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 on 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 Septic Shock Syndrome • 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
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 40 0 C, and a normal BP and Septic Shock Syndrome 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
Case Conclusions • 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
Goals of Triage Patient care • To ensure that patients are treated in the order of 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 Immediate threat to life or Limb Urgent Needs care but can wait few hours Non-urgent Time not critical � Simple � Finds the sick X Too much variability (kappa 0.35*) X Too many ‘Urgent’ X No correlation with disposition
Type of Triage • 3 – level • 5 – level – Australasian Triage Scale (ATS) – Canadian ED Triage and Acuity Scale (CTAS) – Manchester Triage Scale (MTS) – Emergency Severity Index (ESI) • ‘protocol’
5 – Level Triage • Austrian Triage (ATS) • Canadian ED triage Assessment Score (CTAS) – Vital signs + score � Good validity (kappa 0.85, 0.93 � Allows better resource (fast track) • Manchester Triage Scale (MTS) – 52 flow chart+ key discriminators X Takes more time (2-10 min) • Emergency Severity index (ESI) X Requires more training – Severity + recourses USA + vital signs
Type of Triage • 3 – level • 5 – level • ‘protocol’ – Adaptive Process Triage (ADAPT) – Advanced Triage Protocols
Triage Canadian Triage Assessment System (CTAS) Done by nurses
CTAS Category Definitions Level Triage Category Time to medical care Level I Resuscitation See Patient immediately Level II Emergency Within 15 minutes Level III Urgency Within 30 minutes Level IV Less Urgency Within 60 minutes Level V Non Urgency Within 120 minutes
Nursing Assessment • Relationship of • Allergies: accompanying person: • Vital signs: • Referred by: • Child’s weight : • Patient history: • Pain assessment • Past hospitalizations: • Objective description: • Chief complaint: • Treatment initiation: • Immunization status: • (clinical pathways) • Medications:
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!
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