Triage of children in the

Transcription

1 Triage of children in the emergency department Jocelyn Gravel MD, MSc Emergency department CHU Sainte-Justine June 7 th 2011

2 Disclosure No financial relationship to disclose or potential conflicts of interest to resolve Participated in the CTAS committee meetings Published many studies regarding triage

3 Learning objectives Development of the CTAS Specificities of triaging children in comparison to adults Computerization ti of triage Presence of physician at triage

4 History of triage Introduced in the 18 th century Baron Dominique Jean Larrey Chief Surgeon Napoleon s army

5 History of triage Dr Larrey s triage rules: Dangerously wounded treated first Less injured can wait Without regard to rank or distinction Louis-François Lejeune,Musée national du Château, Versailles, France

6 History of triage 1846 British naval surgeon John Wilson Treat the most injured soldier that is salvageable First world war Mass casualty +++ A single case will have to wait if he needs a time consuming procedure Second world war Priority to soldiers that could return to the field

7 History of triage First publication of a triage tool 1966 Three levels of triage Performed by the treating physician Am J Public Health Nations Health Jul;56(7):

8 Australian Triage Scale (ATS) Ipswich Hospital in Quensland in the 90s Based on nurse observation Urgency of patients at arrival: Rescucitation In a bed for the next available doctor In front of the waiting list In the waiting list Encourage the patient to seek help elsewhere

9 Australian Triage Scale (ITS) Ipswich Triage Scale Standardized triage scale 5 levels 1. Seconds 2. Minutes 3. One hour 4. Hours 5. Days Good inter-rater reliability Good association with: -Trauma score, injury scores -Mortality, time in hospital, ICU

10 Australian Triage Scale (NTS) Ipswich Triage Scale 1994 national adoption 5 levels 1. Seconds Immediate 2. Minutes 3. One hour 10 min 30 min 4. Hours 60 min 5. Days 120 min National Triage Scale

11 Australian Triage Scale (ATS) NTS 2000 ATS

12 The Canadian Triage and Acuity Scale (CTAS)

13 1998: first version of CTAS 5 levels of urgency Described presentation for each triage level Fractile response

14 1998: first version of CTAS

15 1998: first version of CTAS Fractile response

16 2001: implementation of Paed CTAS Three steps for triage First impression Chief complaints adapted for children Physiologic assessment (vital signs) Appearance Work of breathing Circulation (normal perfusion)

17 2004 revision of the adult CTAS Revision of chief complaints Introduction of new concepts first and second order modifiers

18 2004 revision of the adult CTAS Revision of chief complaints Based on the Canadian Emergency Department Information System (CEDIS) chief complaints list Introduction of new notions: First order modifier (vital signs, pain mechanism of injury) Second order modifier (specific complaints to help stratify) Ex blood sugar for altered level l of consciousness Development of the educational material

19 2007 Complaint Oriented Triage COT

20 2008 revision of the adult CTAS Changes in the chief complaints list First order modifiers Sepsis and bleeding disorders Second order modifiers Chest pain, dehydration, extremity injury Mental health modifiers

21 2008 revision of the paed CTAS Unified paediatric and adult CTAS New complaints First order modifiers Respiratory, hemodynamic status, consciousness Second order modifiers Fever, pain, mechanism of injury

22 First order modifier respiration

23 First order modifier hemodynamic

24 First order modifier consciousness A sleeping baby is an unconscious baby

25 First order modifier Fever Age Triage level < 3 month old II 3 months 3 years and look II unwell Immunocompromised II 3 months 3 years and look III well > 3 years and look unwell III > 3 years and look well IV

26 Retrospective cohort study Tertiary care children hospital Local protocol Children 6-36 months old with fever and no clinical signs of toxicity can be triaged level IV Primary outcome Admission

27 visits to the ED

28 visits to the ED 3477 patients 3-36 months with fever

29 visits to the ED 3477 patients 3-36 months with fever 257 triaged level 1 or 2 for other reasons 3220 patients should be level 3 according to PeadCTAS

30 visits to the ED 3477 patients 3-36 months with fever 257 triaged level 1 or 2 for other reasons 3220 patients should be level 3 according to PeadCTAS 13 triaged level 2

31 visits to the ED 3477 patients 3-36 months with fever 257 triaged level 1 or 2 for other reasons 3220 patients should be level 3 according to PeadCTAS 1869 triaged level 4 13 triaged level triaged level 3 (protocol) 15 triaged level 5

32 Admission rates vs triage levels all patients months 5 and fever er 0 level 3 level 4 n= 1322 n= 1869

33 LWBS vs triage levels all patients t months 5 and fever e 0 level 3 level 4 n= 1322 n= 1869

34 In tertiary care settings Children 6-36 months old that look very good can safely be down-triaged level IV

35 First order modifier Second step Pain Mechanism of injury Bleeding disorder

36 First order modifier Pain Difficult to assess in children No difference between central vs peripheral pain Pain 8-10 ti triage level lii Pain 4-7 triage level III Pain 1-3 triage level IV Down-triage of I level for chronic pain

37 First order modifier Mechanism of injury

38 First order modifier Bleeding disorder Life or Limb Threatening Bleed Moderate/Minor Bleed CTAS level 2 CTAS level 3 Head (intracranial) i & neck Nose (epistaxis) i Chest,abdomen,pelvis,spine Mouth (including gums) Massive vaginal hemorrhageh Joints (hemarthroses) Iliopsoas muscle & hip Extremity muscle compartments Fractures & dislocations Deep lacerations Any uncontrolled bleeding Menorrhagia Abrasions Superficial lacerations

39 Second order modifiers. Blood sugar levell Children with diabetes or metabolic disease Altered level of consciousness, seizure Intoxication Dehydration Blood pressure (hypertension) Blood pressure (hypertension) Renal disease Medication with potential HBP Condition associated with HBP

40 Paediatric specific new complaints

41 Specific paediatric complaints: Congenital problems Vomiting/diarrhea in child with Inherited metabolic disease II Type 1 diabetes II Adrenal insufficiency II Caregivers identifying need for care Stable child III IV

42 Computerization of triage Few studies Better reliability Increased validity

43 Prospective observationnal study 722 patients assessed twice Intervention Regular nurse using memory Nurse using etriage Oucomes C l ti ith t i l l i d b Correlation with triage level assigned by a panel of experts

44 Results Poor inter-rater agreement Kappa score Agreement with experts etriage vs panel = 0.43 Memory vs panel = 0.26

45 Experimental design 18 nurses 54 case scenarios evaluated twice With or without the computer Primary outcome: inter-rater reliability

46 Results

47 Complaint Oriented Triage Oriented Triage (COT 2008)

48 Oriented Triage (COT 2008)

49 Oriented Triage (COT 2008)

50 Oriented Triage (COT 2008)

51 Oriented Triage (COT 2008)

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57 Physician to assist nurse at triage?

58 Physician to assist triage nurse Multiple roles: - Diagnosis - Initiate lab studies - Start imaging - Take phone calls

59 Results - 28 studies - 13 journal publication, 12 abstracts, 3 web pages - 2 RCT, 23 before and after study

60 ED Mean length of stay for all patients

61 Impact on delay to be seen by a physician

62 Impact on the proportion of patients that left without being seen

63 Limitations of triage

64 Limitations it ti of the CTAS inter-rater t reliability Triage level assigned by the research nurse Triage level for Total regular nurse Total Quadratic weighted Kappa: 0.71 (95%CI: ) Perfect agreement in 76%

65 Limitations of the CTAS Impact on morbidity and mortality?

66 Limitations of triage Impact on morbidity and mortality? No study on clinical outcomes Few studies on satisfaction No control group

67 One ED in France in 1995 Pre-post study (631 patients) - First arrived first seen Vs - Patients seen according to triage Waiting time for patients - Sicker patients 12 min vs 47 min - Less sick 36 min vs 40 min Satisfaction - Patients satisfied: 96 % vs 82%

68 Take-home messages Triage is an understudied topic Triage of children Be cautious with congenital/metabolic disease Then wake them up Computerization improves triage Use the COT Physicians may have a role at triage Potential to limit overcrowding

69 Thank you- Merci Congratulation to the Sea Dogs

70 RCT Intervention A physician involved at triage from 9 AM until 12 noon Randomization 4d days for team triage ti and d4 regular ti triage Outcome Time to see a doctor Time to radiology ogy

71 Results

72 RCT Intervention Liaison physician at triage ( Help triage nurse, recieve phone calls, manage administrative manners) 11 AM - 8PM Randomization 3 blocks of two weeks 1 week intervention, 1 week control Outcome Length of stay LWBS Staff satisfaction

73 Results LWBS: 63%vs79% % Ambulance diversion: similar High satisfaction of nurses and physicians