Principles of Paediatric Triage Prof. Yehezkel (Hezi) Waisman, MD - - PowerPoint PPT Presentation

Principles of Paediatric Triage

• Prof. Yehezkel (Hezi) Waisman, MD
• Dept. of Emergency Medicine

Schneider Children’s Medical Center of Israel

Schneider

Children’s Medical Center of Israel

The lobby

SCMCI’s ED Demographics

• Pediatric Tertiary Care facility (240 beds)
• Age of visitors: 0 – 18 years
• All spectrum of pediatric emergencies
• In house specialists in all subspecialties
• In 201 over 55,000 patients
• Our average hospitalization rate is 14%

Entrance to ED

Zone 1 Acute Care rooms: 15 (18 beds)

Zone 1 Resuscitation rooms: 3 (4 beds)

Zone 2 Observation unit: 5 rooms + 8 spaces

Distribution of ED diagnoses

• Trauma

24%

• Fever

20%

• Respiratory prob.

19%

• Abdominal pain

6%

• Vomiting

5%

• Diarrhea

5%

Treatments Sites/Areas

• Triage
• Zone 1

– Resuscitation rooms: 3 (4 beds) – Acute Care rooms: 15 (18 beds)

• Zone 2

– Observation unit: 5 rooms + 8 spaces

• Zone 3

– Fast track/ambulatory – 5 rooms

Presentation Overview

• Introduction
• Triage goals
• Principles of triage
• Pediatric considerations
• Requirements for effective triage
• Summary /Take home messages

Triage

• When needed?

Patients needs > physicians capacity

• French ‘trier’

To separate, sort or select

• Priority based
• n severity (and?...)

Introduction

• Triage is an essential function in EDs where

many patients may present simultaneously (MCI as an extreme example)

• Principles of pediatric and adult triage are

the same

• Children have unique anatomic, physiologic

and psychological characteristics which must be addressed

Case 1

A 1.5 year-old male is brought to the ED by his parents at 7 am because of fever, diarrhea and vomiting that started at night

Case Progression: Hospital A

• The ED clerk asks the parents to wait for the nurse
• The nurse calls the resident on call
• No vital signs obtained
• The nurse “you can wait, it seems like just a viral illness”
• – parents still wait, shift change
• 8:35 – The parents go in the ED because the baby becomes

lethargic

• The baby is found in profound shock, undergoes resuscitation
• DIC develops/Death

Septic Shock Syndrome

Case Progression: Hospital B

• The parents bring the child to the Peds ED
• In triage, the child looks pale, is tachycardic, has a delayed

capillary refill time, a temp. of 400 C, and a normal BP and O2 saturation

• The triage nurse categorizes Triage level 2 = high priority
• IV fluids and antibiotics are rapidly administered
• 3 hours later, the child is mechanically ventilated in PICU
• Subsequently recovers after a prolonged and complicated

PICU stay

Septic Shock Syndrome

• Triage seems to be an important function in the

ED and may save lives

• Triage is a place where nursing and medical

care complement each other

Case Conclusions

Goals of Triage

Patient care

• To ensure that patients are treated in the order
• f their clinical urgency

– Sickest patients are seen quickly System use

• To allocate the patient to the most appropriate

treatment area – Use limited resources efficiently – Reduce “length of stay” – Improve ED flow

Types of Triage

• 3 Level
• 5 Level
• ‘Protocol’

Type of Triage

• 3 – level

– Red / yellow / green – Emergency Triage Assessment and Treatment (ETAT)

• 5 – level
• ‘protocol’

3 – level Triage

• Red / yellow/ Green

Emergent Urgent Non-urgent Immediate threat to life or Limb Needs care but can wait few hours Time not critical Simple Finds the sick X Too much variability (kappa 0.35*) X Too many ‘Urgent’ X No correlation with disposition

• 3 – level
• 5 – level

– Australasian Triage Scale (ATS) – Canadian ED Triage and Acuity Scale (CTAS) – Manchester Triage Scale (MTS) – Emergency Severity Index (ESI)

• ‘protocol’

Type of Triage

5 – Level Triage

• Austrian Triage (ATS)
• Canadian ED triage Assessment Score (CTAS)

– Vital signs + score

• Manchester Triage Scale (MTS)

– 52 flow chart+ key discriminators

• Emergency Severity index (ESI)

– Severity + recourses USA + vital signs

Good validity (kappa 0.85, 0.93 Allows better resource (fast track) X Takes more time (2-10 min) X Requires more training

• 3 – level
• 5 – level
• ‘protocol’

– Adaptive Process Triage (ADAPT) – Advanced Triage Protocols

Type of Triage

Triage

Canadian Triage Assessment System (CTAS) Done by nurses

CTAS Category Definitions

Time to medical care Triage Category Level

See Patient immediately Resuscitation Level I Within 15 minutes Emergency Level II Within 30 minutes Urgency Level III Within 60 minutes Less Urgency Level IV Within 120 minutes Non Urgency Level V

Nursing Assessment

• Relationship of

accompanying person:

• Referred by:
• Patient history:
• Past hospitalizations:
• Chief complaint:
• Immunization status:
• Medications:
• Allergies:
• Vital signs:
• Child’s weight :
• Pain assessment
• Objective description:
• Treatment initiation:
• (clinical pathways)

Pediatric Considerations in Triage

• Children are less likely to have life-

threatening conditions

• Signs and symptoms of serious problems

may be subtle or develop quickly

• The need for immediate attention can be

determined by a quick assessment PAT -alertness, respiratory effort, and perfusion

Challenges of pediatric triage

Serious illness may not be recognized – Why? Because children:

• Are poor historians
• May manifest non specific symptoms
• May present with subtle signs
• May be uncooperative during examination

Case 2

A 4-month-old male infant is brought to the ED by his parents because of fever, runny nose, cough, difficulty breathing that have been worsening over the past 3 days

Question 1

What are the symptoms of a serious illness in infants under 6 months of age?

Symptoms of serious illness in infants under 6 months

• Feeding:

< 1/2 normal fluid intake

• Arousal:

Often drowsy/lethargic

• Breathing:

Apnea/ RD/cyanosis

• Circulation:

Skin pale and cold

• Fluid output:

Green vomit, <4 wet nappies/day

• Feces:

Bloody stool

Question 2

Which signs are specific for a serious illness in infants under 6 months of age?

Serious illness in infants under 6 months Useful signs

• Alertness:

drowsiness, hypotonia

• Breathing:

moderate/severe recessions cyanosis, wheeze

• Circulation: pallor, signs of dehydration
• Signs of dehydration
• Tender abdomen

Serious illness in infants under 6 months

Specific signs

• Respiratory grunt, crepitations, stridor, apnea

tachypnea >80/min

• Abdominal mass, hernia, distension
• CNS: weak cry, abnormal posture
• Skin: cold periphery, mottling, bruise, rash
• HR: > 200
• Urine output: < 4 wet nappies/day

Conditions which need infection control attention

• Rashes
• Immunocompromised children
• Neonates

Requirements for Effective Triage

• Good communication skills
• Ability to make accurate assessment
• Broad base of knowledge in pediatrics
• Ability to make sound judgment quickly
• Knowledge of ethnic customs and cultural

variability

• A gentle and caring touch, with a smile

Techniques for effective communication

• Show empathy

– my child is the sickest, very young, has high fever…

• Provide information

– Inform parents what is most likely to be done, what is the next step, the approximate time frame for waiting

• Provide education

– Use triage for parent basic education if time allows

Summary

• Triage is an essential function in a pediatric

ED, and often time is life saving

• For optimal triage - unique anatomic,

physiologic and psychological characteristics of children must be addressed

• For effective triage – nurses must be trained

and educated with specific triage skills

• Appropriate triage function plays an important

role in improving patient outcome

Thank you!