Validation of different pediatric triage systems in the emergency department

BACKGROUND: 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.METHODS: This was a prospective observational study. This study was divided into two phases. The fi rst phase determined the inter-rater reliability of fi ve 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.RESULTS: 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%, specifi city of 81%, and AUC 0.78(95%CI 0.74–0.81).CONCLUSION: 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.

Associated Factors with Prolonged Stay in Pediatric Observation Ward of Urban University Hospital in Thailand

Background: Pediatric observation ward (OW) is the area where the patient can be monitored or have early investigation/management and observe part of emergency department (ED);patients are admitted to this area with an expectation of discharge within 24 hours. Observation ward was beneficial in preventing avoidable hospitalizations, due to the high volume of patients in ED, OW increasing demands, overcrowding, and prolonged stay. Objective: This study aimed to examine the characteristics and factors associated with prolonged length of stay (LOS) more than 24 hours in the pediatric observation ward. General demographic data were recorded including age, sex, LOS, diagnosis and disposition. Results: This is a retrospective study of children 15 years old or younger who admit to Pediatric OW at urban university hospital and prolonged stay more than 24 hours during January 2014 to June 2015. There were 670 patients admitted at OW during the study period (median age of 5 years;53% were male). Mean length of stay in OW was 61 hours. The most common top 5 diagnoses were respiratory problem (32%), gastrointestinal problem (29%), infectious disease (11%), neurological (7%), and dental problem (6%). The majority of patients were discharge home 602/670 cases (90%), and 10% (68/670 cases) were admitted to inpatient ward. There were 552 patients (82%) who had prolonged OW more than 24 hours. Compared with the factors in both group, we found that the associated factor for prolonged OW stay was the age of patient, which seems to be younger in the prolonged stay group (median age of 4 years 3 months vs 3 years 5 months, p = 0.04). Younger children had significant factors for prolonged stay in OW (p < 0.001) compared to all age categorized less than 1 year, 1 - 5 years, 5 - 10 years, 10 - 15 years and more than 15 years respectively. Conclusion: This was the study for report of pediatric observation ward utilization. The younger patient was the associated factor for prolonged stay in OW. Understanding this related issue will be the starting points for assessing patients carefully before admitting to OW for improving efficiency and quality of care in pediatric OW.