Accuracy of Triage for Children With Chronic Illness and Infectious Symptoms

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Children with chronic illnesses tend to be sicker during infections than previously healthy children but are triaged in the same way, even though the validity of triage systems has not yet been evaluated in these chronically sick children. WHAT THIS STUDY ADDS:The performance of the Manchester Triage System was lower for children with a chronic illness than for previously healthy children. Children with cardiovascular illnesses, respiratory illnesses, gastrointestinal illnesses, or other congenital or genetic defects were especially at risk of being undertriaged.abstract OBJECTIVE: This prospective observational study aimed to assess the validity of the Manchester Triage System (MTS) for children with chronic illnesses who presented to the emergency department (ED) with infectious symptoms.METHODS: Children (,16 years old) presenting to the ED of a university hospital between 2008 and 2011 with dyspnea, diarrhea/vomiting, or fever were included. Chronic illness was classified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes. The validity of the MTS was assessed by comparing the urgency categories of the MTS with an independent reference standard on the basis of abnormal vital signs, life-threatening working diagnosis, resource utilization, and follow-up. Overtriage, undertriage, and correct triage were calculated for children with and without a chronic illness. The performance was assessed by sensitivity, specificity, and diagnostic odds ratios, which were calculated by dichotomizing the MTS into high and low urgency. RESULTS:Of the 8592 children who presented to the ED with infectious symptoms, 2960 (35%) had a chronic illness. Undertriage occurred in 16% of children with chronic illnesses and in 11% of children without chronic illnesses (P , .001). Sensitivity of the MTS for children with chronic illnesses was 58% (95% confidence interval [CI]: 53%-62%) and was 74% (95% CI: 70%-78%) for children without chronic illnesses. There was no difference in specificity between the 2 groups. The diagnostic odds ratios for children with and without chronic illnesses were 4.8 (95% CI: 3.9-5.9) and 8.7 (95% CI: 7.1-11), respectively. CONCLUSIONS:In children presenting with infectious symptoms, the performance of the MTS was lower for children with chronic illnesses than for children without chronic illnesses. Nurses should be particularly aware of undertriage in children with chronic illnesses.

Validity of triage systems for paediatric emergency care: a systematic review

“…A modified version of the MTS increased the specificity from 78%–79% to 87%, but not the sensitivity (64%), resulting in the reduction of overtriage (47%) without a parallel increase in undertriage (15%) 39. The other two studies assessed subgroups of patients and showed an undertriage rate of 2% in patients levels 1 and 238 and poorer sensitivity (58% vs 74%) and higher undertriage rate (17% vs 11%) in patients with symptoms of infection and chronic disease compared with those without chronic disease 42…”

Clinical prediction models for young febrile infants at the emergency department: an international validation study

“…The Dutch cohort was divided into a cohort of children aged <3 months (the Netherlands <3 months’ cohort) and children aged between 3 and <12 months (the Netherlands >3–12 months’ cohort). In the Dutch cohort we prospectively enrolled all children (1 month to 1 year) presenting with fever at the EDs of the Erasmus MC-Sophia Children’s Hospital (inner city university hospital, 7000 annual paediatric ED visits)25 and the Maasstad Hospital (inner-city teaching hospital, 10 000 paediatric medical emergency consults yearly), Rotterdam (2009–2012), the Netherlands. In both hospitals febrile children were eligible to participate in the study if fever had been noted at home in the 24 hours prior to presentation, if body temperature measured at the ED was ≥38.5°C or ‘fever’ was used as a positive discriminator of the Manchester Triage System.…”

Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department

“…About 35% of the ED population has chronic co-morbidity. [23] We excluded children with chronic diarrhea (>7 days), severe dehydration with hypovolemic shock, children with vomiting/diarrhea with a focus for another infectious disease (e.g., otitis media, urinary tract infection) and chronically ill children with complex needs.…”