‘Down-triage’ for children with abnormal vital signs: evaluation of a new triage practice at a paediatric emergency department in Japan

Abstract

Objective Assessment of abnormal vital signs in triage is a challenge in the paediatric emergency department (PED), since vital signs may reflect anxiety, fever or pain rather than the clinical deterioration of the child. We aimed to evaluate the efficacy of subjective 'down-triage' (change of the initially determined acuity levels) of Japanese Triage and Acuity Scale ( JTAS). Methods This is a retrospective cohort study of patients in PED up to 15 years of age at a tertiary paediatric medical centre in Japan during a 1-year period. At the end of every JTAS triage process, PED nurses were allowed to 'down-triage' acuity levels of well-appearing patients with abnormal HR or RR, which were presumably attributable to fever, crying or being upset. We compared predictive performance of the triage system before and after 'down-triage' using admission rate as the primary outcome. Results Among 37 961 PED visits during the study period, we analysed 37 219 records. A total of 17 089 patients (45.9%) were 'down-triaged' after their initial triage allocation upon arrival. Admission rates after 'down-triage' (83%, 33%, 7%, 1% and 3% for levels 1-5, respectively), compared with those of unmodified initial level (16%, 11%, 6%, 2% and 6% for levels 1-5, respectively), had a better apparent relevance with the anticipated admission rates of Canadian Triage and Acuity Scale. Conclusions Modification of JTAS through 'downtriage' by experienced staff improves prediction of disposition in a PED. Further research is needed to determine an objective protocol for 'down-triage' to ensure safe practice in a PED.

Clinical Considerations When Applying Vital Signs in Pediatric Korean Triage and Acuity Scale

“…Initial vital signs are recommended in assessing the level of PedKTAS ( 2 ); however, limitations have been noted when using the initial vital signs to determine the triage levels in children. Because children who are placed in unfamiliar environments become anxious and irritable, this effect may cause a shift of vital signs beyond the normal range ( 3 4 5 ). Therefore, although a child may have a non-emergent condition, the level of severity may seem to be higher when his or her initial vital signs are applied directly to determine the triage levels.…”

“…This incorrect ‘over-triage’ can lead to overcrowding of the pediatric ED with an increased length of stay, unnecessary utilization of medical resources, increased medical costs, and potential threats to patients' safety ( 4 6 7 ). Therefore, a nationwide controversy has emerged regarding whether the vital signs of children should be directly applied to PedKTAS or whether a modified interpretation of vital signs should be used.…”

“…The pediatric CTAS guideline suggests that even if the patient's vital signs are measured to be abnormal, such as tachycardia in upset child, triaging lower than the measured abnormal vital signs can be done with careful clinical decision ( 5 ). Furthermore, a retrospective cohort study using the Japanese Triage and Acuity Scale based on CTAS also demonstrated that patients who were down-triaged (assignment of lower triage level) by clinical decision based on the patient's general condition had better predictability for the disposition from the pediatric ED ( 4 ).…”

Retrospective observational study indicates that the paediatric assessment triangle may suggest the severity of Kawasaki disease

“…First, we did not evaluate the inter‐observer reliability of the PAT among the staff in this study, but all the triage nurses in our hospital have been trained in Paediatric Advanced Life Support and this ensures that they consistently evaluate patients using the PAT. Studies of decisions made by our triage nurses have previously been shown to be useful for predicting patients’ needs in the emergency department . Second, we only performed this study at a single tertiary care institution in Japan and we diagnosed and treated the participants in accordance with the Japanese clinical guidelines .…”

Incidence and aetiology of serious viral infections in young febrile infants

“…All the patients received in‐hospital triage by nurses specialised in paediatric emergency triage using the Japan Triage and Acuity Scale. All triage data were consecutively collected by an in‐hospital electronic triage system (eTriage, DankNet and DoWell Inc., Tokyo, Japan) and served as the mother cohort . The triage system was developed in accordance with previous literature .…”