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Prehospital paediatric emergency care: paediatric triage

J M Sandell,1 I K Maconochie,2 F Jewkes3
Department of Child Health, Poole Hospital NHS Foundation Trust, Dorset, UK; 2 Department of Accident & Emergency, Queen Elizabeth the Queen Mother Wing, Imperial College School of Medicine at St. Marys Hospital, London, UK; 3 NHS Pathways Connecting for Health, UK Correspondence to: Dr Julian M Sandell, Department of Child Health, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB, UK; julian.sandell@poole.nhs.uk Accepted 8 July 2008
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ABSTRACT The practice of triage was conceived during the Napoleonic wars, with the aim of salvaging those soldiers whose injuries were readily treatable, returning them to the battlefield at the earliest opportunity. Literally, the word triage means to sieve or to sort (French trier), and those earlier battlefield principles have been refined and expanded to now encompass trauma and medical emergencies, with triage practiced in prehospital and hospital settings. To address the anatomical, physiological and developmental differences encountered when dealing with children, specific paediatric triage systems have also been developed, and this article discusses their merits.
Generic triage principles typically involve: c patient sieve and sortthis should be quick and simple, providing an assessment that is reproducible and reliable (the initial primary triage assessment being the sieve followed by a more comprehensive secondary triage, sorting the patients in more detail); c anatomical and/or physiological assessments as well as consideration of either the mechanism of injury or the presenting illness; c a dynamic process requiring regular reassessment, responding to changes in the patients clinical status; c doing the most, for the mostassigning treatment and/or evacuation priorities whenever demand outstrips the skilled help or resources available (triage cannot be applied to a single patient but should clearly aim to benefit the individual and the cohort to which it is being applied); c a process totally separate from treatment (not always adhered to), which should ideally be performed by experienced, senior staff, reducing the risk of undertriage and overtriage. These principles underlie adult triage systems and form the basis of the paediatric triage systems currently being used.

(b)

PREHOSPITAL PAEDIATRIC TRIAGE

Paediatric triage takes many forms in the prehospital setting, including:

1. Telephone triage
(a) The NHS Direct telephone triage system, introduced in 2000, is linked to emergency call-handling centres and provides public healthcare information and advice 24 h per day via either a nurse-led telephone helpline (0845 4647), via the internet (http://www. nhsdirect.nhs.uk) or more recently via Digital TV (Freeview channel 108). Twenty-five per

cent of their calls are paediatric. NHS Direct acts as a triage sieve, attempting to identify all serious conditions, and by necessity, its advice tends to be conservative, prompting direct face-to-face medical assessment. Like NHS Direct, other telephone triage systems exist (such as NHS Pathways), again utilising decision-support algorithms. These systems are again designed to identify serious illness and to provide self-management information when appropriate, as well as provide information about alternative healthcare services, enabling best use of available resources. Ambulance call handling and response. UK Ambulance Service calls had until recently been assigned one of four categories: Category A: immediately life-threatening, Category B: serious but not immediately life-threatening, Category C: not immediately life-threatening, and GP Urgents, with targets for responses assigned to each category. The 2005 report, Taking Healthcare to the Patient1, describes a move away from these target driven responses and recommends that patients be assigned to one of two ambulance response priorities either Category A: immediately life-threatening (response within 8 minutes irrespective of location in 75% of cases); with all other patients responses assessed on clinical and outcome indicators rather than primarily on time-based targets. Regardless of condition, children aged 2-years and under had automatically received a Category A response under the previous system. Today however, children of all ages are triaged along with all other patient groups on clinical condition without such additional prioritisation. This change was made to allow more appropriate allocation of resources and follows recommendations from the Emergency Call Prioritisation Advisory Group (ECPAG) with the approval of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). National developments in the management of emergency and urgent care has seen an increasing move for healthcare to be taken to the patient in the community. Ambulance Service Trusts are playing a key role in the development of these local strategies and care pathways, providing telephone advice and telephone reviews (hear and treat), providing assessment and treatments in the home (see and treat), referring patients to their GP as well as referrals to other out-of-hours services and urgent care facilities. As the range of community-based services increases, the need for safe and reliable call-handling and robust triage systems becomes all the more important.2
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Emerg Med J 2009;26:767768. doi:10.1136/emj.2008.061556

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Review
2. Trauma
There are a variety of prehospital triage systems available in the UK, each with differences in their triage priorities, and as a result, rescuers need to familiarise themselves with the system and colour codes used in their locality. The triage sieve, a brief assessment of mobility and Airway, Breathing, Circulation (ABC) physiology, was designed to manage adult trauma victims in a major incident, and its use is widespread. Non-intentionally, the triage sieve overtriages otherwise healthy children ,1 year (non-ambulant by design), and so the Paediatric Triage Tape (PTT),2 a modified adult triage sieve, was developed to overcome these difficulties (see fig 1). It relates the childs supine length to age-related changes in normal paediatric physiological values (respiratory rate, heart rate and capillary refill time) and assigns comparable priorities as immediate (P1, red), urgent (P2, yellow) or delayed (P3, green). (In keeping with adult practice, child victims of entrapment would automatically be given priority P1.) The PTT is designed for use in children of height ,140 cm or of weight ,32 kg (approximately 011 years old). It has been found to have excellent specificity (the ability to detect non-P1 patients) but poor sensitivity (38% ability to identify P1 children), although these overtriage and undertriage rates are within the ranges deemed acceptable by the American College of Surgeons.3 In a trauma setting, clinical limitations can physically restrict the usefulness of such a length-based system because of difficulties encountered when taking the measurements of the child. It is not uncommon for an injured child to be rendered immobile by their injuries, making movement hazardous and impairing attempts to assess their physical lengthfor example, the child with spinal injuries. Similarly, the injured child is likely to be agitated, in pain and uncooperative, which can again affect attempts to measure their supine length.

Figure 1

The Paediatric Triage Tape in use.

The UK Paediatric Early Warning Score (PEWS) has also recently been evaluated in a paediatric emergency department as a possible alternative triage tool, but in such a setting, with children presenting with undifferentiated disease, it was found to have only limited value in predicting the need for hospital admission and so was not recommended for triage purposes.9 (The Paediatric Early Warning Score was primarily developed to predict impending need for paediatric high-dependency unit or paediatric intensive care unit, by prompt recognition of early clinical deterioration in a population of paediatric inpatients.)

SUMMARY
Accurate and reliable triage systems will be required to safely manage patient care wherever demand exceeds available health resources. With emergency care systems evolving, the UKs ambulance service is set to play an increasingly integral role in the coordination and allocation of these resources, sieving and sorting patients to primary care facilities and hospital emergency departments. Ideally, a common triage system should be developed for this purpose, designed to be equally applicable in prehospital and hospital settings and able to triage adult and paediatric patients simultaneously. Ensuring that children receive the appropriate level of prioritisation will no doubt be one of the major challenges the development team of any such system will face.
Competing interests: Declared. IKM is a coauthor of the Paediatric Triage Tape, available commercially from TSG Associates, under the registered trade name SMART TAPE.

3. Illness
In most cases, triage decisions relating to sick children in the community concern individual children and relate to the severity of their illness and the resulting urgency of need for transfer to definitive care. Such cases would include any child with compromised ABCs, suspected meningococcal disease or severe pain.

HOSPITAL PAEDIATRIC TRIAGE

It is standard practice for all patients to receive an initial assessment on arrival at the emergency department. The Manchester Triage System (MTS)4 has been widely used in the UK for such purposes (see below), although more recently see-and-treat practices have become more widely adopted, streaming the flow of patients throughout our departments. Published in 1997, the MTS utilises six general discriminators (life threat, pain, haemorrhage, conscious level, temperature and acuteness) to provide a risk-averse system of patient prioritisation (adults and children) offering five time-targeted triage priorities (immediate, very urgent, urgent, standard and nonurgent). Like almost all hospital triage scales, the MTS tends to overtriage children and appears to have only moderate sensitivity and specificity.5 Some departments assign children a higher MTS triage category intentionally, especially at night, although this practice is contentious and can divert limited resources from patients with more acute needs. In North America, the Canadian Paediatric Triage and Acuity Scale (PaedCTAS)6 and the Emergency Severity Index (ESI)7 are similarly used, and in the developing world, triage systems have been developed by the World Health Organization for the Emergency Triage, Assessment and Treatment (ETAT)8 of sick children presenting in resource-poor locations.

REFERENCES
1. Taking Healthcare to the Patient Transforming NHS Ambulance Services. DH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH4114269?IdcService=GETFILE&dID= 2256&Rendition=Web (accessed on 17 June 2009). Hodgetts TJ, Hall J, Maconochie IK, et al. Paediatric Triage Tape. Pre-hospital Immediate Care 1998;2:1559. Wallis LA, Carley S. Validation of the Paediatric Triage Tape. Emerg Med J 2006;23:4750. Mackway-Jones K. Emergency triage: Manchester Triage Group. London: BMJ Publishing Group, 1997. Roukema J, Steyerberg EW, van Meurs A, et al. Validity of the Manchester Triage System in paediatric emergency care. Emerg Med J 2006;23:90610. The National Triage Task Force. Canadian Paediatric Triage and Acuity Scale: implementation guidelines for emergency departments. Can J Emerg Med 2001;3(Suppl):S127. Wuerz RC, Milne LW, Eitel DR, et al. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7:23642. Gove S, Tamburlini G, Molyneux E, et al, for the WHO IMIC Referral Care Project. Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. Arch Dis Child 1999;81:4737. Bradman K, Maconochie I. Can PEWS be used as a triage tool in paediatric A&E? Arch Dis Child 2007;92(Suppl I):A102.

2. 3. 4. 5. 6. 7. 8. 9.

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Emerg Med J 2009;26:767768. doi:10.1136/emj.2008.061556

Downloaded from emj.bmj.com on June 23, 2011 - Published by group.bmj.com

Prehospital paediatric emergency care: paediatric triage

J M Sandell, I K Maconochie and F Jewkes Emerg Med J 2009 26: 767-768

doi: 10.1136/emj.2008.061556

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