Pediatric Triage System Research Articles

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

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). 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. 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. 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.

Current Disaster Triage Methods in Mass Casualty Incidents

Introduction:Triage in a disaster scenario centers around doing the greatest good for the greatest number of people. There are a variety of triage systems, and to this date there is no US national endorsement of one system because triage is a dynamic procedure and there is no fixed rule for it. The Simple Triage and Rapid Treatment (START); Sort, Assess, Life-saving interventions, Treatment/Transport (SALT); Sacco; CareFlight; JumpSTART; and Pediatric Triage Tape (PTT) triage systems are discussed with emphasis on how they perform.Method:There are approximately 20 adult and two pediatric triage systems that exist for primary disaster triage. The focus is on six primary triage systems. A literature search was performed using textbooks and original research.Results:A basic assignment to immediate, delayed, minimal, or expectant can sort a large group of casualties in a matter of minutes, but improper category assignment can lead to under-triage or over-triage.When assessed by a trained paramedic arriving at a Level 1 pediatric trauma center, SALT was found to be the most accurate triage system at 59% compared to JumpSTART, CareFlight, and TriageSieve. All triage systems exhibited under-triage rates of at least 33% and SALT had the highest over-triage rate at 6%. In another study, the START triage system was found to be 85% sensitive and 86% specific in predicting critical injury in designated trauma patients.Conclusion:Mass casualty incidents are unfortunately becoming more common as the increasing numbers of violent attacks produce an overwhelming number of victims. One triage process may not work in all disasters, but first responders should be trained to evaluate for the most critical patients in a sea of evolving patient presentations. Furthermore, randomized, controlled trials in real-world conditions are nearly impossible to perform given the specific circumstances of disasters.

Pediatric emergency triage systems.

ABSTRACTObjective:The aim of this study was to perform a narrative review of the leading pediatric triage systems in emergency departments (EDs).Data source:Articles published between 1999 and 2019 were identified by searching the MEDLINE, EMBASE, and PubMed databases using the keywords “pediatric triage”, “pediatric assessment tools”, and “emergency department triage” with an emphasis on studies that evaluated the validation and reliability of triage systems.Data synthesis:A total of 105 articles on pediatric emergency triage systems in 12 countries were evaluated. Triage systems were divided into two groups: color-stratified triage systems and alert systems. The color-stratified triage systems included in this review were the Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), Emergency Severity Index (ESI), and Australasian Triage Scale (ATS), and the alert systems included were the Paediatric Observation Priority Score (POPS), Pediatric Early Warning Score (PEWS), and Pediatric Approach Triangle (PAT). Evidence corroborates the validity and reliability of MTS, PaedCTAS, ESI version 4, PEWS, POPS, and PAT in pediatric emergency services.Conclusions:These are fundamental tools for risk classification of patients seeking treatment in EDs. Not all triage systems have been assessed for validity and reliability; nor are they well suited for all regions of the world. Employing triage systems in Brazil requires cultural adaptation and rigorous training of the local health staff, in addition to validation and reliability studies in our country, since the social and cultural context of this country differs from those where these tools were developed.

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

ObjectiveTo evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil. MethodsProspective, 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. ResultsThe 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%. ConclusionThis 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.

Pediatric Disaster Triage System

Pediatric Disaster Triage System

Analysis of the validity of the five-level TRIPED-GM paediatric triage system

ObjectiveTo determine the validity of the five-level TRIPED-GM pediatric triage system. MethodsUnicentric, observational, descriptive, cross-sectional study of 485 patients aged 0–16 years in the pediatric emergency department of the HGU Gregorio Marañon. Two measures of validity were used: a direct measure calculated by the sensitivity and specificity obtained based on the number of infratriages and overtriages of the priorities given by classification nurses compared with a panel of experts and another indirect measure by the length of stay, the resources consumed and the percentage of income for each priority level. Results10 patients were incorrectly classified, 4 (0.8%) were considered infratriages and 6 (1.2%) overtriages. The results showed a sensitivity of 99.45% (95% CI 96.5–99.97%) and a specificity of 99.01% (95% CI 96.9−99.7%) for high priorities (P2 and P3) and 98.99% (95% CI 96.8–99.6%) and 98.4% (95% CI 96.84−99.74%) respectively for low priorities (P4 and P5). The quadratic weighted Kappa index was 0.96 (95% CI 0.94−0.98; p = 0.0000). Resource consumption showed moderate Spearman correlation coefficients as the priority level increased. The percentage of admissions and the need for observation increased as the priority level p = 0,000 increased, not requiring observation or admitting any patients with priority 5. ConclusionsThe TRIPED-GM pediatric triage system is valid for use in emergency departments with similar patients.

Risk factors predicting early in-hospital mortality among underfive children and need for decentralization of pediatric emergency care services.

Lack of pediatric triage and emergency care system in peripheral healthcare centers leads to unnecessary referral of low- and medium-risk patients. This study was conducted to study the risk factors predicting mortality within 48 h of admission in neonates and under-five children referred to the pediatric emergency of a tertiary care hospital in India. This prospective study was conducted on children (0-5 years) referred to the pediatric emergency who were enrolled and followed up. The outcome was defined as "survival" or "death" at 48 hours. Logistic regression analysis was conducted to assess the predictors of early in-hospital mortality. A total of 246 consecutive pediatric (62 neonates, 52 young infants, and 132 children aged 1-5 years) referral cases were enrolled; mortality within 48 hours was 20%. Lack of pediatric intensive care (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.0, 8.32, P = 0.02), lack of neonatal intensive care (OR 2.10, 95% CI 1.01,4.28, P ≤ 0.001), distance from referral center >20 km (OR 4.61, 95% CI 2.01, 10.58, P = 0.0003), >1 h taken during transport (OR 7.75, 95% CI 2.93, 20.46, P < 0.001), lack of ambulance facility (OR 0.04, 95% CI 0.009, 0.143, P < 0.0001), very sick condition on arrival (OR 210.1, 95% CI 12.1, 3643.41, P = 0.0002), and unstable temperature-oxygenation-perfusion-sugar on arrival were the independent risk factors predicting in early in-hospital mortality. Developing a pediatric triage and monitoring system, tele-pediatric intensive care unit, regionalizing referral-back-referral services with robust interhospital communication, and strengthening pediatric emergency services are the need of the hour to reduce early in-hospital mortality.

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

ObjectiveTo evaluate the validity of the computerized version of the pediatric triage system CLARIPED. MethodsProspective, 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. Results19,122 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%. ConclusionThe 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.

Implementing a triage tool to improve appropriateness of care for children coming to the emergency department in a small hospital in India

BackgroundIn 2015, senior consultants at Sitaram Bhartia Institute of Science and Research saw several sick children in their outpatient clinics for which they had been seen in the emergency department...

Are Pediatric Triage Systems Reliable in the Emergency Department?

Background Few studies have focused on the agreement level of pediatric triage scales (PTSs). The aim of this meta-analytic review was to examine the level of inter-rater reliability of PTSs. Methods Detailed searches of a number of electronic databases were performed up to 1 March 2019. Studies that reported sample sizes, reliability coefficients, and a comprehensive description of the assessment of the inter-rater reliability of PTSs were included. The articles were selected according to the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) taxonomy. Two reviewers were involved in the study selection, quality assessment, and data extraction and performed the review process. The effect size was estimated by z-transformation of reliability coefficients. Data were pooled with random-effects models, and a metaregression analysis was performed based on the method of moments estimator. Results Thirteen studies were included. The pooled coefficient for the level of agreement was 0.727 (confidence interval (CI) 95%: 0.650–0.790). The level of agreement on PTSs was substantial, with a value of 0.25 (95% CI: 0.202–0.297) for the Australasian Triage Scale (ATS), 0.571 (95% CI: 0.372–0.720) for the Canadian Triage and Acuity Scale (CTAS), 0.810 (95% CI: 0.711–0.877) for the Emergency Severity Index (ESI), and 0.755 (95% CI: 0.522–0.883) for the Manchester Triage System (MTS). Conclusions Overall, the reliability of pediatric triage systems was substantial, and this level of agreement should be considered acceptable for triage in the pediatric emergency department. Further studies on the level of agreement of pediatric triage systems are needed.

Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality

Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a Nationwide Cross-Sectional Study in Korea.

BackgroundPrevious studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage.MethodsThis was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class.ResultsDuring the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468).ConclusionDown-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

Application of the five-level pediatric emergency triage system: a single center study

Objective: To assess the effectiveness in optimizing resources and shortening critical children's waiting time in pediatric emergency department (PED) with five-level pediatric emergency triage system (PETS). Methods: This retrospective study was conducted in the First Affiliated Hospital of Xiamen University after PETS was applied. The data of patients who visited the pediatric emergency department from January 2015 to December 2017 were collected and analyzed, including age, sex, diseases, visiting time, triage rate and destination. Results: A total of 375 985 patients were included, among whom males were 225 308 (59.9%) and females were 150 677 (40.1%), all younger than 14 years of age. The number of critical cases (level Ⅰ, level Ⅱ and level Ⅲ) was increased from 4 719 (3.7%) in 2015, 12 209 (10.2%) in 2016 to 16 188 (12.7%) in 2017. The number of non-critical patients (level Ⅴ) decreased year by year, as from 98 213 (76.8%) in 2015 to 75 210 (62.6%) in 2016 and 78 857 (61.7%) in 2017. The patients who classified as level Ⅰ or levelⅡaccording to the PETS were seen immediately by physician (n=1855, 0.5%). Overall, 119 738 patients (98.3%) who were classified as level Ⅲ or level Ⅳ could be seen by physician in a timely manner according to triage guidelines, while 2 112 patients (1.7%) could not. The mean waiting time was 9.09 min in level Ⅲ, 17.7 min in level Ⅳ, and 55.76 min in level Ⅴ patients, respectively. The critical cases admitted to the intensive care units were 175 (36.2%) in 2015, 350 (62.8%) in 2016 and 374 (66.2%) in 2017. The etiologies were respiratory diseases (73.3%), gastrointestinal diseases (15.8%) and infectious diseases (3.1%). Conclusion: The application of PETS could optimize emergency resources and shorten the waiting time of critically ill children.

Pediatric emergency triage system

To introduce the technical process, manpower, equipment preparation and attentions of children′s emergency triage system, and briefly introduce the common triage system at home and abroad, and the new technology and development in this field. Key words: Emergency; Pediatrics; Triage system

Implementing the first standardised and validated paediatric triage system at a National Hospital in Guinea Bissau

Introduction: Guinea-Bissau is situated on the west coast of Sub-Saharan Africa; the country population is very young: 44% under 15 years old. Simâo Mendes National Hospital, run by the Ministry of Health (MoH), is the only tertiary level facility and therefore the reference hospital for the whole country. Paediatric emergency room (ER) did not have a proper triage system before the beginning of MSF support in January 2017.

Can ambulance telephone triage using NHS Pathways accurately identify paediatric cardiac arrest?

BackgroundMost out-of-hospital paediatric cardiac arrests (CA) are not identified until a call is made to the emergency medical services. Accurate identification increases overall survival by enabling immediate ambulance dispatch and delivery of bystander CPR. European ambulance services use a variety of didactic telephone scripts to interrogate the caller and rapidly identify paediatric CA. The performance of these scripts has not been reported. This study aims to evaluate the diagnostic accuracy of the NHS Pathways as a telephone triage tool to identify patients less than 16 years age in cardiac arrest. MethodsAll emergency calls to South Central Ambulance Service (SCAS) over a 12-month period screened by ‘NHS Pathways’ v9.04 were identified. All actual or presumed paediatric CAs (<16 years age) identified by the emergency call taker were cross-referenced with the ambulance crew’s Patient Report Form to identify all confirmed CAs. ResultsOver a 12-month period from March 2015, a total of 540,715 emergency calls were received by SCAS, of which 53,213 related to children, 2052 (3.86%) being categorised by ‘NHS Pathways’ as paediatric CA. On arrival of the ambulance crew, only 87/2052 (4.24%) patients were in CA. Sensitivity=71.3%; specificity=96.3%; positive predictive value=4.2%. NHS Pathways missed the CA in 28.7% cases. ConclusionsThis is the first reported evaluation of any currently used European paediatric telephone triage system for identifying CA. Further work is required to refine telephone triage pathways for paediatric cardiac arrest.

Pediatric Disaster Triage System Utilization Across the United States.

The study goal was to determine which pediatric disaster triage (PDT) systems are used in US states/territories and whether there is standardization to their use. Secondary goals were to understand user satisfaction with each system, user preferences, and the nature and magnitude of incidents for which the systems are activated. A survey was developed regarding PDT systems used in each state/territory, satisfaction with those used, preference for specific systems, and type and magnitude of incidents prompting system activation. The survey was distributed to emergency medical services for children leads in each state/territory. Eighty-six percent of states/territories responded. Eighty-eight percent of respondents used some formal PDT system, 50% of whom reported utilization of multiple systems. JumpSTART was most commonly used, most often in conjunction with other systems. Of formal systems, JumpSTART has been in use the longest. JumpSTART was also preferred by 71% of those stating a preference; it tied with Smart for median satisfaction level. Although types of incidents prompting system activation was similar across responding states/territories, number of patients prompting activation varied from 1 to 3 to greater than 20, median range of 4 to 7. Most states/territories use some formal PDT system; few have 1 standardized approach. JumpSTART is predominantly used and is preferred by most respondents. With all systems, there is marked variation in number of patients prompting activation although the reported nature of incidents prompting activation is similar.

Inter-rater reliability between nurses for a new paediatric triage system based primarily on vital parameters: the Paediatric Triage Instrument (PETI)

IntroductionThe major paediatric triage systems are primarily based on flow charts involving signs and symptoms for orientation and subjective estimates of the patient's condition. In contrast, the 4-level Paediatric Triage...

Validation of different pediatric triage systems in the emergency department.

Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department. This was a prospective observational study. This study was divided into two phases. The first phase determined the inter-rater reliability of five triage systems: Manchester Triage System (MTS), Emergency Severity Index (ESI) version 4, Pediatric Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and Ramathibodi Triage System (RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients (triage level 1, 2) and low acuity patients (triage level 3, 4, and 5). Then we compared the triage acuity with actual admission. In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0 (P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8-0.9 (P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5-0.7 (P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specificity of 81%, and AUC 0.78 (95%CI 0.74-0.81). RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

Paediatric triage system at the Emergency Department of the Western Hospital in Grodzisk Mazowiecki, Poland

Paediatric triage system at the Emergency Department of the Western Hospital in Grodzisk Mazowiecki, Poland