Triage assessment in pediatric emergency departments: a national survey

Subjective Study on Pediatric Emergency Department Nurses' Perceptions of Urgency Using Q Methodology

PURPOSE

In the emergency department (ED), triage significantly impacts patient safety. Therefore, triage nurses must make decisions accurately and timeously. This study aims to investigate how South Korean pediatric emergency nurses perceive urgency and classify severity using the Q methodology, which examines individuals' subjectivity.

METHODS

We collected 84 statements from a Q population based on a literature review and interviews and selected 33 Q samples. The P samples included 30 pediatric emergency nurses at a Seoul tertiary care hospital. The principal component factor analysis method was used to analyze data using the PC-QUANL program.

RESULTS

Four urgency perception types were identified among pediatric ED nurses-Type 1: "Experiential coping"; Type 2: "Careful reasoning"; Type 3: "Patient-centered thinking"; and Type 4: "Intuitive prediction." These types appear to be an integrated process of knowledge and clinical experience that considers children's characteristics and developmental stages.

CONCLUSION

This study may serve as a basis for future education to improve pediatric ED nurses' urgency judgment and severity classification skills.

Predictive Validity of a New Triage System for Outcomes in Patients Visiting Pediatric Emergency Departments: A Nationwide Study in Korea

Triage is essential for rapid and efficient intervention in patients visiting an emergency department. In Korea, since 2016, the Pediatric Korean Triage and Acuity Scale (PedKTAS) has been implemented nationwide for the triage of patients visiting pediatric emergency departments (PEDs). The aim of this study was to evaluate the validity of the PedKTAS in patients who visit PEDs. This study was a retrospective observational study of national registry data collected from all emergency medical centers and institutions throughout Korea. We analyzed data from patients aged <15 years who visited emergency departments nationwide from January 2016 to December 2019. The hospitalization and intensive care unit (ICU) admission rates were analyzed on the basis of triage level. In total, 5,462,964 pediatric patients were included in the analysis. The hospitalization rates for PedKTAS Levels 1-5, were 63.5%, 41.1%, 17.0%, 6.5%, and 3.7%, respectively, and were significantly different (p < 0.001). The ICU admission rates for PedKTAS Levels 1-5 were 14.4%, 6.0%, 0.3%, 0.1%, and 0.1%, respectively, and were significantly different (p < 0.001). The hospitalization and ICU admission rates were highest for PedKTAS Level 1, and differences were significant based on the level. We identified that the PedKTAS is suitable for predicting the emergency status of pediatric patients who visit PEDs.

Validation of the Computerized Pediatric Triage Tool, pediaTRI, in the Pediatric Emergency Department of Lenval Children's Hospital in Nice: A Cross-Sectional Observational Study

INTRODUCTION

A reliable pediatric triage tool is essential for nurses working in pediatric emergency departments to quickly identify children requiring priority care (high-level emergencies) and those who can wait (low-level emergencies). In the absence of a gold standard in France, the objective of our study was to validate our 5-level pediatric triage tool -pediaTRI- against the reference tool: the Pediatric Early Warning Score (PEWS) System.

MATERIALS AND METHODS

We prospectively included 100,506 children who visited the Pediatric Emergency Department at Lenval Children's Hospital (Nice, France) in 2016 and 2017. The performance of pediaTRI to identify high-level emergencies (severity levels 1 and 2) was evaluated in comparison with a PEWS ≥ 4/9. Data from 2018-19 was used as an independent validation cohort.

RESULTS

pediaTRI agreed with the PEWS score for 84,896 of the patients (84.5%): 15.0% (14.8-15.2) of the patients were over-triaged and 0.5% (0.5-0.6) under-triaged compared with the PEWS score. pediaTRI had a sensitivity of 76.4% (74.6-78.2), a specificity of 84.7% (84.4-84.9), and positive and negative likelihood ratios of 5.0 (4.8-5.1) and 0.3 (0.3-0.3), respectively, for the identification of high-level emergencies. However, the positive likelihood ratios were lower for patients presenting with a medical complaint [4.1 (4.0-4.2) v 10.4 (7.9-13.7 for trauma), and for younger children [1.2 (1.1-1.2) from 0 to 28 days, and 1.9 (1.8-2.0) from 28 days to 3 months].

CONCLUSION

pediaTRI has a moderate to good validity to triage children in a Pediatric Emergency Department with a tendency to over-triage compared with the PEWS system. Its validity is lower for younger children and for children consulting for a medical complaint.

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 (range 0.05-0.12) and high specificity (range 0.95-0.99) for ICU admission. Combining hypotension and tachycardia did not change the predictive value for ICU admission. Similar results were found for hospitalisation. Shock index was associated with serious illness. However, no specific cut-off value was identified in different age groups.

CONCLUSIONS

Hypotension, adjusted for tachycardia, is associated with serious illness, although its sensitivity is limited. Shock index showed an association with serious illness, but no acceptable cut-off value could be identified. Routine BP measurement in all children to detect hypotension has limited value in the ED. Future studies need to confirm which patients could benefit from BP measurement.

Predicting patient disposition in a paediatric emergency department

AIM

The aim of this study is to directly compare published prediction tools with triage nurse (TN) predictions within a defined paediatric population.

METHOD

A prospective observational study carried out over a week in May 2010 in the Emergency Department (ED) at Princess Margaret Hospital for Children in Perth, Western Australia. TN predicted which patients would be admitted to hospital at the time of ED presentation. Data required for the other prediction tools (paediatric early warning score (PEWS); triage category and the Pediatric Risk of Admission Score (PRISA) and PRISA II were obtained from the notes following the patient's ED attendance.

RESULTS

A total of 1223 patients presented during the study week, 91 patients were excluded and a total of 946 patients (83.6%) had TN predictions and were included in the analysis. TN predictions were compared against a PEWS ≥ 4, triage category 1, 2 and 3, PRISA ≥ 9 and PRISA II ≥ 2. TNs had the highest prediction accuracy (87.7%), followed by an elevated PEWS (82.9%), triage category of 1, 2, or 3 (82.9%). The PRISA and PRISA II score had an accuracy of 80.1% and 79.7%, respectively.

CONCLUSION

When compared with validated prediction tools, the TN is the most accurate predictor of need to admit. This study provides valuable information in planning efficient flow of patients through the ED.

Predictors of clinically significant upper gastrointestinal hemorrhage among children with hematemesis

OBJECTIVES

The aim of the study was to determine the proportion of children with hematemesis who experience a clinically significant upper gastrointestinal hemorrhage (UGIH) and to identify variables predicting their occurrence.

METHODS

A retrospective cohort study was conducted. All of the emergency department visits by children ages 0 to 18 years who presented with hematemesis between 2000 and 2007 were reviewed. The primary aim of the study was to determine the proportion of children who developed a clinically significant UGIH; the secondary aim was to identify risk factors predictive of a clinically significant UGIH. A significant UGIH was defined by any of the following: hemoglobin drop >20 g/L, blood transfusion, or emergent endoscopy or surgical procedure.

RESULTS

Twenty-seven of 613 eligible children (4%; 95% confidence interval 3%-6%) had a clinically significant UGIH. Clinically significant hemorrhages were associated with older age (9.7 vs 2.9 years; P<0.001), vomiting moderate to large amounts of fresh blood (58% vs 20%; P<0.001), melena (37% vs 5%; P<0.001), significant medical history (63% vs 24%; P<0.001), unwell appearance (44% vs 6%; P<0.001), and tachycardia (41% vs 10%; P<0.001). The frequency of laboratory investigations increased with age (P<0.001). The hemoglobin level was the only laboratory investigation whose results differed between those with and without significant bleeds. The presence of any one of the following characteristics identified all of the children with a clinically significant hemorrhage: melena, hematochezia, unwell appearance, or a moderate to large volume of fresh blood in the vomitus, sensitivity 100% (95% confidence interval 85%-100%).

CONCLUSIONS

The occurrence of a clinically significant UGIH was uncommon among children with hematemesis, especially in well-appearing children without melena, hematochezia, or who had not vomited a moderate to large amount of fresh blood.

Application of emergency severity index in pediatric emergency department

BACKGROUND

The purpose of triage is to identify patients needing immediate resuscitation, to assign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures as appropriate. This study aimed to use emergency severity index (ESI) in a pediatric emergency room.

METHODS

From July 2006 to August 2010, a total of 21 904 patients visited the International Department of Beijing Children's Hospital. The ESI was measured by nurses and physicians, and compared using SPSS.

RESULTS

Nurses of the hospital took approximately 2 minutes for triage. The results of triage made by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This finding indicated that the nurses are able to identify severe pediatric cases.

CONCLUSION

In pediatric emergency rooms, ESI is a suitable tool for identifying severe cases and then immediate interventions can be performed accordingly.