Manchester triage system in paediatric emergency care: prospective observational study

Epidemiological trends of febrile infants presenting to the Paediatric Emergency department, in a tertiary care hospital, Karachi, Pakistan: a retrospective review

BACKGROUND

Understanding the epidemiological patterns of febrile infants can offer valuable insights for optimising management strategies and developing quality improvement initiatives, aiming to improve healthcare delivery in high-volume, low-resource emergency departments (EDs).

OBJECTIVES

To characterise the epidemiology of febrile infants presenting to the paediatric ED of a tertiary care hospital.

METHODS

A retrospective chart review of medical records was performed for febrile infants ≤1 year old, at paediatric ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan (1 January 2020-31 December 2020).

RESULTS

There were a total of 2311 patients in the study, with a male-to-female ratio of 1.4:1. The mean age of presentation was 4.9±2.7 months. Cough (n=1002, 43.2%) was the most frequent presenting symptom. The most common provisional ED diagnosis in ≤1 month of age was sepsis (n=98, 51%), bronchopneumonia (n=138, 28.6%) in 1.1-3 and 3.1-6 months (n=176, 36.45%); and upper respiratory tract illness (n=206, 47.4%) in 6.1-12 months of age. Age was significantly associated with provisional ED diagnosis and outcomes (p<0.001). Of 175 ED admissions (n=47, 26.8%), patients were discharged with a hospital diagnosis of bronchopneumonia and (n=27, 15.4) of sepsis. The infant mortality rate was 3/1000 live births.

CONCLUSIONS

This study is the first of its kind to explore the epidemiology of febrile infants in Pakistan, highlighting the burden and severity of respiratory illnesses and sepsis. It underscores the challenges of resource-limited settings, failing to meet the need for admission of febrile infants presenting to ED, IHHN. Moreover, it has highlighted the necessity to optimise the existing triage systems to effectively allocate resources and manage high patient volumes in low-resource EDs.

Factors associated with non-urgent presentations in the paediatric emergency department using Andersen's behavioural model: A cross-sectional descriptive study

OBJECTIVES

To explore the rate of NUPs and associated factors in the PED of the 'Hospital Universitario y Politécnico La Fe' in Valencia (Spain) using Andersen's Behavioural Model.

METHODS

We conducted a descriptive cross-sectional study using Andersen's Behavioural Model in parents visiting the PED with their children at the 'Hospital Universitario y Politécnico La Fe' in Valencia (Spain).

RESULTS

The study involved a total of 530 participants, of whom 419 (79%) had made an NUP. The predisposing factors identified were: (I) paediatric patients brought in by their fathers (OR = 0.460; p = 0.005), (II) lower educational attainment (OR = 3.841; p = 0.000), (III) first-time parenthood (OR = 2.335; p = 0.000) and (IV) higher parental stress (OR = 1.974; p = 0.023). The enabling factors included: (I) responsibility for a significant part of the childcare shared with others (OR = 0.348; p = 0.041) and (II) the perception that PEDs provide better care than primary care (PC) services (OR = 1.628; p = 0.005). The need factors were: (I) existing chronic illness in the child seeking care (OR = 0.343; p = 0.000) and (II) the perceived severity of the urgency (OR = 0.440; p = 0.031).

CONCLUSIONS

The NUP rates found in this study are similar to those found internationally. In accordance with Andersen's Behavioural Model, we identify predisposing, enabling and need factors to explain the multifactorial nature of NUPs in PEDs.

IMPLICATIONS FOR PRACTICE

Identifying the factors associated with NUPs enables interventions to be targeted at those groups most likely to engage in NUPs, thereby optimising the functioning of the PED and improving the well-being of children and families. These interventions should focus on improving parental health literacy, providing education on making appropriate decisions about accessing health services and recognising severe symptoms in children, as well as improving access to high-quality PC services. Providing support to parents during the transition to parenthood would also be beneficial.

REPORTING METHOD

This paper adheres to the STROBE initiative guidelines.

CONTRIBUTION FROM PATIENTS OR MEMBERS OF THE PUBLIC

Participants, who voluntarily agreed to take part, contributed to the study by completing a paper-based questionnaire containing all the study variables as prepared by the research team.

Reliability and Accuracy of the Pediatric Swiss Emergency Triage Scale-the SETSped Study

BACKGROUND AND IMPORTANCE

The Swiss Emergency Triage Scale (SETS) is an adult triage tool used in several emergency departments. It has been recently adapted to the pediatric population but, before advocating for its use, performance assessment of this tool is needed.

OBJECTIVES

The purpose of this study was to assess the reliability and the accuracy of the pediatric version of the SETS for the triage of pediatric patients.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional study among a sample of emergency triage nurses (ETNs) exposed to 17 clinical scenarios using a computerized simulator.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was the reliability of the triage level performed by the ETNs. It was assessed using an intraclass correlation coefficient.Secondary outcomes included accuracy of triage compared with expert-based triage levels and factors associated with accurate triage.

MAIN RESULTS

Eighteen ETNs participated in the study and completed the evaluation of all scenarios, for a total of 306 triage decisions. The intraclass correlation coefficient was 0.80 (95% confidence interval, 0.69-0.91), with an agreement by scenario ranging from 61.1% to 100%. The overall accuracy was 85.8%, and nurses were more likely to undertriage (16.0%) than to overtriage (4.3%). No factor for accurate triage was identified.

CONCLUSIONS

This simulator-based study showed that the SETS is reliable and accurate among a pediatric population. Future research is needed to confirm these results, compare this triage scale head-to-head with other recognized international tools, and study the SETSped in real-life setting.

A low proportion of undertriage validates the new West coast system for triage-Paediatric

AIM

There is a lack of studies on paediatric triage systems. This study aimed to evaluate patient safety of the Gothenburg-developed paediatric triage system West Coast System for Triage-Paediatric (WEST-P).

METHOD

This study was performed at the paediatric emergency department in Gothenburg, Sweden, October 2020 to April 2021. Included patients were double-triaged with the WEST-P, and the established Rapid Emergency Triage and Treatment System-Paediatrics (RETTS-p). We compared the level of urgency between both systems to identify potentially undertriaged patients. Also, we assessed the patient safety according to clinical assessment at presentation, and pre-defined criteria.

RESULTS

This study included 2290 (23%) of triaged patients (44% girls, median age: 5.0 years) during the study period. A higher number of patients triaged to low urgency in WEST-P compared to RETTS-p (p < 0.0001) was observed, and 497 cases with low WEST-P and high RETTS-p urgencies identified. Of these, 29 had a clinical assessment indicating high urgency. After patient safety assessment, seven (0.4%) were determined undertriaged by the new triage system WEST-P.

CONCLUSION

Our findings demonstrate a low risk of undertriage in the new WEST-P. Thus, the WEST-P has a high degree of patient safety when used in a paediatric emergency department.

Clinical support system for triage based on federated learning for the Korea triage and acuity scale

Background and aims

This study developed a clinical support system based on federated learning to predict the need for a revised Korea Triage Acuity Scale (KTAS) to facilitate triage.

Methods

This was a retrospective study that used data from 11,952,887 patients in the Korean National Emergency Department Information System (NEDIS) from 2016 to 2018 for model development. Separate cohorts were created based on the emergency medical center level in the NEDIS: regional emergency medical center (REMC), local emergency medical center (LEMC), and local emergency medical institution (LEMI). External and temporal validation used data from emergency department (ED) of the study site from 2019 to 2021. Patient features obtained during the triage process and the initial KTAS scores were used to develop the prediction model. Federated learning was used to rectify the disparity in data quality between EDs. The patient's demographic information, vital signs in triage, mental status, arrival information, and initial KTAS were included in the input feature.

Results

3,626,154 patients' visits were included in the regional emergency medical center cohort; 8,278,081 patients' visits were included in the local emergency medical center cohort; and 48,652 patients' visits were included in the local emergency medical institution cohort. The study site cohort, which is used for external and temporal validation, included 135,780 patients visits. Among the patients in the REMC and study site cohorts, KTAS level 3 patients accounted for the highest proportion at 42.4% and 45.1%, respectively, whereas in the LEMC and LEMI cohorts, KTAS level 4 patients accounted for the highest proportion. The area under the receiver operating characteristic curve for the prediction model was 0.786, 0.750, and 0.770 in the external and temporal validation. Patients with revised KTAS scores had a higher admission rate and ED mortality rate than those with unaltered KTAS scores.

Conclusions

This novel system might accurately predict the likelihood of KTAS acuity revision and support clinician-based triage.

Whole-Body Magnetic Resonance Tomography and Whole-Body Computed Tomography in Pediatric Polytrauma Diagnostics-A Retrospective Long-Term Two-Center Study

Although serious accidents remain the leading cause of pediatric mortality, protocols to orient diagnostic procedures towards a certain type of initial imaging are widely needed. Since 2007, we have performed whole-body magnetic resonance imaging (WBMR) and whole-body computed tomography (WBCT) for diagnoses of severely injured children. We retrospectively reviewed 134 WBMR and 158 WBCT in patients younger than 16 years that were performed at two trauma centers between 2007 and 2018. A higher Injury Severity Score (ISS) was found in WBCT vs. WBMR (10.6 vs. 5.8; p = 0.001), but without any significant difference in mortality. The WBMR was significantly preferred at younger ages (9.6 vs. 12.8 years; p < 0.001). The time between patient's arrival until diagnosis was 2.5 times longer for WBCT (92.1 vs. 37.1 min; p < 0.001). More patients in the CT group received analgesic sedation and/or intubation at 37.3% vs. 21.6% in the MRI group. Of these patients, 86.4% (CT) and 27.6% (MRI) were already preclinically sedated (p < 0.001). Correspondingly, 72.4% of the patients were first sedated in-hospital for MRIs. In conclusion, WBMR is an alternative and radiation-free imaging method for high-energy-traumatized children. Although the selected diagnostics seemed appropriate, limitations regarding longer duration or additional analgesic sedation are present, and further studies are needed.

Development of outcomes for evaluating emergency care triage: a Delphi approach

BACKGROUND

Triage is used as standard of care for prioritization and identification of time-critical patients in the emergency department (ED) globally, but it is unclear what outcomes should be used to evaluate triage. Currently used outcomes do not include important time-critical diagnoses and conditions.

METHOD

We used 18 Swedish triage experts to collect and assess outcomes for the evaluation of 5-level triage systems. The experts suggested 68 outcomes which were then tested through a modified Delphi approach in three rounds. The outcomes aimed to identify correctly prioritized red patients (in need of a resuscitation team), and orange patients (other time critical conditions). Consensus was pre-defined as 70% dichotomized (positive/negative) concordance.

RESULTS

Diagnoses, interventions, mortality, level of care and lab results were included in the outcomes. Positive consensus was reached for 49 outcomes and negative consensus for 7 outcomes, with an 83% response rate. The five most approved outcomes were the interventions Percutaneous coronary intervention, Surgical airway and Massive transfusion together with the diagnoses Tension pneumothorax and Intracerebral hemorrhage that received specific interventions. The outcomes with the clearest disapproval included Admittance to a ward, Treatment with antihistamines and The ordering of a head computed tomography scan. The outcomes were considered valid only if occurring in or from the ED.

CONCLUSION

This study proposes a standard of 49 outcomes divided into two sets tied to red and orange priority respectively, to be used when evaluating 5-level priority triage systems; Lund Outcome Set for Evaluation of Triage (LOSET). The proposed outcomes include diagnoses, interventions and laboratory results. Before widespread implementation of LOSET, prospective testing is needed, preferably at multiple sites.

Validity of the Paediatric Canadian Triage Acuity Scale in a Tertiary Hospital: An Analysis of Severity Markers' Variability

With the increasing influx of patients and frequent overcrowding, the adoption of a valid triage system, capable of distinguishing patients who need urgent care, from those who can wait safely is paramount. Hence, the aim of this study is to evaluate the validity of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) in a Portuguese tertiary hospital. Furthermore, we aim to study the performance and appropriateness of the different surrogate severity markers to validate triage. This is a retrospective study considering all visits to the hospital's Paediatric Emergency Department (PED) between 2014 and 2019. This study considers cut-offs on all triage levels for dichotomization in order to calculate validity measures e.g. sensitivity, specificity and likelihood ratios, ROC curves; using hospital admission, admission to intensive care and the use of resources as outcomes/markers of severity. Over the study period there were 0.2% visits triaged as Level 1, 5.7% as Level 2, 39.4% as Level 3, 50.5% as Level 4, 4.2% as Level 5, from a total of 452,815 PED visits. The area under ROC curve was 0.96, 0.71, 0.76, 0.78, 0.59 for the surrogate markers: "Admitted to intensive care"; "Admitted to intermediate care"; "Admitted to hospital"; "Investigations performed in the PED" and "Uses PED resources", respectively. The association found between triage levels and the surrogate markers of severity suggests that the PedCTAS is highly valid. Different surrogate outcome markers convey different degrees of severity, hence different degrees of urgency. Therefore, the cut-offs to calculate validation measures and the thresholds of such measures should be chosen accordingly.

Validity of the Brazilian pediatric triage system CLARIPED at a secondary level of emergency care

OBJECTIVE

To evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil.

METHODS

Prospective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0-18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates.

RESULTS

The distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23-2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17-79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70-0.98); specificity, 0.76 (95%CI: 0.75-0.76); NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 23.0%, and undertriage, 11.5%.

CONCLUSION

This study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service.

Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis

INTRODUCTION

Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification.

METHODS

This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS.

RESULTS

In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries.

CONCLUSION

The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.

Validity of the computerized version of the pediatric triage system CLARIPED for emergency care

OBJECTIVE

To evaluate the validity of the computerized version of the pediatric triage system CLARIPED.

METHODS

Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed.

RESULTS

19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%.

CONCLUSION

The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.

Triaging and referring in adjacent general and emergency departments (the TRIAGE-trial): A process evaluation of medical staff experiences in a nurse-led triage system

AIMS

This process evaluation aims at identifying the facilitators and inhibitors that influenced the successful uptake of a nurse-led triage system streaming low-risk patients from an emergency department (ED) to the general practitioner (GP).

DESIGN & METHODS

Semi-structured interviews with ED nurses (n = 12), ED doctors (n = 6) from the ED of a Belgian general hospital and GPs (n = 5) affiliated with the adjacent GP cooperative (GPC). The process evaluation ran in parallel with the TRIAGE trial that started in March 2019 and ended 31st of December 2019. The first set of interviews was conducted in June 2019 and the second set in January 2020. Data were analysed based on grounded theory.

RESULTS

Through a deductive framework, facilitators and inhibitors could be identified on three levels: the organisational, group and individual level. Main inhibitors are the degree of risk aversion of individual nurses, possible language barriers during delivery of the triage advice and the non-adapted ED infrastructure. Training on both the use of the triage protocol and effective delivery of the triage advice, in combination with periodical feedback from the GPC were the most important facilitators.

CONCLUSION

Based on the process evaluation we can conclude that a consensus exists among stakeholders that the ED Nurses are considered ideally positioned to perform the triage of walk-in patients, although a certain degree of experience is necessary. Although the extended triage protocol and GPC referral increases the complexity and duration of triage and entails a higher workload for the triage nurses, ED nurses found it did lead to a lower (perceived) workload for the ED in general.

Effect of In-Situation Versus Manchester Triage System-Based Initial Case Management on Hospital-Based Mortality: A Before and After Study

OBJECTIVE

To compare mortality and treatment-initiation time pre- and post introduction of Manchester Triage System (MTS) in patients of age group 1 mo to 15 y admitted in a tertiary care hospital in India.

METHODS

Pre- and post intervention study conducted on a prospective cohort of patients hospitalized over a period of 6 mo, who were triaged using MTS and compared with a retrospective cohort, who were not formally triaged using any system and were admitted to the hospital during the past 6 mo, prior to commencement of the study. Intervention was training of resident doctors for five MTS urgencies using flowcharts and discriminators and displaying them in the emergency room. Data on clinical and outcome variables were abstracted from hospital case record sheets in both the cohorts.

RESULTS

The present study was conducted from May 2019 to April 2020 including 450 patients hospitalized from August 2019 to January 2020 in a prospective cohort and a retrospective cohort of 450 patients hospitalized from January 2019 to June 2019. Overall mortality in pre-MTS group was 26.2% (118/450) as compared to 20.9% (94/450) in post-MTS group (p value = 0.021). Average treatment time was reduced from 30 to 10 min after implementation of MTS (p value = 0.001).

CONCLUSION

Implementation of MTS in pediatric emergency leads to statistically significant reduction of mortality and average treatment-initiation time.

Reliability and validity of an original nurse telephone triage tool for out-of-hours primary care calls: the SALOMON algorithm

OBJECTIVES

Due to the persistent primary care physicians shortage and the substantial increase in their workload, the organization of primary care calls during out-of-hours periods has become an everyday challenge. The SALOMON algorithm is an original nurse telephone triage tool allowing to dispatch patients to the best level of care according to their conditions. This study evaluated its reliability and criterion validity in rea-life settings.

METHODS

In this 5-year study, out-of-hours primary care calls were dispatched into four categories: Emergency Medical Services Intervention (EMSI), Emergency Department referred Consultation (EDRC), Primary Care Physician Home visit (PCPH), and Primary Care Physician Delayed visit (PCPD). We included data of patients' triage category, resources, and destination. Patients included into the primary care cohort were classified undertriaged if they had to be redirected to an emergency department (ED). Patients from the ED cohort were considered overtriaged if they did not require at least three diagnostic resources, one emergency-specific treatment or any hospitalization. In the ED cohort, only patients from the University Hospitals were considered.

RESULTS

10,207 calls were triaged using the SALOMON tool: 19.2% were classified as EMSI, 15.8% as EDRC, 62.8% as PCPH, and 2.2% as PCPD. The triage was appropriate for 85.5% of the calls with a 14.5% overtriage rate. In the PCPD/PCPH cohort, 96.9% of the calls were accurately triaged and 3.1% were undertriaged. SALOMON sensitivity and specificity reached 76.6% and 98.3%, respectively.

CONCLUSION

SALOMON algorithm is a valid triage tool that has the potential to improve the organization of out-of-hours primary care work.

Prediction of Pediatric Patient Admission/Discharge in the Emergency Department: Irish Pediatric Early Warning Score, Pediatric Observation Priority Score, and Irish Children's Triage System

OBJECTIVE

The aim of this study was to evaluate the ability of the Irish Paediatric Early Warning Score (PEWS), the Paediatric Observation Priority Score (POPS), and the Irish Children's Triage System (ICTS) to predict patient disposition pathways in an emergency department (ED) setting.

METHODS

Data were prospectively collected on patients aged less than 16 years presenting to an Irish mixed adult/pediatric ED over 3 weeks during December 2018. After calculating a once-off PEWS, POPS, and ICTS, we investigated the ability of the scoring systems to predict admission or discharge from the ED. Primary comparison of the index tests was conducted using receiver operating characteristic (ROC) curves.

RESULTS

A total of 550 patients were included in this study. There were 114 admissions (20.7%) and 436 discharges (79.3%). The POPS had an area under the ROC curve of 0.7 [95% confidence interval (CI), 0.65-0.75]. The PEWS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.64). The ICTS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.63).

CONCLUSIONS

The POPS has greater accuracy as a predictor of admission from the ED than PEWS and ICTS. Possible future implementation of POPS into pediatric EDs as a cognitive prompt before admission decision seems to be merited. Further multicenter validation in Ireland would be helpful.

Reliability and validity of the Netherlands Triage Standard in emergency care settings: a case scenario study

BACKGROUND

The Netherlands Triage Standard (NTS) is a triage system that can be used by different types of emergency care organisations. Our objective was to determine the interrater reliability and construct validity of the NTS when applied to self-presenting patients.

METHODS

We performed a cross-sectional case scenario study consisting of two parts: (1) paediatric triage in January-February 2019 and (2) adult triage in October-November 2020. In each part, we invited nurse triagists from three general practitioner cooperatives, three ambulance dispatching centres and three hospital emergency departments in the Netherlands to participate. We used 40 case scenarios involving paediatric patients and 41 involving adult patients who could self-present to any emergency care organisation. In advance, an expert panel determined the urgency (six levels) of the case scenarios (reference standard). The main outcome for reliability was the intraclass correlation coefficient (ICC) for urgency level. The main outcomes for validity were degree of agreement with the reference standard, for urgency level, and sensitivity and specificity for high versus low urgency. We used descriptive statistics and logistic multilevel modelling with both case and triagist as random effects.

RESULTS

218 out of 240 invited triagists participated. The ICC among all triagists was 0.73 for paediatric cases and 0.88 for adult cases and was highest in general practitioner cooperatives. For paediatric cases, there was 62.3% agreement with the reference standard about urgency, 17.4% underestimation and 20.2% overestimation. The sensitivity of the NTS for identifying highly urgent paediatric cases was 85.2%; the specificity was 89.7%. For adult cases, there was 68.3% agreement, 13.7% underestimation and 18.0% overestimation. The sensitivity of triage for high urgency in adults was 94.5% and the specificity 83.3%.

CONCLUSION

NTS appears to have good reliability and construct validity for estimating the urgency of health complaints of non-referred patients presenting themselves in emergency care.

The Manchester Triage System in a Pediatric Emergency Department of an Austrian University Hospital: A Retrospective Analysis of Urgency Levels

OBJECTIVES

The Manchester Triage System (MTS) has entered widespread international use in emergency departments (EDs). This retrospective study analyzes urgency of patient visits (PV) at the ED of the Clinic for Pediatrics at the Medical University of Innsbruck.

METHODS

We collected demographic and outcome information, including PV urgency levels (UL) according to the MTS, for 3 years (2015-2018), separating PV during regular office hours (ROH; 8:00 am to 5:00 pm) from PV during afternoon and night hours (5:00 pm to 8:00 am), and PV on weekdays from PV on weekends and bank holidays (WE).

RESULTS

A total of 56,088 PV were registered with a UL. Most (68.4%) PV were classified as nonurgent. During ROH, more PV per hour (PV/h) were recorded than during afternoon and night hours (3.0 PV/h vs 1.6 PV/h), with a higher proportion of less urgent cases during ROH. On WE, the amount of PV/h was higher than on weekdays (3.6 PV/h vs 2.8 PV/h), with a higher proportion of nonurgent cases (74.6% vs 68.6%). Likelihoods of inpatient admission and hospital stay lengths increased in step with UL.

CONCLUSIONS

The MTS proved useful for delineating UL distributions. The MTS analyses may be of value in managing EDs. Prompted by the results of our study, a general practice pediatric care unit was established to support the ED during WE.

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.

Improving the safety of the Manchester triage system for children with congenital heart disease

This study is a prospective evaluation of the validity of a Manchester triage system (MTS) modification for detecting under-triaged pediatric patients with congenital heart disease (CHD). Children with CHD visiting the emergency unit of the Department of Pediatrics and Adolescent Medicine, University Hospital Vienna in 2014 were included. The MTS modification updated the prioritization of patients with complex syndromic diseases, specific symptoms related to chronic diseases, decreased general condition (DGC), profound language impairment, unknown medical history, or special needs. A four-level outcome severity index based on diagnostic and therapeutic interventions, admission to hospital, and follow-up strategies was defined as a reference standard for the correct clinical classification of the MTS urgency level. Of the 19,264 included children, 940 had CHD. Of this group, 266 fulfilled the inclusion criteria for the modified triage method. The MTS modification was significantly more often applied in under-triaged (65.9%) than correctly or over-triaged (25%) children with CHD (p-value χ² test < 0.0001, OR 5.848, 95% CI: 3.636-9.6).

CONCLUSION

The MTS urgency level upgrade modification could reduce under-triage in children with CHD. Applying a safety strategy concept to the MTS could mitigate under-triage in such a high-risk patient group.

WHAT IS KNOWN

• The Manchester triage system is considered to be valid and reliable but tends to over-triage. • A study by Seiger et al. showed poor performance in children with chronic illnesses, especially in children with cardiovascular diseases.

WHAT IS NEW

• The MTS modification with one urgency level upgrade could decrease under-triage in children with congenital heart disease. • As reference standard a four level outcome severity index (OSI) was established to include diagnostic investigations, medical interventions, hospital admission or follow up visits in the assessment.

Analysis of Plastic Surgery Consultations in a High-Volume Paediatric Emergency Department: A Quality Improvement Initiative

Introduction

Consult services influence emergency department (ED) workflow. Prolonged ED length of stay (LOS) correlates with ED overcrowding and as a consequence decreased quality of care and satisfaction of health team professionals. To improve management of paediatric ED patients requiring plastic and reconstructive surgery (PRS) expertise, current processes were analyzed.

Methods

Patient characteristics and metrics of PRS consultations in our paediatric ED were collected over a 3-month period. Data analysis was followed by feedback education intervention to ED and PRS staff. Data collection was then resumed and results were compared to the pre-intervention period.

Results

One hundred ninety-eight PRS consultations were reviewed, mean patient age was 6.3 years. Most common (52%) diagnoses were burns and hand trauma; 81% of PRS referrals were deemed appropriate; 25% of PRS consults were requested after hour with no differences in patient characteristics compared to regular hours; 60% of consultations involved interventions in the ED. Time between ED registration and PRS consultation request (116.5 minutes), quality of procedural sedation (52% rated inadequate), and overall ED LOS (289.2 minutes) were identified as main areas of concern and addressed during feedback education intervention. Emergency department LOS and quality of sedation did not improve in the post-intervention period.

Conclusion

The study provides detailed insights in the characteristics of PRS consultation in the paediatric ED population. Despite high referral appropriateness and education feedback intervention, significant inefficiencies were identified that call for further collaborative efforts to optimize quality of care for paediatric ED patients and improve satisfaction of involved healthcare professionals.

Implementation of a checklist to improve pediatric trauma assessment quality in a Brazilian hospital

BACKGROUND

Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers.

MATERIAL AND METHODS

A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed.

RESULTS

A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed.

CONCLUSION

In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

Comparative Analysis Of Triage Systems At Emergency Departments Of Different Countries: Implementation In Kazakhstan

Medical sorting is aimed at assessment of disease severity and has to be carried out within a short time to determine the priorities for patient care and transportation to the most appropriate place for future treatment. The goal of this study was to provide an integrative review by analyzing the publications on the most common triage systems worldwide in order to select and implement the most reliable system at emergency departments. We searched for publications relevant to our comparative analysis in evidence-based medicine databases. A total of 1,740 literary sources were identified, of which 42 were selected for analysis. Comparative analysis of different triage systems may help implementing the most efficient system in Kazakhstan. The Emergency Severity Index is considered the most reliable and accurate tool used in international practice, and it could provide a basis for introduction of triage system at emergency departments in Kazakhstan.

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

BACKGROUND

To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.

METHODS AND FINDINGS

A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit ('index' visit), in 2012-2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7-2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65-0.74) and summary calibration slope of 0.83 (95% CI 0.67-0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87-5.01) and specificity 0.96 (95% CI 0.95-0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25-0.35), sensitivity 0.88 (95% CI 0.86-0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68-0.75) and summary calibration slope of 0.84 (95% CI 0.71-0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.

CONCLUSION

We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Validation of Dutch Obstetric Telephone Triage System: A Prospective Validation Study

Objective and Purpose

A triage system that prioritizes care according to medical urgency has a favorable effect on safety and efficiency of emergency care. The Dutch obstetric telephone triage system is comparable to physical triage systems. It consists of five urgency levels: resuscitation and life threatening (U1), emergency (U2), urgent (U3), non-urgent (U4) and self-care advice (U5). The purpose of this study was to determine the diagnostic and external validity of the Dutch obstetric telephone triage system in obstetric emergency care.

Patients and Methods

The validity of the Dutch obstetric telephone triage system was studied in a prospective observational study in four hospitals. Diagnostic validity of usual care was determined by comparing the assigned urgency level of the Dutch obstetric telephone triage system with a reference standard. This reference standard was obtained by face-to-face clinical assessment in hospital following telephone triage. Clinical follow-up after assessment was also recorded. For statistical analyses, urgency levels were dichotomized into high urgency (U1, U2) and intermediate urgency (U3, U4). Self-care advice (U5) could not be studied because these patients were not referred to hospital.

Results

In total, 983 cases (U1-U4) across the four hospitals were included, 625 (64%) cases were categorized as high urgency and 358 (36%) as intermediate urgency. The Dutch obstetric telephone triage system’s urgency level agreed with the reference standard in 53% (n=525; 95% CI 50–57%). According to the reference standard the Dutch obstetric telephone triage system had undertriage in 16% (n=160) and overtriage in 30% (n=298) of the cases. Sensitivity for high urgency was 76% (95% CI 72–80), specificity 49% (95% CI 44–53). Positive predictive value and negative predictive value were 60% (95% CI 56–63) and 67% (95% CI 62–72), respectively. After clinical assessment, urgent care was needed in 8.7% (n=31) of the intermediate-urgency cases, none of these cases were life threatening situations.

Conclusion

DOTTS shows an acceptable diagnostic validity with room for improvement.

Obstetric Telephone Triage

Objective

Little is known about obstetric telephone triage: the methods used to prioritize the severity of symptoms of obstetric emergency and other unplanned care requests originating by telephone. In large-scale obstetric units, there is a need for an evidence-based triage guideline. The aim of this study was to develop an obstetric guideline for telephonic triage.

Design Setting and Participants

A multi-phase multi-center study was performed with consecutive drafts of the triage guideline using four focus groups, four observations of training sessions and two expert consultations based on the Delphi method. The study was performed in ten hospitals in the Netherlands. The obstetric care professionals involved were gynecologists, midwives, nurses, doctor's assistants, team managers and application managers. After each focus group, each observation and each expert consultation, an interpretative analysis was undertaken. Based on these analyses, the obstetric telephone triage guideline was drafted.

Measurements and Results

The designed guideline describes the primary symptoms presented, five prioritization categories and several descriptors. Consensus (>90%) was reached during the second expert consultation. Fifty-seven (91.9%) participants stated that the obstetric telephone triage guideline was clinically complete, correct, user-friendly and well designed, and 61 (98.4%) participants judged that the newly designed triage guideline was ready to use in daily practice.

Key-Conclusions and Implications for Practice

An evidence-based guideline for obstetric telephone triage was developed through a multi-phase multi-center study with all stakeholders. The guideline was found to be clinically complete, correct, well-designed and user-friendly. It provides a uniform and concrete basis for assessing the severity of the symptoms of obstetric emergency and other unplanned care requests originating by telephone. It also provides a good basis to further develop this evidence-based guideline for telephone triage by continuous registration of all calls.

Pediatric trauma primary survey performance among surgical and non-surgical pediatric providers in a Brazilian trauma center

INTRODUCTION

Trauma is the leading cause of death and disability among Brazilian children and adolescents. Trauma protocols such as those developed by the Advanced Trauma Life Support course are widely taught, but few studies have assessed the degree to which the use of protocolized trauma assessment improves outcomes. This study aims to quantify the adherence of trauma assessment protocols among different types of frontline trauma providers.

METHODS

A prospective observational study of pediatric trauma care in one of the busiest Latin American trauma centers was conducted during 6 months. Trauma primary survey assessments were observed and adherence to each step of a standardized primary assessment protocol was recorded. Adherence to the assessment protocol was compared among different types of providers, the time of presentation and severity of injury. The relationship between protocol adherence and clinical outcomes including mortality, length of hospital stay, admission to pediatric intensive care unit, use of blood components, mechanical ventilation and number of imaging exams performed in the first 24 hours were also assessed.

RESULTS

Emergency department evaluations of 64 patients out of 274 pediatric admissions were observed over a period of 6 months. 50% of the primary assessments were performed by general surgeons, 34.4% by residents in general surgery and 15.6% by pediatricians. There was an average adherence rate of 34.1% to the trauma protocol. Adherence among each specific step included airway: 17.2%; breathing: 59.4%; circulation: 95.3%; disability: 28.8%; exposure: 18.8%. No differences between specialties were observed. Patients with a more thorough primary assessment underwent fewer CT scans (receiver operating characteristic curve area: 0.661; p=0.027).

CONCLUSIONS

Our study demonstrates that trauma assessment protocol adherence among trauma providers is low. Thorough initial assessment reduced the use of CT scans suggesting that standardized pediatric trauma assessments may be a way to reduce unnecessary radiological imaging among children.

LEVEL OF EVIDENCE

IV.

STUDY TYPE

Pediatric and global trauma.

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.

The performance of the EMS triage (RETTS-p) and the agreement between the field assessment and final hospital diagnosis: a prospective observational study among children < 16 years

Background

The rapid triage and treatment system for paediatrics (RETTS-p) has been used by the emergency medical services (EMS) in the west of Sweden since 2014. The performance of the RETTS-p in the pre-hospital setting and the agreement between the EMS nurse’s field assessment and the hospital diagnosis is unknown. The aim of this study was to evaluate the performance of the RETTS-p in the EMS and the agreement between the EMS field assessment and the hospital diagnosis.

Methods

A prospective observational study was conducted among 454 patients < 16 years of age who were assessed and transported to the PED. Two instruments were used for comparison: 1) Classification of an emergent patient according to predefined criteria as compared to the RETTS-p and 2) Agreement between the EMS nurse’s field assessment and the hospital diagnosis.

Results

Among all children, 11% were identified as having vital signs associated with an increased risk of death and 7% were diagnosed in hospital with a potentially life-threatening condition. Of the children triaged with RETTS-p (85.9%), 149 of 390 children (38.2%) were triaged to RETTS-p red or orange (life-threatening, potentially life-threatening), of which 40 (26.8%) children were classified as emergent. The hospitalised children were triaged with the highest frequency to level yellow (can wait; 41.5%). In children with RETTS-p red or orange, the sensitivity for a defined emergent patient was 66.7%, with a corresponding specificity of 67.0%. The EMS field assessment was in agreement with the final hospital diagnosis in 80% of the cases.

Conclusions

The RETTS-p sensitivity in this study is considered moderate. Two thirds of the children triaged to life threatening or potentially life threatening were later identified as non-emergent. Of those, one in six was discharged from the PED without any intervention. Further, one third of the children were under triaged, the majority were found in the yellow triage level (can wait). The highest proportion of hospitalised patients was found in the yellow triage level. Our result is in agreement with previous studies using other triage instruments. A computerised decision support system might help the EMS triage to increase sensitivity and specificity.

A validation of machine learning-based risk scores in the prehospital setting

BACKGROUND

The triage of patients in prehospital care is a difficult task, and improved risk assessment tools are needed both at the dispatch center and on the ambulance to differentiate between low- and high-risk patients. This study validates a machine learning-based approach to generating risk scores based on hospital outcomes using routinely collected prehospital data.

METHODS

Dispatch, ambulance, and hospital data were collected in one Swedish region from 2016-2017. Dispatch center and ambulance records were used to develop gradient boosting models predicting hospital admission, critical care (defined as admission to an intensive care unit or in-hospital mortality), and two-day mortality. Composite risk scores were generated based on the models and compared to National Early Warning Scores (NEWS) and actual dispatched priorities in a prospectively gathered dataset from 2018.

RESULTS

A total of 38203 patients were included from 2016-2018. Concordance indexes (or areas under the receiver operating characteristics curve) for dispatched priorities ranged from 0.51-0.66, while those for NEWS ranged from 0.66-0.85. Concordance ranged from 0.70-0.79 for risk scores based only on dispatch data, and 0.79-0.89 for risk scores including ambulance data. Dispatch data-based risk scores consistently outperformed dispatched priorities in predicting hospital outcomes, while models including ambulance data also consistently outperformed NEWS. Model performance in the prospective test dataset was similar to that found using cross-validation, and calibration was comparable to that of NEWS.

CONCLUSIONS

Machine learning-based risk scores outperformed a widely-used rule-based triage algorithm and human prioritization decisions in predicting hospital outcomes. Performance was robust in a prospectively gathered dataset, and scores demonstrated adequate calibration. Future research should explore the robustness of these methods when applied to other settings, establish appropriate outcome measures for use in determining the need for prehospital care, and investigate the clinical impact of interventions based on these methods.

Remote Pediatric Critical Care Telephone Consultations: Quality and Outcomes

There are no studies describing the nature and quality of telephone consultations for critically ill children despite being an important part of pediatric intensive care. We described pediatric telephone consultations to a PICU in Ontario, Canada in 2011 and 2012. Of 203 consultations, 104 patients (51.2%) were admitted to the PICU; this was associated with weekend consultations ( p  = 0.005) and referral hospital location ( p  = 0.036). Frequency of interruptions was 1 in every 3.2 (2.0, 5.7) minutes and not associated with call content. Twenty-one percent of consults had limited discussion of vital signs. Our study described our center's remote critical care consultation program and outcomes.

Development and validation of the Heidelberg Neurological Triage System (HEINTS)

BACKGROUND/OBJECTIVE

Neurological syndromes are underrepresented in existing triage systems which are not validated for neurological patients; therefore, we developed and validated the new Heidelberg Neurological Triage System (HEINTS) in a prospective, single-center observational study.

METHODS

Patients were triaged according to the new triage system by nurses and physicians (stage 1) as well as trained nurses (stage 2). In stage 1, all patients presenting to the neurological emergency room (ER) were triaged by nurses and physicians. In stage 2, three specially trained nurses triaged patients according to HEINTS. The main outcomes comprised interrater agreement between nurses' and physicians' triage (stage 1), sensitivity and specificity to detect emergencies (stages 1 and 2), and improvement in triage quality as a result of training (stage 2), as well as correlation of HEINTS with hospital admissions and resource utilization.

RESULTS

In stage 1 (n = 2423 patients), sensitivity and specificity to detect neurological emergencies were 84.2% (SD 0.8%) and 85.4% (SD 0.8%) for nurses, as well as 92.4% (SD 0.6%) and 84.1% (SD 0.9%) for physicians, respectively. The interrater-reliability between nurses and physicians in stage 1 was moderate [Cohen's kappa 0.44, standard deviation (SD) 0.02]. In stage 2 (n = 506 patients), sensitivity of trained nurses increased to 94.3% (SD 1.0%), while specificity decreased to 74.8% (SD 1.9%). Correlation of HEINTS triage with hospital admission and resource utilization in both stages was highly significant.

CONCLUSIONS

HEINTS predicted hospital admissions and resource utilization. Agreement between nurses and physicians was moderate. HEINTS, applied by physicians and by nurses after training, reliably detected neurological emergencies.

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

BACKGROUND

Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes.

METHODS

We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing.

RESULTS

Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations.

CONCLUSION

The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.

Performance characteristics of a local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania

Background

A number of region-specific validated triage systems exist; however very little is known about their performance in resource limited settings. We compare the local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania.

Methodology

Prospective descriptive study of consecutive under-fives seen at Muhimbili National Hospital (MNH), ED between November 2017 to April 2018. Patients were triaged according to Local Triage System (LTS), and the information collected were used to assign acuities in the other triage scales: Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), Manchester Triage Scale (MTS) and South African Triage Scale (SATS). Patients were then followed up to determine disposition and 24 h outcome. Sensitivity, specificity, positive and negative predictive values for admission and mortality were then calculated.

Results

A total of 384 paediatric patients were enrolled, their median age was 17 months (IQR 7–36 months). Using LTS, 67(17.4%) patients were triaged in level one, 291(75.8%) level 2 and 26 (6.8%) in level 3 categories. Overall admission rate was 59.6% and at 24 h there were five deaths (1.3%). Using Level 1 in LTS, and Levels 1 and 2 in other systems, sensitivity and specificity for admission for all triage scales ranged between 27.1–28.4% and 95.4–98% respectively, (PPV 90.3–95.3%, NPV 47.1–47.4%). Sensitivity for mortality was 80% for LTS, and 100% for the other scales, while specificity was low, yielding a PPV for all scales between 6.9 and 8%.

Conclusion

All triage scales showed poor ability to predict need for admission, however all triage scales except LTS predicted mortality. The test characteristics for the other scales were similar. Future studies should focus on determining the reliability and validity of each of these triage tools in our setting.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1417-7) contains supplementary material, which is available to authorized users.

VALIDITY AND RELIABILITY OF THE MANCHESTER SCALE USED IN THE ORTHOPEDIC EMERGENCY DEPARTMENT

Objectives:

To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals.

Methods:

Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity.

Results:

The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively.

Conclusion:

The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions. Level of Evidence III, Retrospective Study.

VALIDADE E CONFIABILIDADE DE UM NOVO SISTEMA DE CLASSIFICAÇÃO DE RISCO PARA EMERGÊNCIAS PEDIÁTRICAS: CLARIPED

Objective:

To assess the validity and reliability of a triage system for pediatric emergency care (CLARIPED) developed in Brazil.

Methods:

Validity phase: prospective observational study with children aged 0 to 15 years who consecutively visited the pediatric emergency department (ED) of a tertiary hospital from July 2 to 18, 2013. We evaluated the association of urgency levels with clinical outcomes (resource utilization, ED admission rate, hospitalization rate, and ED length of stay); and compared the CLARIPED performance to a reference standard. Inter-rater reliability phase: a convenience sample of patients who visited the pediatric ED between April and July 2013 was consecutively and independently double triaged by two nurses, and the quadratic weighted kappa was estimated.

Results:

In the validity phase, the distribution of urgency levels in 1,416 visits was the following: 0.0% red (emergency); 5.9% orange (high urgency); 40.5% yellow (urgency); 50.6% green (low urgency); and 3.0% blue (no urgency). The percentage of patients who used two or more resources decreased from the orange level to the yellow, green, and blue levels (81%, 49%, 22%, and 2%, respectively, p<0.0001), as did the ED admission rate, ED length of stay, and hospitalization rate. The sensitivity to identify patients with high urgency level was 0.89 (confidence interval of 95% [95%CI] 0.78-0.95), and the undertriage rate was 7.4%. The inter-rater reliability in 191patients classified by two nurses was substantial (kw²=0.75; 95%CI 0.74-0.79).

Conclusions:

The CLARIPED system showed good validity and substantial reliability for triage in a pediatric emergency department.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Validity and Reliability of the Emergency Severity Index and Australasian Triage System in Pediatric Emergency Care of Mofid Children's Hospital in Iran

Objective:

To evaluate the validity, reliability, sensitivity, and specificity of the Emergency Severity Index (ESI) and Australasian Triage System (ATS) for children visiting admitted to the emergency department (ED).

Methods:

This was a prospective study occurred in the Mofid children's Hospital in Iran from August 2017 to November 2018 and children had aged ≤14 years and presented at the ED with a medical symptom were considered eligible for participation. This study was divided into two phases: in the first phase, we determined the inter-rater reliability of ESI version 4 and ATS by triage nurses and pediatric residents. In the second phase, to analyze the validity, sensitivity, and specificity of each triage system. Reliability and agreement rates were measured using kappa statistics.

Results:

ESI showed inter-rater reliability with kappa of 0.65–0.92 (P<0.001) and ATS showed inter-rater reliability with kappa of 0.51–0.87 ESI had sensitivity ranged from 81% to 95% and specificity ranged from 73% to 86%. In addition, sensitivity ranged of the ATS were 80% to 95% and specificity ranged from 74% to 87%. Under triage and over triage occurred in 12% and 15% of patients respectively in ESI and 13% and 15% of patients respectively in ATS.

Conclusion:

The ESI and ATS both valid to triage children in the ED section of Mofid children's Hospital paediatric. Reliability of the ESI is good, moderate to good for the ATS.

Factors Associated With Discharge Home After Transfer to a Pediatric Emergency Department

OBJECTIVES

The transfer of children from community emergency departments (EDs) to tertiary care pediatric EDs for investigations, interventions, or a second opinion is common. In order to improve health care system efficiency, we must have a better understanding of this population and identify areas for education and capacity building.

METHODS

We conducted a retrospective chart review of all patients (aged 0-17 years) who were transferred from community ED to a pediatric ED from November 2013 to November 2014. The primary outcome was the frequency of referred patients who were discharged home from the pediatric ED.

RESULTS

Two hundred four patients were transferred from community EDs in the study period. One hundred thirteen children (55.4%) were discharged home from the pediatric ED. Presence of inpatient pediatric services (P = 0.04) at the referral hospital and a respiratory diagnosis (P = 0.03) were independently associated with admission to the children's hospital. In addition, 74 patients (36.5%) had no critically abnormal vital signs at the referral hospital and did not require any special tests, interventions, consultations, or admission to the children's hospital. Younger age (P = 0.03), lack of inpatient pediatric services (P = 0.04), and a diagnosis change (P = 0.03) were independently associated with this outcome.

CONCLUSIONS

More than half of patients transferred to the pediatric tertiary care ED did not require admission, and more than one third did not require special tests, interventions, consults, or admission. Many of these patients were likely transferred for a second opinion from a pediatric emergency medicine specialist. Education and real-time videoconferencing consultations using telemedicine may help to reduce the frequency of transfers for a second opinion and contribute to cost savings over the long term.

Validation of the Feverkidstool and procalcitonin for detecting serious bacterial infections in febrile children

BackgroundTo validate the Feverkidstool, a prediction model consisting of clinical signs and symptoms and C-reactive protein (CRP) to identify serious bacterial infections (SBIs) in febrile children, and to determine the incremental diagnostic value of procalcitonin.MethodsThis prospective observational study that was carried out at two Dutch emergency departments included children with fever, aged 1 month to 16 years. The prediction models were developed with polytomous logistic regression differentiating "pneumonia" and "other SBIs" from "non-SBIs" using standardized, routinely collected data on clinical signs and symptoms, CRP, and procalcitonin.ResultsA total of 1,085 children were included with a median age of 1.6 years (interquartile range 0.8-3.4); 73 children (7%) had pneumonia and 98 children (9%) had other SBIs. The Feverkidstool showed good discriminative ability in this new population. After adding procalcitonin to the Feverkidstool, c-statistic for "pneumonia" increased from 0.85 (95% confidence interval (CI) 0.76-0.94) to 0.86 (0.77-0.94) and for "other SBI" from 0.81 (0.73-0.90) to 0.83 (0.75- 0.91). A model with clinical features and procalcitonin performed similar to the Feverkidstool.ConclusionThis study confirms the external validity of the Feverkidstool, with CRP and procalcitonin being equally valuable for predicting SBI in our population of febrile children. Our findings do not support routine dual use of CRP and procalcitonin.

Characteristics of revisits of children at risk for serious infections in pediatric emergency care

In this study, we aimed to identify characteristics of (unscheduled) revisits and its optimal time frame after Emergency Department (ED) discharge. Children with fever, dyspnea, or vomiting/diarrhea (1 month-16 years) who attended the ED of Erasmus MC-Sophia, Rotterdam (2010-2013), the Netherlands, were prospectively included. Three days after ED discharge, we applied standardized telephonic questionnaires on disease course and revisits. Multivariable logistic regression analysis was used to identify independent characteristics of revisits. Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with revisits (n = 527) in children at risk for serious infections discharged from the ED (n = 1765). Children revisited the ED within a median of 2 days (IQR 1.0-3.0), but this was proven to be shorter in children with vomiting/diarrhea (1.0 day (IQR 1.0-2.0)) compared to children with fever or dyspnea (2.0 (IQR 1.0-3.0)).

CONCLUSION

Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with emergency health care revisits in children with fever, dyspnea, and vomiting/diarrhea. These characteristics could help to define targeted review of children during post-discharge period. We observed a disease specific and differential timing of control revisits after ED discharge. What is Known • Fever, dyspnea, and vomiting/diarrhea are major causes of emergency care attendance in children. • As uncertainty remains on uneventful recovery, patients at risk need to be identified on order to improve safety netting after discharge from the ED. What is New • In children with fever, dyspnea, and vomiting/diarrhea, young age, parental concern and chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea help to define targeted review of children during the post-discharge period. • A revisit after ED discharge is disease-specific and seems to be shorter for children with vomiting/diarrhea than others.

Multiple performance measures are needed to evaluate triage systems in the emergency department

OBJECTIVES

Emergency department triage systems can be considered prediction rules with an ordinal outcome, where different directions of misclassification have different clinical consequences. We evaluated strategies to compare the performance of triage systems and aimed to propose a set of performance measures that should be used in future studies.

STUDY DESIGN AND SETTING

We identified performance measures based on literature review and expert knowledge. Their properties are illustrated in a case study evaluating two triage modifications in a cohort of 14,485 pediatric emergency department visits. Strengths and weaknesses of the performance measures were systematically appraised.

RESULTS

Commonly reported performance measures are measures of statistical association (34/60 studies) and diagnostic accuracy (17/60 studies). The case study illustrates that none of the performance measures fulfills all criteria for triage evaluation. Decision curves are the performance measures with the most attractive features but require dichotomization. In addition, paired diagnostic accuracy measures can be recommended for dichotomized analysis, and the triage-weighted kappa and Nagelkerke's R² for ordinal analyses. Other performance measures provide limited additional information.

CONCLUSION

When comparing modifications of triage systems, decision curves and diagnostic accuracy measures should be used in a dichotomized analysis, and the triage-weighted kappa and Nagelkerke's R² in an ordinal approach.

The role of nurses' clinical impression in the first assessment of children at the emergency department

OBJECTIVE

To assess the diagnostic value and determinants of nurses' clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED).

DESIGN

Secondary analysis of a prospective cohort.

SETTING AND PATIENTS

6390 consecutive children <16 years of age presenting to a paediatric ED with a non-surgical chief complaint and complete data available.

MAIN OUTCOME MEASURES

Diagnostic accuracy of nurses' clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses' impression that a child appeared ill.

RESULTS

Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses' clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses' impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

CONCLUSION

The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.

Is this child sick? Usefulness of the Pediatric Assessment Triangle in emergency settings

OBJECTIVE

The Pediatric Assessment Triangle is a rapid assessment tool that uses only visual and auditory clues, requires no equipment, and takes 30-60s to perform. It's being used internationally in different emergency settings, but few studies have assessed its performance. The aim of this narrative biomedical review is to summarize the literature available regarding the usefulness of the Pediatric Assessment Triangle in clinical practice.

SOURCES

The authors carried out a non-systematic review in the PubMed®, MEDLINE®, and EMBASE® databases, searching for articles published between 1999-2016 using the keywords "pediatric assessment triangle," "pediatric triage," "pediatric assessment tools," and "pediatric emergency department."

SUMMARY OF THE FINDINGS

The Pediatric Assessment Triangle has demonstrated itself to be useful to assess sick children in the prehospital setting and make transport decisions. It has been incorporated, as an essential instrument for assessing sick children, into different life support courses, although little has been written about the effectiveness of teaching it. Little has been published about the performance of this tool in the initial evaluation in the emergency department. In the emergency department, the Pediatric Assessment Triangle is useful to identify the children at triage who require more urgent care. Recent studies have assessed and proved its efficacy to also identify those patients having more serious health conditions who are eventually admitted to the hospital.

CONCLUSIONS

The Pediatric Assessment Triangle is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperative to promote research for clinical validation, especially for clinical use by emergency pediatricians and physicians.

To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED)

Objective

To evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions.

Design

Retrospective cohort study.

Setting

Alder Hey Children’s NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK.

Participants

From October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as ‘GP appropriate’. The natural experiment compared patients triaged as ‘GP appropriate’ and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as ‘GP appropriate’ seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes.

Results

5223 patients were designated as ‘GP appropriate’—18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63–141) for the GP group compared with 113 min (IQR 70–167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95% CI 0.24 to 0.44), wait longer than 4 hours (2.3% vs 5.1%, OR 0.45, 95% CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95% CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95% CI 1.10 to 1.56). Sensitivity analyses yielded similar results.

Conclusions

Introducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children’s emergency services.

[The Spanish triage system in the evaluation of neonates in paediatric emergency departments]

The triage system in the emergency department classifies patients according to priority levels of care. Neonates are a vulnerable population and require rapid assessment.

OBJECTIVE

To correlate the priority levels in newborns seen in the paediatric emergency department with admissions, resource consumption, and service times.

PATIENTS AND METHOD

Observational study, using the Andorran triage model (MAT-SET) with ePATV4 software database, in paediatric emergencies. Neonates were classified into 3 levels of care established for them as level I resuscitation, level II emergency, and level iii urgent. The correlation between levels of priority and admission and resource consumption were analysed, as well as the time spent on medical care and stay in the emergency department.

RESULTS

The study included 1103 infants. The highest priority level was positively correlated with hospital admission (r = 0.66, P<.005) and resource consumption (r = 0.59, P < .005). The medical care times were 126 ± 203, 119 ± 51, and 33 ± 81 min for levels i, ii, and iii, respectively and the stay in emergency department was 150 ± 203, 131 ± 80, and 55 ± 86 min, respectively for these levels (P < .05).

CONCLUSION

The higher level of priority in the care of neonates in the paediatric emergency department was positively correlated with increased need for hospital admission and resource consumption. They also required a longer time for medical care and stay in the emergency department.