The Soterion Rapid Triage System: Evaluation of inter-rater reliability and validity

FRENCH versus ESI: comparison between two nurse triage emergency scales with referent scenarios

OBJECTIVES

Acute triage is needed to prioritize care and achieve optimal resource allocation in busy emergency departments. The main objective is to compare the FRench Emergency Nurse Classification in Hospital scale (FRENCH) to the American scale Emergency Severity Index (ESI). Secondary objectives are to compare for each scale the over and under-triage, the triage matching to the gold standard and the inter-individual sorting reproducibility between the nurses.

METHODS

This is a prospective observational study conducting among the nursing staffs and nursing students, selected from Caen University College Hospital and Lisieux Hospital Center emergency departments between two months. Each group individually rank 60 referent clinical cases composed by scales designers. An assessment of scale practicality is collected after for each tool. The collected parameters are analyzed by a Cohen kappa concordance test (κ).

RESULTS

With 8151 triage results of gold standard scenarios sorting in two scales by the same nurses, the FRENCH scale seems to give better triage results than the US ESI scale (nurse: FRENCH 60% and ESI 53%, p = 0.003 ; nursing students: FRENCH 49% and ESI 42%, p < 0.001). In the two groups ESI has also a big tendency to under-sort (p = 0.01), particularly for the most severe patients (p < 0.01). The interobserver sorting concordance for any experience gives good results for the FRENCH and the ESI without any difference (nurses : FRENCH K_PQ=0.72 ESI K_PQ=0.78; p = 0.32 ; students K_PQ=0.44 K_PQ=0.55; p = 0.22).

CONCLUSION

The ESI and FRENCH scales comparison on 8151 sorting results shows direct validity in favor of FRENCH one and similar interobserver agreement for both scales.

Coupling Wearable Devices and Decision Theory in the United States Emergency Department Triage Process: A Narrative Review

This research was motivated by the nurses' decision-making process in the current emergency department (ED) triage process in the United States. It explores how continuous vital signs monitoring can be integrated into the ED. The article presents four shortcomings on current ED triage systems and proposes a new conceptual clinical decision support model that exploits the benefits of combining wireless wearable devices with Multi-Attribute Utility Theory to address those shortcomings. A literature review was conducted using various engineering and medical research databases, analyzing current practices and identifying potential improvement opportunities. The results from the literature review show that advancements in wireless wearable devices provide opportunities to enhance current ED processes by monitoring patients while they wait after triage and, therefore, reduce the risk of an adverse event. A dynamic mathematical decision support model to prioritize patients is presented, creating a feedback loop in the ED. The coupling of wearable devices (to collect data) with decision theory (to synthesize and organize the information) can assist in reducing sources of uncertainty inherent to ED systems. The authors also address the feasibility of the proposed conceptual model.

Electronic and manual registration of Manchester System: reliability, accuracy, and time evaluation

OBJECTIVE

to evaluate the degree of reliability, accuracy and timing to perform the Manchester Triage System in electronic and manual records.

METHOD

exploratory-descriptive research. Case series corresponded to a total of 20 validated simulated clinical cases applied to a sample of 10 nurses. For data collection each participant received 4 clinical cases in 2 different phases of the study, using manual and electronic registration. The variables related to the triage were: incomplete data filling, discriminator, flowchart, priority level, vital signs and triage timing.

RESULTS

moderate reliability for choosing flowcharts and substantial reliability for determining discriminators in both records; substantial and moderate, for priority, respectively, in manual and electronic registration. For vital signs, it was weak in manual recording and substantial in electronic. Accuracy showed a statistically significant difference related to vital signs. The average timing on triage was shorter with the use of electronic registration.

CONCLUSION

the use of electronic registration has advantages regarding reliability, accuracy and timing to perform the triage, pointing to the importance of adopting technologies in the management and care work process in health services.

Five-level emergency triage systems: variation in assessment of validity

INTRODUCTION

Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems.

METHODS

We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use).

RESULTS

A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively.

CONCLUSION

Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures.

The effect of training on nurse agreement using an electronic triage system

Objectives:

Emergency department (ED) triage prioritizes patients based on urgency of care, and the Canadian Triage and Acuity Scale (CTAS) is the national standard. We describe the inter-rater agreement and manual overrides of nurses using a CTAS-compliant web-based triage tool (eTRIAGE) for 2 different intensities of staff training.

Methods:

This prospective study was conducted in an urban tertiary care ED. In phase 1, eTRIAGE was deployed after a 3-hour training course for 24 triage nurses who were asked to share this knowledge during regular triage shifts with colleagues who had not received training (n = 77). In phase 2, a targeted group of 8 triage nurses underwent further training with eTRIAGE. In each phase, patients were assessed first by the duty triage nurse and then by a blinded independent study nurse, both using eTRIAGE. Inter-rater agreement was calculated using kappa (weighted κ) statistics.

Results:

In phase 1, 569 patients were enrolled with 513 (90.2%) complete records; 577 patients were enrolled in phase 2 with 555 (96.2%) complete records. Inter-rater agreement during phase 1 was moderate (weighted κ = 0.55; 95% confidence interval [CI] 0.49–0.62); agreement improved in phase 2 (weighted κ = 0.65; 95% CI 0.60–0.70). Manual overrides of eTRIAGE scores were infrequent (approximately 10%) during both periods.

Conclusions:

Agreement between study nurses and duty triage nurses, both using eTRIAGE, was moderate to good, with a trend toward improvement with additional training. Triage overrides were infrequent. Continued attempts to refine the triage process and training appear warranted.

A modified simple triage and rapid treatment algorithm from the New York City (USA) Fire Department

INTRODUCTION

The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise.

METHODS

A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n=1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n=110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system.

RESULTS

Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2).

CONCLUSIONS

The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.

Critically ill patients in emergency department may be characterized by low amplitude and high variability of amplitude of pulse photoplethysmography

Background

The aim of the present pilot study was to determine if pulse photoplethysmography amplitude (PPGA) could be used as an indicator of critical illness and as a predictor of higher need of care in emergency department patients.

Methods

This was a prospective observational study. We collected vital signs and one minute of pulse photoplethysmograph signal from 251 consecutive patients admitted to a university hospital emergency department. The patients were divided in two groups regarding to the modified Early Warning Score (mEWS): > 3 (critically ill) and ≤ 3 (non-critically ill). Photoplethysmography characteristics were compared between the groups.

Results

Sufficient data for analysis was acquired from 212 patients (84.5%). Patients in critically ill group more frequently required intubation and invasive hemodynamic monitoring in the ED and received more intravenous fluids. Mean pulse photoplethysmography amplitude (PPGA) was significantly lower in critically ill patients (median 1.105 [95% CI of mean 0.9946-2.302] vs. 2.476 [95% CI of mean 2.239-2.714], P = 0.0257). Higher variability of PPGA significantly correlated with higher amount of fluids received in the ED (r = 0.1501, p = 0.0296).

Conclusions

This pilot study revealed differences in PPGA characteristics between critically ill and non-critically ill patients. Further studies are needed to determine if these easily available parameters could help increase accuracy in triage when used in addition to routine monitoring of vital signs.

A method for reviewing the accuracy and reliability of a five-level triage process (canadian triage and acuity scale) in a community emergency department setting: building the crowding measurement infrastructure

Objectives. Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance. Methods. A trained nurse reviewer (NR) retrospectively triaged two separate month's ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics. Results. There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits. Conclusions. We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts.

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

BACKGROUND

Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland.

METHODS

The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services.

RESULTS

After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter.

CONCLUSIONS

The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.

Emergency department triage scales and their components: a systematic review of the scientific evidence

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥ 15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

The use of and satisfaction with the Emergency Severity Index

INTRODUCTION

The Emergency Severity Index (ESI) is a 5-level emergency department triage algorithm designed to facilitate the sorting and streaming of patients. The purpose of this study was to assess the use of the ESI in emergency departments, including satisfaction with the ESI, usefulness of the ESI compared with other triage algorithms, and lessons learned from implementation.

METHODS

A self-administered questionnaire was sent to 935 people who requested the ESI training materials from the Agency for Healthcare Research and Quality (AHRQ) at the U.S. Department of Health and Human Services and who volunteered to participate in a study about the ESI. The response rate for the survey was 42% (n = 392). Telephone interviews were conducted with an additional 19 ED professionals. Descriptive statistics and qualitative content analysis were used in the data analysis.

RESULTS

Three hundred twenty-two survey respondents (82%) reported that they use the ESI in their emergency department. Satisfaction with the ESI triage algorithm is high. ESI users indicated that the ESI is more accurate than other triage algorithms and that its strengths are simplicity of use and the ability to reduce the subjectivity of triage.

DISCUSSION

The majority of ED professionals who reported using the ESI were very satisfied with the tool. Users found that it was more accurate than other triage algorithms and reduced the subjectivity of the triage process. Both survey and interview findings indicated that few emergency departments have formally assessed the impact of the ESI on ED operations.

Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study

OBJECTIVES

It is difficult to compare the reliability of triage systems with the kappa statistic. In this article, a method for comparing triage systems was developed and applied to previously conducted triage reliability studies.

STUDY DESIGN AND SETTING

From simulations with theoretical distributions, the minimum, normal, and maximum weighted kappa for 3- to 5-level triage systems were computed. To compare the reliability of triage systems in previously conducted triage reliability studies, the normal kappa was calculated. Furthermore, the reported quadratically weighted kappas were compared with the minimum, normal, and maximum weighted kappa to characterize the degree and direction of skewness of the data.

RESULTS

The normal kappa was higher in 3-level triage systems (median: κ=0.84) compared with 4-level (median: κ=0.37) and 5-level (median: κ=0.57) systems. In 3-level triage systems, the percentages observed agreement were unequally distributed, which resulted in small quadratically weighted kappas. In 4- and 5-level systems, the percentages observed agreement were more equally distributed compared with 3-level systems, which resulted in higher quadratically weighted kappa values.

CONCLUSION

When comparing triage systems with different numbers of categories, one should report both the normal and quadratically weighted kappa. Calculating normal kappas from previously conducted triage reliability studies revealed substantial theoretical differences in interrater reliability of triage systems than previously reported.

Patient experience of the triage encounter in a Swedish emergency department

Emergency department triage is a prerequisite for the rapid identification of critically ill patients and for allocation of the correct acuity level which is pivotal for medical safety. The patient's first encounter with a medical professional in the emergency department is often with the triage nurse.

OBJECTIVES

To identify patient experience of the triage encounter.

METHODS

A questionnaire focusing on the patient-triage nurse relationship in terms of satisfaction with the medical and administrative information, privacy and confidentiality in the triage area as well as triage nurse competence and attitude was answered by 146 participating patients.

RESULTS

The majority of patients perceived that while they were triaged immediately upon arrival to the emergency department, they were often given limited information about the waiting time. Although almost a quarter of the patients did not wish to have information about their medical condition from the triage nurse, 97% of the patients considered the triage nurse to be medically competent for the triage task.

CONCLUSIONS

Patients were generally satisfied with the reception and care given by the triage nurses, but less satisfied about information about expected waiting time. We suggest therefore, that patients should be routinely informed about their estimated waiting time to be seen by the doctor in addition to their triage level.

Interrater agreement between nurses for the Pediatric Canadian Triage and Acuity Scale in a tertiary care center

OBJECTIVES

The objective was to measure the interrater agreement between nurses assigning triage levels to children visiting a pediatric emergency departments (EDs) assisted by a computerized version of the Pediatric Canadian Triage and Acuity Scale (PedCTAS).

METHODS

This was a prospective cohort study evaluating children triaged from Level 2 (emergent) to Level 5 (nonurgent). A convenience sample of patients triaged during 38 shifts from April to September 2007 in a tertiary care pediatric ED was evaluated. All patients were initially triaged by regular triage nurses using a computerized version of the PedCTAS. Research nurses performed a second evaluation blinded to the first evaluation using the same triage tool. These research nurses were regular ED nurses performing extra hours for research purposes exclusively. The primary outcome measure was the interrater agreement between the two nurses as measured by the linear weighted kappa score. Secondary outcomes included the proportion of patient for which nurses did not apply the triage level suggested by Staturg (override) and agreement for these overrides.

RESULTS

A total of 499 patients were recruited. The overall interrater agreement was moderate (linear weighted kappa score of 0.55 [95% confidence interval {CI} = 0.48 to 0.61] and quadratic weighted kappa score of 0.61 [95% CI = 0.42 to 0.80]). There was a discrepancy of more than one level in only 10 patients (2% of the study population). Overrides occurred in 23.2 and 21.8% for regular and research triage nurses, respectively. These overrides were equally distributed between increase and decrease in triage level.

CONCLUSIONS

Nurses using Staturg, which is a computerized version of the PedCTAS, demonstrated moderate interrater agreement for assignment of triage level to children presenting to a pediatric ED.

Emergency department utilization patterns among older adults

BACKGROUND

We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them.

METHODS

A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used.

RESULTS

The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns.

CONCLUSIONS

Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.

Reliability of a computerized version of the Pediatric Canadian Triage and Acuity Scale

BACKGROUND

The use of a standardized triage tool allows better comparison of the patients; a computerized version could theoretically improve its reliability.

OBJECTIVES

To compare the interrater agreement of the Pediatric Canadian Triage and Acuity Scale (PedCTAS) and a computerized version (Staturg).

METHODS

A two-phase experimental study was conducted to compare the interrater agreement between nurses assigning triage level to written case scenarios using either traditional PedCTAS or Staturg. Participants were nurses with at least one year of experience in pediatric emergency medicine and trained at triage. Each of the 54 scenarios was evaluated first by all nurses using either one of the strategies. Four weeks later, they evaluated the same scenarios using the other tool. The primary outcome was the interrater agreement measured using kappa score.

RESULTS

Eighteen of the 29 eligible nurses participated in the study. The computerized triage tool showed a better interrater agreement, with a Staturg kappa score of 0.55 (95% confidence interval = 0.53 to 0.57) versus a PedCTAS kappa score of 0.51 (95% confidence interval = 0.49 to 0.53). The computerized version was also associated with higher agreements for scenarios describing patients with the highest severity of triage (kappa score of 0.72 vs. 0.55 for level 1; kappa score of 0.70 vs. 0.51 for level 2).

CONCLUSIONS

A computerized version of the PedCTAS showed a statistically significant improvement in the interrater agreement for nurses evaluating the triage level of 54 clinical scenarios, but this difference has probably small clinical significance.

The use of the soterion rapid triage system in children presenting to the Emergency Department

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system's reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system's validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system's validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281-99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83-0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.