Irish Children s Triage System (ICTS) Project Presented by Ruth Devers CNM3 Children's University Hospital Temple St Mary Tumelty CNM3 National Children's Hospital, Tallaght Bridget Conway CNM3 Our Lady's Children's Hospital, Crumlin National Emergency Medicine Programme Seminar February 10th 2016
What is ICTS Irish Children s Triage System (ICTS) is a quality improvement initiative, the aim of which is to standardise a formal, comprehensive triage tool that would improve consistency between users and be suitable for triaging children in all emergency departments with paediatric attendances in Ireland.
Objectives of ICTS To develop a specific triage tool to clinically assess children attending EDs that facilitates the prompt recognition of acuity for ill or injured children. Develop a tool tailored to include clinical elements such as, physiological vital signs, pain management, temperature and other special guidelines specific to the needs of children. Provide an evidencebased approach to the triage of children that supports clinical decision making Develop a National Standard for Children s Triage which ensures that children receive the same standard and quality of care regardless of where in the country they present for treatment.
Project Design ICTS project steering group convened in 2011 (Chair M.Forde, Nurse Lead EMP) Literature review of existing international triage tools Flowchart design base on MTS & existing tools developed locally in paediatric EDs in Dublin Training package developed & delivered by CNM3s from three Paediatric EDs Champions identified in 6 pilot sites to support staff & identify and resolve any issues/concerns highlighted during pilot phase
General Discriminators Definition Triage categories General discriminators Colour Triage category Meaning of triage category Recommended time to be seen by doctor/reassessment Colour Triage category Meaning of triage category Recommended time to be seen by doctor/reassessment Colour Triage category Meaning of triage category Ideal time targets Colour Triage category Meaning of triage category Ideal time targets Colour Triage category Meaning of triage category Ideal time targets Red 1 Immediate Immediate (ongoing assessment) Orange 2 Very urgent 10 minutes Yellow 3 Urgent 60 minutes Green 4 Standard 120 minutes Blue 5 Non urgent 240 minutes Airway compromise Inadequate breathing Exsanguinating haemorrhage Currently seizing Age related abnormal pulse and respiratory rate * GCS 12 Oxygen saturations 90% Severe pain (pain score 7-10) Uncontrollable major haemorrhage GCS 13 or 14 Age related abnormal pulse and respiratory rate * Signs of compensated shock Oxygen saturations 92% Moderate pain (pain score 4-6) Uncontrollable minor haemorrhage Age related abnormal pulse and respiratory rate * History of unconsciousness Mild pain (Pain score 1-3) Problem <48 hours Problem > 48 hours
Vital Signs Reference Grids Respiratory Rate Values Table 1. Age - 2 S/D - 1 S/D Normal + 1 S/D + 2 S/D > + 2 S/D 0 3 months < 20 21 30 30-60 60 70 70 80 > 80 4 6 months < 20 20 30 30 60 60 70 70 80 > 80 7-12 months < 17 17 25 25 45 45 55 55 60 > 60 1 3 years < 15 15 20 20 30 30 34 35 40 > 40 4 6 years < 12 12 16 16 24 24 28 28 32 > 32 > 7 years < 10 10 14 14 20 20 24 24 26 > 26 Heart Rate Values Table 2. Age - 2 S/D - 1 S/D Normal + 1 S/D + 2 S/D > + 2 S/D 0 3 months < 65 65 90 90 180 180 205 205 230 > 230 4 6 months < 63 63 80 80 160 160 180 180 210 > 210 7-12 months < 60 60 80 80 140 140 160 160 180 > 180 1 3 years < 58 58 75 75 130 130 145 145 165 > 165 4 6 years < 55 55 70 70 110 110 125 125 140 > 140 > 7 years < 45 45 60 60 90 90 105 105 120 > 120 Colour Triage category Red Triage category 1 Orange Triage category 2 Yellow Triage category 3 White Triage category not determined by pulse or respiration rate
Data Collection Pilot Phase Champions in each pilot site collected data: % of each category patient presenting to ED Admission rates per triage categories Triage categories of all patients admitted to PICU Staff satisfaction questionnaire completed by staff at pilot sites Feedback from champions informed revision of ICTS flowcharts.
Audit Results
Attendance rate per triage category (across 6 pilot hospitals Mar-May 2012 & 2013) Attendance rates per triage category March- May 2012 Attendance per triage category March - May 2013 70 70 60 50 40 30 20 60 50 40 30 20 10 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6
% % Admissions as an overall % of admissions per triage category Mar- May 2012 & 2013 Admissions as an overall admission % per triage category 2012 Admissions as an overall admission % per triage category 2013 70 70 60 60 50 40 30 20 50 40 30 20 10 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6
% % Admission rate per triage category Mar- May 2012 & 2013 Admissions per triage category 2012 Admissions per triage category 2013 100 90 80 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 100 90 80 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6
Patients admitted to PICU Triage categories of patients admitted to PICU 2012 Triage categories of patients admitted to PICU 2013 7% 0% 6% 0% 31% 45% 62% 49%
National Implementation Plan Pilot sites request to continue using ICTS Support for national roll out from Centre of Children's Nurse Education CNM3s delivered Train the Trainer education sessions in 5 locations around the country in 2014
Successes & Challenges 10 out of 18 EDs have implemented some ICTS training as result of Train the trainer programme 6 sites (3 PEDs) already trained & available to support other sites ED staff enthusiastic & willing to use a child specific triage tool Electronic version ICTS in IPMS supported EDs No dedicated funding for a coordinator for a national rollout Skill mix / RCN s not available on each shift in all EDs Time constraints on trainers due to poor staffing levels Crowding & trollies Inconsistent access to IT
Next Steps Continue to work through identifying the barriers at sites who currently do not have ICTS Resource additional train the trainer day(s) Publish & launch National EMP ICTS document