Improvements of Paediatric Triage at the Emergency Department

__Abstract__ The practice of triage, originated from the French word “trier” which means to sort, was conceived around 1792 by Baron Dominique-Jean Larrey, Surgeon in Chief to Napoleon’s Imperial Gard. In these days, triage was used to identify soldiers whose injuries were readily treatable in order to return them to battlefield at the earliest opportunity. In 1846, the British naval surgeon John Wilson was the first who argued that treatment should be given first to patients who need immediate and potentially successful treatment. During World War I, the introduction of new weapons created an unprecedented number of potentially treatable mass casualties. This led to a wide introduction of the term “triage” and to a new definition of its concept, in which triage was not only aimed at sorting treatable patients from untreatable patients, but also took into account the complexity of treatable patients in order to save as much patients as possible. Nowadays, triage aims to prioritise patients according to their medical presentation in situations with modest scarcity of health care resources. This scarcity of resources is not only present at the military battlefield or in case of mass casualties and disasters, but can also occur at the emergency department (ED) or in the hospital settings with limited numbers of beds such as the intensive care unit. Although all these settings have distinguishing features, each requires the presence of a trained health care worker (“triage nurse”) to assess the patient’s medical needs, and an established system or plan to determine patient’s priority

Performance of triage systems in emergency care: a systematic review and meta-analysis

Objective To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED). Design Systematic review and meta-analysis. Data sources EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018. Eligibility criteria Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded. Review methods Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems’ performance. Results Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems’ performance. Conclusions Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems’ performance and how the performance of existing triage systems can be improved

Validity of different pediatric early warning scores in the emergency department

Objective: Pediatric early warning scores (PEWS) are being advocated for use in the emergency department (ED). The goal of this study was to compare the validity of different PEWS in a pediatric ED. Methods: Ten different PEWS were evaluated in a large prospective cohort. We included children aged >16 years who had presented to the ED of a university hospital in The Netherlands (200922012). The validity of the PEWS for predicting ICU admission or hospitalization was expressed by the area under the receiver operating characteristic (ROC) curves. Results: These PEWS were validated in 17 943 children. Two percent of these children were admitted to the ICU, and 16% were hospitalized. The areas under the ROC curves for predicting ICU admission, ranging from 0.60 (95% confidence interval [CI]: 0.5720.62) to 0.82 (95% CI: 0.79-0.85), were moderate to good. The area under the ROC curves for predicting hospitalization was poor to moderate (range: 0.56 [95% CI: 0.55-0.58] to 0.68 [95% CI: 0.66-0.69]). The sensitivity and specificity derived from the ROC curves ranged widely for both ICU admission (sensitivity: 61.3%-94.4%; specificity: 25.2%-86.7%) and hospital admission (sensitivity: 36.4%-85.7%; specificity: 27.1%-90.5%). None of the PEWS had a high sensitivity as well as a high specificity. Conclusions: PEWS can be used to detect children presenting to the ED who are in need of an ICU admission. Scoring systems, wherein the parameters are summed to a numeric value, were better able to identify patients at risk than triggering systems, which need 1 positive parameter

Accuracy of triage for children with chronic illness and infectious symptoms

OBJECTIVE: This prospective observational study aimed to assess the validity of the Manchester Triage System (MTS) for children with chronic illnesses who presented to the emergency department (ED) with infectious symptoms. METHODS: Children (<16 years old) presenting to the ED of a university hospital between 2008 and 2011 with dyspnea, diarrhea/vomiting, or fever were included. Chronic illness was classified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes. The validity of the MTS was assessed by comparing the urgency categories of the MTS with an independent reference standard on the basis of abnormal vital signs, life-threatening working diagnosis, resource utilization, and follow-up. Overtriage, undertriage, and correct triage were calculated for children with and without a chronic illness. The performance was assessed by sensitivity, specificity, and diagnostic odds ratios, which were calculated by dichotomizing the MTS into high and low urgency. RESULTS: Of the 8592 children who presented to the ED with infectious symptoms, 2960 (35%) had a chronic illness. Undertriage occurred in 16% of children with chronic illnesses and in 11% of children without chronic illnesses (P < .001). Sensitivity of the MTS for children with chronic illnesses was 58% (95% confidence interval [CI]: 53%-62%) and was 74% (95% CI: 70%-78%) for children without chronic illnesses. There was no difference in specificity between the 2 groups. The diagnostic odds ratios for children with and without chronic illnesses were 4.8 (95% CI: 3.9-5.9) and 8.7 (95% CI: 7.1-11), respectively. CONCLUSIONS: In children presenting with infectious symptoms, the performance of the MTS was lower for children with chronic illnesses than for children without chronic illnesses. Nurses should be particularly aware of undertriage in children with chronic illnesses