 (2012), 25 (2013) After Innovation (after 2014) 7 4. Number of visitors Before Innovation (before 2013) 86 per day in average After Innovation (after 2014) 120 per day in average 5. Number of visitors Before Innovation (before 2013) 67.03 After Innovation (after 2014) 81.56 6. Number of death in less than 24 hours Before Innovation (before 2013) 12.2 ‰ After Innovation (after 2014) 2.2 ‰ 7. Emergency facilities Before Innovation (before 2013) Could not meet the standard/ under the standard After Innovation (after 2014) Could meet the international standard 8. Call Center service Before Innovation (before 2013) No After Innovation (after 2014) Yes 9. pre-Hospital service Before Innovation (before 2013) No After Innovation (after 2014) Yes

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Instagram and TEMS focuses on the case of emergency services both medical and non-medical. Instagram and TEMS priority are based on the level of acuity regardless of economic status, gender, and age. Instagram and TEMS also provide special services provided include: 1. Maternal neonatal emergency services. Provide special hospital service flow in emergency conditions of mothers and children. 2. The psychiatric emergency service. Provide a special place and service in patients with acute mental disorders /restless. 3. The pre-hospital services for cases of violence against women and children. This service uses the call center Tulungagung Emergency Medical Services (TEMS) with hotline number 0355-320119. An example in case of violence on children and mothers in the community directly to the call center phone TEMS. Data and location of the complainant will be transferred to the Pre Hospital Care team medical TEMS and to Tulungagung Police Command Centre. So that the police and an ambulance will come to the scene simultaneously.

Contact Information

Institution Name:   Dr. Iskak Tulungagung General Hospital
Institution Type:   Local Government  
Contact Person:   Bobi Prabowo
Title:   doctor  
Telephone/ Fax:   +62355320609 / +62355322165
Institution's / Project's Website:  
E-mail:   bprabowo28@gmail.com  
Address:   Dr. Wahidin sudiro husodo street
Postal Code:   66223
City:   Tulungagung
State/Province:   East Java
Country:  

          Go Back

Print friendly Page
video porno.. brasileiros xxx xhamster