The identification of WHO emergency signs in children by nurses at triage in an emergency department

Abstract

ABSTRACT Background The World Health Organization recommends the use of a three-tier triage system to recognise a sick child in low- and middle-income countries. The three tiers are based on standardised emergency and priority signs. No studies have evaluated the prevalence or reliable detection of these emergency signs. Aims To determine the prevalence of WHO emergency signs and the underlying causes, and to determine whether nurses could reliably detect these signs in children presenting to the emergency department at Port Moresby General Hospital in Papua New Guinea. Methods A prospective study measured inter-rater agreement between nurses at triage and a blinded second assessor trained in paediatrics. Results The prevalence of emergency signs was 16.7%: 32 of 192 children had these signs at presentation; 18 (9.4%) had severe respiratory distress; 10 (5.2%) had severe dehydration; and 3 (1.6%) had convulsions. There was an acceptable inter-rater agreement between nurses and doctors (Cohen’s Kappa score >0.4) for some signs: subcostal recession, intercostal recession, nasal flaring, lethargy, weak volume pulses, convulsions, sunken eyes and a poor conscious state. Obstructed breathing, cyanosis, tracheal tug and cold hands and feet were less commonly detected and had poor inter-rater agreement (Kappa score <0.4). Conclusions Effective screening at triage can enable prompt emergency treatment by nurses and can help focus doctors’ attention on children who require it most. There is a need for additional training in the identification of some emergency signs. Abbreviations CED: children’s emergency department; ETAT: emergency triage assessment and treatment; HCC: Hospital Care for Children; PMGH: Port Moresby General Hospital; PNG: Papua New Guinea; WHO: World Health Organization