12 research outputs found
Paediatric Emergency Triage: Improving the initial assesssment of children in the emergency department using electronic health record data
This thesis aims to improve the first assessment of children presenting at the emergency department. It consists of several studies based on electronic health record data that 1) describe the performance of triage systems; 2) assess how the Manchester Triage System can be improved; 3) evaluate and develop novel predictors and tools for the triage of childre
Association between hypotension and serious illness in the emergency department: an observational study
Background The value of routine blood pressure
measurement in the emergency department (ED) is
unclear.
Objective To determine the association between
hypotension in addition to tachycardia and the Shock
Index for serious illness.
Design Observational study.
Setting University ED (2009–2016).
Participants, methods and main outcomes Routine
data collected from consecutive children <16 years.
Using logistic regression, we assessed the association
between hypotension (adjusted for tachycardia) and
Shock Index (ratio heart rate/blood pressure [BP]) for
serious illness. The predictive accuracy (sensitivity,
specificity) for hypotension and Shock Index was
determined for serious illness, defined as intensive care
unit (ICU) and hospital admissions.
Results We included 10 698 children with measured
BP. According to three age-adjusted clinical cut-offs
(Advanced Paediatric Life Support, Paediatric Advanced
Life Support and Paediatric Early Warning Score),
hypotension was significantly associated with ICU
admission when adjusted for tachycardia (range OR
2.6–5.3). Hypotension showed low sensitivity (rang
A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: A systematic review
Background: Different definitions exist for hypotension in children. In this study, we aim to identify evidence-based reference values for low blood pressure and to compare these with existing definitions for systolic hypotension. Me
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
Sex-specific differences in children attending the emergency department: prospective observational study
Objective To assess the role of sex in the presentation
and management of children attending the emergency
department (ED).
Design The TrIAGE project (TRiage Improvements Across
General Emergency departments), a prospective observational
study based on curated electronic health record data.
Setting Five diverse European hospitals in four countries
(Austria, The Netherlands, Portugal, UK).
Participants All consecutive paediatric ED visits of
children under the age of 16 during the study period (8–36
months between 2012 and 2015).
Main outcome measures The association between
sex (male of female) and diagnostic tests and disease
management in general paediatric ED visits and in
subgroups presenting with trauma or musculoskeletal,
gastrointestinal and respiratory problems and fever.
Results from the different hospitals were pooled in a
random effects meta-analysis.
Results 116172 ED visits were included of which
63042 (54%) by boys and 53715 (46%) by girls. Boys
accounted for the majority of ED visits in childhood, and
girls in adolescence. After adjusting for age, triage urgency
and clinical presentation, girls had more laboratory tests
compared with boys (pooled OR 1.10, 95%CI 1.05 to 1.15).
Additionally, girls had more laboratory tests in ED visits for
respiratory problems (pooled OR 1.15, 95%CI 1.04 to 1.26)
and more imaging in visits for trauma or musculoskeletal
problems (pooled OR
Management of children visiting the emergency department during out-of-office hours: An observational study
Background The aim was to study the characteristics
and management of children visiting the emergency
department (ED) during out-of-office hours.
Methods We analysed electronic health record data from
119 204 children visiting one of five EDs in four European
countries. Patient characteristics and management
(diagnostic tests, treatment, hospital admission and
paediatric intensive care unit admission) were compared
between children visiting during office hours and evening
shifts, night shifts and weekend day shifts. Analyses were
corrected for age, gender, Manchester Triage System
urgency, abnormal vital signs, presenting problems and
hospital.
Results Patients presenting at night were younger
(median (IQR) age: 3.7 (1.4–8.2) years vs 4.8 (1.8–9.9)),
more often classified as high urgent (16.3% vs 9.9%) and
more often had ≥2 abnormal vital signs (22.8% vs 18.1%)
compared with office hours. After correcting for disease
severity, laboratory and radiological tests were less likely
to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78–
0.86 and aOR: 0.64, 95% CI 0.60–0.67, respectively);
treatment
Improving the prioritization of children at the emergency department: Updating the Manchester Triage System using vital signs
BACKGROUND: Vital signs are used in emergency care settings in the first assessment of children to identify those that need immediate attention. We aimed to develop and validate vital sign based Manchester Triage System (MTS) discriminators to improve triage of children at the emergency department. METHODS AND FINDINGS: The TrIAGE project is a prospective observational study based on electronic health record data from five European EDs (Netherlands (n = 2), United Kingdom, Austria, and Portugal). In the current study, we included 117,438 consecutive children <16 years presenting to the ED during the study period (2012-2015). We derived new discriminators based on heart rate, respiratory rate, and/or capillary refill time for specific subgroups of MTS flowcharts. Moreover, we determined the optimal cut-off value for each vital sign. The main outcome measure was a previously developed 3-category reference standard (high, intermediate, low urgency) for the required urgency of care, based on mortality at the ED, immediate lifesaving interventions, disposition and resource use. We determined six new discriminators for children <1 year and ≥1 year: "Very abnormal respiratory rate", "Abnormal heart rate", and "Abnormal respiratory rate", with optimal cut-offs, and specific subgroups of flowcharts. Application of the modified MTS reclassified 744 patients (2.5%). Sensitivity increased from 0.66 (95%CI 0.60-0.72) to 0.71 (0.66-0.75) for high urgency patients and from 0.67 (0.54-0.76) to 0.70 (0.58-0.80) for high and intermediate urgency patients. Specificity decreased from 0.90 (0.86-0.93) to 0.89 (0.85-0.92) for high and 0.66 (0.52-0.78) to 0.63 (0.50-0.75) for high and intermediate urgency patients. These differences were statistically significant. Overall performance improved (R2 0.199 versus 0.204). CONCLUSIONS: Six new discriminators based on vital signs lead to a small but relevant increase in performance and should be implemented in the MTS
Improving triage for children with comorbidity using the ED-PEWS: an observational study
Objective To assess the value of the Emergency Department-Pediatric Early Warning Score (ED-PEWS) for triage of children with comorbidity.Design Secondary analysis of a prospective cohort.Setting and patients 53 829 consecutive ED visits of children <16 years in three European hospitals (Netherlands, UK and Austria) participating in the TrIAGE (Triage Improvements Across General Emergency departments) project in different periods (2012-2015).Intervention ED-PEWS, a score consisting of age and six physiological parameters.Main outcome measure A three-category reference standard as proxy for true patient urgency. We assessed discrimination and calibration of the ED-PEWS for children with comorbidity (complex and non-complex) and without comorbidity. In addition, we evaluated the value of adding the ED-PEWS to the routinely used Manchester Triage System (MTS).Results 5053 (9%) children had underlying non-complex morbidity and 5537 (10%) had complex comorbidity. The c-statistic for identification of high-urgency patients was 0.86 (95% prediction interval 0.84-0.88) for children without comorbidity, 0.87 (0.82-0.92) for non-complex and 0.86 (0.84-0.88) for complex comorbidity. For high and intermediate urgency, the c-statistic was 0.63 (0.62-0.63), 0.63 (0.61-0.65) and 0.63 (0.55-0.73) respectively. Sensitivity was slightly higher for children with comorbidity (0.73-0.75 vs 0.70) at the cost of a lower specificity (0.86-0.87 vs 0.92). Calibration was largely similar. Adding the ED-PEWS to the MTS for children with comorbidity improved performance, except in the setting with few high-urgency patients.Conclusions The ED-PEWS has a similar performance in children with and without comorbidity. Adding the ED-PEWS to the MTS for children with comorbidity improves triage, except in the setting with few high-urgency patients.Development and application of statistical models for medical scientific researchAnalysis and support of clinical decision makin
Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre study
Background: Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS. Methods: The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece). Findings: Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82–0·90) for high-urgency patients and 0·67 (0·61–0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87–0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81–0·85). Interpretation: The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs. Funding: Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme. © 2020 Elsevier Lt