Improving the Manchester Triage System for pediatric emergency care: an international multicenter study

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.

The association between prehospital vital signs of children and their critical clinical outcomes at hospitals

Vital signs are important for patient assessment, but little is known about interpreting those of children in prehospital settings. We conducted an observational study to investigate the association between prehospital vital signs of children and their clinical outcomes in hospitals. We plotted the data of patients with critical outcomes on published reference ranges, such as those of healthy children to evaluate the clinical relevance. Of the 18,493 children screened, 4477 transported to tertiary hospitals were included in the analysis. The outcomes 12 h after being transported to a tertiary hospital were as follows: deceased, 41; hospitalization with critical deterioration events, 65; hospitalization without critical deterioration events, 1086; returned home, 3090; and unknown, 195. The reference ranges of the heart rates (sensitivity: 57.7%, specificity: 67.5%) and respiratory rates (sensitivity: 54.5%, specificity: 67.7%) of healthy children worked best to detect the critical outcomes. Therefore, the reference ranges of healthy children were concluded to be suitable in prehospital settings; however, excessive reliance on vital signs carried potential risks due to their limited sensitivities and specificities. Future studies are warranted to investigate indicators with higher sensitivities and specificities.

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.

The Dynamics of Patient Visits to a Public Hospital Pediatric Emergency Department: A Time-Series Model

BACKGROUND

The overcrowding of emergency departments (EDs) is an increasingly relevant public health problem. The main aims of this study were to identify and analyze temporal periodicities of a self-referred pediatric ED (PED), correlate them with meteorological and calendar variables and build a robust forecasting model.

METHODS

An 8-year administrative data set (2010-2017) of the daily number of admissions to the PED of a public hospital in Lisbon, Portugal, was used (n = 670,379). A time-series model of the daily number of visits was built, including temporal periodicities, the Portuguese school calendar, and a meteorological comfort index (humidex).

RESULTS

Several temporal cycles were identified: 1 year (peak in January/February related to respiratory infections in younger children and infants), 6 months (peaks in May and October with an increase in the admissions of older children and adolescents with trauma, gastrointestinal infections and atopic symptoms), 4 months (related to annual school vacations), 1 week (lower admission values on Saturday), and half a week (low from Friday to Monday morning). School calendar and humidex were significantly correlated with daily admissions. The model yielded a mean absolute percentage error of 10.7% ± 1.10% when cross-validation was performed for the full data set.

CONCLUSION

Although PED visits are multifactorial, they may be predicted and explained by a relatively small number of variables. Such a model may be easily reproduced in different settings and represents a relevant tool to improve quality in EDs through correctly adapting human resources to ED demand.

Decision-making for children requiring interhospital transport: assessment of a novel triage tool

OBJECTIVE

The use of specialist retrieval teams to transport critically ill children is associated with reduced risk-adjusted mortality and morbidity; however, there is a paucity of data to guide decision-making related to retrieval team activation. We aimed to assess the accuracy of a novel triage tool designed to identify critically ill children at the time of referral for interhospital transport.

DESIGN

Prospective observational study.

SETTING

Regional paediatric retrieval and transport services.

PATIENTS

Data were collected for 1815 children referred consecutively for interhospital transport from 87 hospitals in Queensland and northern New South Wales.

INTERVENTION

Implementation of the Queensland Paediatric Transport Triage Tool.

MAIN OUTCOME MEASURES

Accuracy was assessed by calculating the sensitivity, specificity and negative predictive value for predicting transport by a retrieval team, or admission to intensive care following transport.

RESULTS

A total of 574 (32%) children were transported with a retrieval team. Prediction of retrieval (95% CIs): sensitivity 96.9% (95% CI 95.1% to 98.1%), specificity 91.4% (95% CI 89.7% to 92.9%), negative predictive value 98.4% (95% CI 97.5% to 99.1%). There were 412 (23%) children admitted to intensive care following transport. Prediction of intensive care admission: sensitivity 96.8% (95% CI 94.7% to 98.3%), specificity 81.2% (95% CI 79.0% to 83.2%), negative predictive value 98.9% (95% CI 98.1% to 99.4%).

CONCLUSIONS

The triage tool predicted the need for retrieval or intensive care admission with high sensitivity and specificity. The high negative predictive value indicates that, in our setting, children categorised as acutely ill rather than critically ill are generally suitable for interhospital transport without a retrieval team.

[Risk management in the triage of emergency room patients to outpatient care : Manchester Triage System and CEReCo-blue as a tool for low-risk patient management in integrated emergency centers]

Hintergrund

Zur frühzeitigen Entscheidung in zukünftigen „Integrierten Notfallzentren“, ob eine ambulante oder innerklinische Versorgung indiziert ist, wäre es hilfreich, ein System zu haben, mit dem die Identifizierung von Patienten mit ambulanter Behandlungsindikation möglich ist. In dieser Studie untersuchten wir, ob das Manchester Triage System (MTS) dafür geeignet ist, Patienten zu erkennen, die sicher der ambulanten medizinischen Versorgung zugeteilt werden können.

Methode

Notaufnahmepatienten der „blauen“ MTS-Dringlichkeitsstufe wurden auf den Endpunkt „stationäre Aufnahme“ untersucht und mit der nächsthöheren MTS-Kategorie „grün“ verglichen. In einem zweiten Schritt wurde die „blaue“ Dringlichkeitsstufe auf die häufigsten gemeinsamen Kriterien untersucht, die zur stationären Aufnahme führten.

Ergebnisse

Nach Ausschluss von Patienten, die durch den Rettungsdienst oder nach vorherigem Arztbesuch vorstellig wurden, war die Rate der stationären Aufnahmen in der blauen Dringlichkeitsstufe signifikant niedriger als in der grünen Kategorie (10,8 % vs. 29,0 %). Die Rate konnte durch die Etablierung einer Untergruppe mit den zusätzlichen Ausschlusskriterien chronische Erkrankung und Wiedervorstellung nach vorheriger stationärer Behandlung auf 0,9 % gesenkt werden. (CEReCo-blue-Gruppe: Chronic Disorder (C), Emergency Medical Service (E), Readmission (R), Prior Medical Consultation (Co)).

Schlussfolgerung

Die blaue MTS-Dringlichkeitsstufe scheint zur Selektion von Patienten mit ambulanter Behandlungsindikation nicht geeignet zu sein. Wir schlagen die Einführung einer Untergruppe, der sog. CEReCo-blue-Gruppe vor, die für die Selektion dieser Patientengruppe hilfreich sein könnte.

Improving the prioritization of children at the emergency department: Updating the Manchester Triage System using vital signs

Background

Vital signs are used in emergency care settings in the first assessment of children to identify those that need immediate attention. We aimed to develop and validate vital sign based Manchester Triage System (MTS) discriminators to improve triage of children at the emergency department.

Methods and findings

The TrIAGE project is a prospective observational study based on electronic health record data from five European EDs (Netherlands (n = 2), United Kingdom, Austria, and Portugal). In the current study, we included 117,438 consecutive children <16 years presenting to the ED during the study period (2012–2015). We derived new discriminators based on heart rate, respiratory rate, and/or capillary refill time for specific subgroups of MTS flowcharts. Moreover, we determined the optimal cut-off value for each vital sign. The main outcome measure was a previously developed 3-category reference standard (high, intermediate, low urgency) for the required urgency of care, based on mortality at the ED, immediate lifesaving interventions, disposition and resource use. We determined six new discriminators for children <1 year and ≥1 year: “Very abnormal respiratory rate”, “Abnormal heart rate”, and “Abnormal respiratory rate”, with optimal cut-offs, and specific subgroups of flowcharts. Application of the modified MTS reclassified 744 patients (2.5%). Sensitivity increased from 0.66 (95%CI 0.60–0.72) to 0.71 (0.66–0.75) for high urgency patients and from 0.67 (0.54–0.76) to 0.70 (0.58–0.80) for high and intermediate urgency patients. Specificity decreased from 0.90 (0.86–0.93) to 0.89 (0.85–0.92) for high and 0.66 (0.52–0.78) to 0.63 (0.50–0.75) for high and intermediate urgency patients. These differences were statistically significant. Overall performance improved (R² 0.199 versus 0.204).

Conclusions

Six new discriminators based on vital signs lead to a small but relevant increase in performance and should be implemented in the MTS.

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.

Management of children visiting the emergency department during out-of-office hours: an observational study

BACKGROUND

The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours.

METHODS

We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital.

RESULTS

Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining.

CONCLUSIONS

Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Effectiveness of a Training Course on Accuracy of Triaging of Pediatric Patients

BACKGROUND:

In the context of a new but busy Pediatric Emergency Department, the risk of missing patients who need more emergent care can be reduced by timely and accurate triaging. In the emergency department of King Fahad Armed Forces Hospital, the Canadian Triage and Acuity Scale had already been implemented, including the pediatric version (PaedCTAS). However, a common observation remained that critical patients did not always receive priority with subsequent delays in management. To improve this accuracy, a training course was administered to health care professionals responsible for triaging of pediatric patients.

AIM:

To determine the effectiveness of a training course on accuracy of triaging of Pediatric Patients.

METHODS:

A triage training course was conducted over two months, with patient encounter sheets reviewed before the course for 6 months and after the course for 12 months. Accuracy was calculated by comparing it to level as determined by two pediatric emergency physicians. Also, admission rates were used as a surrogate marker to also determine accuracy.

RESULTS:

A total of 31 053 patient sheets were reviewed. There was a considerable improvement in the correct determination of all triage levels, with accuracy ranging from 56.5% to 78.3% before the course, and reaching from 79.1% to 90.8% after the course with a statistically significant difference. Triaging errors still present were mainly in the form of down-triage.

CONCLUSION:

Our training course in triage has a significant impact on the accuracy of triaging of ill pediatric patients. Further improvement can be obtained by repeated courses and direct feedback with debriefing sessions on challenges to triage level determination.

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.

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%.

An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care?

Background

Measurement and correct interpretation of vital signs is part of routine clinical care. Repeated measurement enhances early recognition of deterioration, may help prevent morbidity and mortality and is a standard of care in most countries.

Objective

To examine documentation of vital signs by clinicians for admissions to paediatric wards in Kenyan hospitals, to describe monitoring frequency by nurses and explore factors influencing frequency.

Methods

Vital signs information (temperature, respiratory and pulse rate) for the first 48 hours of admission was collected from case records of children admitted with non-surgical conditions to 13 Kenyan county hospitals between September 2013 and April 2016. A mixed effect negative binomial regression model was used to explore whether the severity of illness (indicated by danger signs or severe diagnostic episodes) is associated with increased vital signs observation frequency.

Results

We examined 54 800 admission episodes with an overall mortality 6.1%. Nurse to bed ratios were very low (1:10 to 1:41 across hospitals). Admitting clinicians documented all or no vital signs in 57.0% and 8.4% cases respectively. For respiratory and pulse rates there was pronounced even end-digit preference (an indicator of incorrect information) and high frequency recording of specific values (P < 0.001) suggesting approximation. Monitoring frequency was explored in 41 738 children. Those with inpatient stays ≥48 hours were expected to have a vital signs count of 18, hospitals varied but most did not achieve this benchmark (median 9, range 2-30). There were clinically small but significant associations between vital signs count and presence of multiple severe illnesses or presence of severe pallor (adjusted relative risk ratio = 1.04, P < 0.01, 95% confidence interval CI = 1.02-1.06 and 1.05, P = 0.02, 95% CI = 1.01-1.09, respectively).

Conclusions

Data suggest accurate admission measures are sometimes missing especially for pulse and respiratory rates, possibly linked to manual measurement. Monitoring frequency is often low in the high risk population studied probably indicating how quality of nursing care is undermined by considerable human resource shortages.

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.

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.

How to Predict Oral Rehydration Failure in Children With Gastroenteritis

OBJECTIVES

Oral rehydration is the standard in most current guidelines for young children with acute gastroenteritis (AGE). Failure of oral rehydration can complicate the disease course, leading to morbidity due to severe dehydration. We aimed to identify prognostic factors of oral rehydration failure in children with AGE.

METHODS

A prospective, observational study was performed at the Emergency department, Erasmus Medical Centre, Rotterdam, The Netherlands, 2010-2012, including 802 previously healthy children, ages 1 month to 5 years with AGE. Failure of oral rehydration was defined by secondary rehydration by a nasogastric tube, or hospitalization or revisit for dehydration within 72 hours after initial emergency department visit.

RESULTS

We observed 167 (21%) failures of oral rehydration in a population of 802 children with AGE (median 1.03 years old, interquartile range 0.4-2.1; 60% boys). In multivariate logistic regression analysis, independent predictors for failure of oral rehydration were a higher Manchester Triage System urgency level, abnormal capillary refill time, and a higher clinical dehydration scale score.

CONCLUSIONS

Early recognition of young children with AGE at risk of failure of oral rehydration therapy is important, as emphasized by the 21% therapy failure in our population. Associated with oral rehydration failure are higher Manchester Triage System urgency level, abnormal capillary refill time, and a higher clinical dehydration scale score.

Validity of triage systems for paediatric emergency care: a systematic review

AIM

To present a systematic review on the validity of triage systems for paediatric emergency care.

METHODS

Search in MEDLINE, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Nursing Database Index (BDENF) and Spanish Health Sciences Bibliographic Index (IBECS) for articles in English, French, Portuguese or Spanish with no time limit. Validity studies of five-level triage systems for patients 0-18 years old were included. Two reviewers performed data extraction and quality assessment as recommended by PRISMA statement.

RESULTS

We found 25 studies on seven triage systems: Manchester Triage System (MTS); paediatric version of Canadian Triage and Acuity Scale (PedCTAS) and its adaptation for Taiwan (paediatric version of the Taiwan Triage and Acuity System); Emergency Severity Index version 4 (ESI v.4); Soterion Rapid Triage System and South African Triage Scale and its adaptation for Bostwana (Princess Marina Triage Scale). Only studies on the MTS used a reference standard for urgency, while all systems were evaluated using a proxy outcome for urgency such as admission. Over half of all studies were low quality. The MTS, PedCTAS and ESI v.4 presented the largest number of moderate and high quality studies. The three tools performed better in their countries or near them, showing a consistent association with hospitalisation and resource utilisation. Studies of all three tools found that patients at the lowest urgency levels were hospitalised, reflecting undertriage.

CONCLUSIONS

There is some evidence to corroborate the validity of the MTS, PedCTAS and ESI v.4 for paediatric emergency care in their own countries or near them. Efforts to improve the sensitivity and to minimise the undertriage rates should continue. Cross-cultural adaptation is necessary when adopting these triage systems in other countries.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Validity of the Pediatric Assessment Triangle as the First Step in the Triage Process in a Pediatric Emergency Department

OBJECTIVE

This study aimed to assess the association between pediatric assessment triangle (PAT) findings during triage and markers of severity in a pediatric emergency department (PED).

METHODS

During the study period, patients arriving to the PED were classified by trained nurses with the Pediatric Canadian Triage and Acuity Scale using a computer system, from which data were obtained and analyzed retrospectively. The primary outcome measure was the percentage of children hospitalized related with PAT findings. The secondary outcome measures were the admission to the intensive care unit (%), PED length of stay, and performance of blood tests (%).

RESULTS

Among the 302,103 episodes included, there were abnormal PAT findings in 24,120 cases (7.9%). Multivariate analysis adjusted for age confirmed that PAT findings and triage level were independent risk factors for admission (odds ratio [OR], 2.21; 95% confidence interval [CI], 2.13-2.29; OR, 6.01; 95% CI, 5.79-6.24, respectively). Abnormal findings in appearance or in more than 1 PAT component were even more strongly associated with admission (3.99; 95% CI, 3.63-4.38; 14.99, 95% CI, 11.99-18.74, respectively). When adjusted for triage level and age, abnormal PAT findings were also an independent risk factor for intensive care unit admission (OR, 4.44; 95% CI, 3.77-5.24) and a longer stay in the PED (OR, 1.78; 95% CI, 1.72-1.84).

CONCLUSIONS

Abnormal findings in the PAT applied by trained nurses at triage identify patients with a higher risk of hospitalization. The PAT seems to be a valid tool for identifying the most severe patients as a first step in the triage process.

Implementation of a Pediatric Emergency Triage System in Xiamen, China

Background:

Pediatric emergency rooms (PERs) in Chinese hospitals are perpetually full of sick and injured children because of the lack of sufficiently developed community hospitals and low access to family physicians. The aim of this study was to evaluate the clinical value of a new five-level Chinese pediatric emergency triage system (CPETS), modeled after the Canadian Triage System and Acuity Scale.

Methods:

In this study, we compared CPETS outcomes in our PER relative to those of the prior two-level system. Patients who visited our PER before (January 2013–June 2013) and after (January 2014–June 2014) the CPETS was implemented served as the control and experimental group, respectively. Patient flow, triage rates, triage accuracy, wait times (overall and for severe patients), and patient/family satisfaction were compared between the two groups.

Results:

Relative to the performance of the former system experienced by the control group, the CPETS experienced by the experimental group was associated with a reduced patient flow through the PER (Cox-Stuart test, t = 0, P < 0.05), a higher triage rate (93.40% vs. 90.75%; χ² = 801.546, P < 0.001), better triage accuracy (96.32% vs. 85.09%; χ² = 710.904, P < 0.001), shorter overall wait times (37.30 ± 13.80 min vs. 41.60 ± 15.40 min; t = 11.27, P < 0.001), markedly shorter wait times for severe patients (2.07 [0.65, 4.11] min vs. 3.23 [1.90,4.36] min; z = –2.057, P = 0.040), and higher family satisfaction rates (94.23% vs. 92.21%; χ² = 321.528, P < 0.001).

Conclusions:

Implementing the CPETS improved nurses’ abilities to triage severe patients and, thus, to deliver the urgent treatments more quickly. The system shunted nonurgent patients to outpatient care effectively, resulting in improved efficiency of PER health-care delivery.

Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department

Acute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children's hospital in The Netherlands ( 2010-2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09-4.31 p < 0.05). We observed no differences in other outcome measures.

CONCLUSION

Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures. What is Known: • Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments. • Guidelines advocate standardized oral treatment in children with mild to moderate dehydration, but appear to be applied infrequently in clinical practice. What is New: • Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility, resulting in a more standardized ORS use in children with mild to moderate dehydration, compared to usual care. • Given the challenges to perform research in emergency care setting, the ED should be experienced and adequately equipped, especially during peak times.