Validation of different pediatric triage systems in the emergency department

doi:10.5847/wjem.j.1920-8642.2017.03.010

Abstract

Abstract:

BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.

METHODS: This was a prospective observational study. This study was divided into two phases. The first phase determined the inter-rater reliability of five triage systems: Manchester Triage System (MTS), Emergency Severity Index (ESI) version 4, Pediatric Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and Ramathibodi Triage System (RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients (triage level 1, 2) and low acuity patients (triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.

RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0 (P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8-0.9 (P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5-0.7 (P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specificity of 81%, and AUC 0.78 (95%CI 0.74-0.81).

CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

Key words: Triage, Pediatric, Emergency department

Kanokwan Aeimchanbanjong, Uthen Pandee. Validation of different pediatric triage systems in the emergency department[J]. World Journal of Emergency Medicine, 2017, 8(3): 223-227.

Figures/Tables 4

Table 1

Table 2

Table 3

Figure 1.

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Triage system	Doctor - Doctor	Nurse - Nurse	Doctor - Nurse
MTS	0.72	0.61	0.56
ESI	0.81	0.73	0.9
CTAS	0.818	0.72	0.81
ATS	0.69	0.68	0.55
RTS	1	1	1

Characteristics	N	Cumulative percentage (%)
Gender	1 041	100
Male	598	57.4
Female	443	42.6
Underlying diseases
None	691	66.4
Yes	350	33.6
Hematology	94	9.0
Allergy	75	7.2
Respiratory	76	7.3
Neurologic	42	4.0
Gastrointestinal	17	1.6
Cardiovascular	16	1.5
Genetics	7	0.7
Renal	3	0.3
Endocrine	1	0.1
Miscellaneous	19	1.8
Chief complaint
Fever	358	34.4
Gastrointestinal	247	23.7
Respiratory	220	21.1
Skin and mucosa	69	6.6
Neurology	26	2.5
Ear problem	26	2.5
Eye problem	23	2.2
Hematology	15	1.4
Musculoskeletal	11	1.1
Renal	7	0.7
Cardiovascular	6	0.6
Miscellaneous	33	3.2
Diagnosis
Respiratory	376	36.1
Gastrointestinal	241	23.2
Infectious	244	23.4
Skin	52	5.0
Neurology	27	2.6
Hematology	19	1.8
Allergy	13	1.2
Renal	9	0.9
Cardiovascular	7	0.7
Muscle strain	11	1.1
Endocrine	1	0.1
Miscellaneous	41	3.9

Triage system	Sensitivity	Specificity	ROC curve
MTS	57%	69%	0.70 (95%CI 0.66-0.744)
ESI	52%	81%	0.78 (95%CI 0.73-0.81)
CTAS	50%	74%	0.64 (95%CI 0.59-0.70)
ATS	13%	94%	0.73 (95%CI 0.69-0.77)
RTS	64%	64%	0.66 (95%CI 0.60-0.70)

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