Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital

Abstract

IMPORTANCEThe capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients.OBJECTIVE To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016. MAIN OUTCOMES AND MEASURES Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate. RESULTS Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%. CONCLUSIONS AND RELEVANCEOur estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.

Triage

“…9,[30][31][32][33] Effective public health triage may decreased demand on critical care resources. Reverse triage [34][35][36] is used to discharge patients at low risk of adverse events from either the intensive care unit (ICU) or hospital wards in turn to create ICU capacity.…”

Inpatient disposition in overcrowded hospitals: is it safe and effective to use reverse triage and readmission screening tools for appropriate discharge? An observational prospective study of an Italian II level hospital

“…Mean LOS was 12 [8][9][10][11][12][13][14][15][16][17][18][19][20] days: LOS was significantly shorter in HDU patients (9 [6][7][8][9][10][11][12][13][14][15][16] in HDU, 15 [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] in Ger, 12 [8][9][10][11][12][13][14][15][16]…”

“…While in disaster setting a risk of CME of 12% (class 2) could be tolerated, RT has been proposed to cope with daily surge with a lower cut‐off (<4% risk of CME—class 1), as it gives priority to ED patients with urgent needs over inpatients who can be discharged with little to no health risks …”

“…[2][3][4] Reverse triage (RT) has been created by Kelen et al 5,6 to increase hospital surge capacity in case of disasters. [5][6][7][8][9] It consists in a method for adult and paediatric inpatient disposition, based on a risk assessment of consequential medical events (CME) in the 72 hours after discharge (eg, unexpected death, irreversible impairment, or functional reduction), that would have required an adequate in-hospital intervention. [5][6][7] The classification system includes five categories expressing the CME risk as increasing percentage (class 1 CME risk <4% to class 5 CME risk >90%).…”

“…[5][6][7] The classification system includes five categories expressing the CME risk as increasing percentage (class 1 CME risk <4% to class 5 CME risk >90%). 5 While in disaster setting a risk of CME of 12% (class 2) could be tolerated, [6][7][8][9][10] RT has been proposed to cope with daily surge with a lower cut-off (<4% risk of CME-class 1), as it gives priority to ED patients with urgent needs over inpatients who can be discharged with little to no health risks. [10][11][12][13][14] Nevertheless, while it is well known that appropriate discharge of inpatients could decrease the delay to admission and reduce ED crowding and related adverse events, no universal consensus about safe early discharge criteria exists.…”