Pediatric Emergency Triage - Dissertation Example

 Pediatric Emergency Medicine Triage Introduction It is common for infants and children to be victims of disasters and mass casualties since they are vulnerable and suffer more than just physical wounds, they also suffer from trauma that can be caused by separation from their parents (Lyle, Thompson and Graham, 2009). According to the Disaster Medical Assistance Team (DMAT), about one third of DMAT field patients are children (Gnauck, Nufer and La Valley, 2007). About one fourth of the child population gets treated in emergency departments of hospitals every year (Emergency Nurses Association, 2004). Moreover, children demonstrate higher mortality and morbidity rates in contrast to adults during disasters (Becker, 2006). However, providing initial and stabilizing treatment to children is different from adults in several ways. First, they are different physiologically. Some guidelines and protocols in adult triage do not apply to children. It was also shown in a national survey that pediatric care has deficiencies especially in terms of preparedness in mass casualties involving children like school shootings or school bus road accidents (Shirm, Liggin and Dick, 2007). It was also shown in studies that there is no practice or higher education being offered for pediatric emergencies (Graham, Stuemky, and Lera, 1993). The study aims to establish what pediatric triage is and systematically review guidelines, protocols, triage systems and their accuracy and efficiency in pediatric emergency departments. It also aims to critically evaluate the issues, challenges and difficulties experienced by medical professionals in pediatric triage and what makes pediatric triage different from adult triage. In order to achieve this, the study will analyze pediatric triage-related literature available in medical articles and journals. Related Literature Introduction According to the Save the Children Fund (1923) and United Nations Children’s Fund (1990), children should be given special consideration in cases of mass casualties and disasters. This recommendation of prioritizing children first for treatment has been controversial and is not widely accepted by many (Last, 1994). Pediatric Triage: An Overview Concept. According to the National Committee for the Management of Pediatric Mass Casualty incidents (MCI) pediatric triage is applied to those 12 years and below. It also emphasized that staff must prioritize children in all stages of health care (i.e. prehospital, primary triage, hospital triage and secondary triage). Vital signs. Studies show that about 98% of unexpected deaths have demonstrated abnormal vital signs (Roller, Prasad, Garrison and Whitney, 1992). Commons signs evaluated in children’s hospital emergency departments are temperature (92%), respiratory and heart rates (100%), and pulse oximetry (41%) or blood pressure (60%) (Keddington, 1998; Thompson, Dick, Stanford and Graham, 2007). For patients 3 months and above, tympanic thermometer may be used, while for 3 months and below, a rectal thermometer must be used. Weight must also be recorded using a scale or Broslow tape. Infants 3 months and below should have naked weight measured and documented. Blood pressure is also required in urgent and critical conditions, although not necessarily for non-urgent conditions, within 30 minutes after admission. Vital signs should be measured in intervals depending on the severity of the condition. For very urgent conditions, it should be measured every 30 minutes until condition is stabilized. For urgent patients, it should be done every hour, non-urgent patients should be every 2 hours. Those who suffered from head injuries and trauma should be assessed using Glasgow Trauma Score for eye, verbal and motor skills, separately (Emergency Nurses Association, 1993). Across the room assessment: Vital signs are not exact and infallible indicators of a patient's condition. Observational assessment should also be provided during emergencies. This method uses observational assessment skills in airways, breathing, circulation and disability. Airways can be assessed using the child’s position, normal vocalization, and difficulty in swallowing, drooling and breathing. Breathing can be measured by observing the chest for respiratory rates. When assessing breathing, the age of the patient is vital. Audible noises like wheezing during respiration should also be observed. Circulation can be measured by assessing the child’s color (pale, grey-looking, flushed). Temperature can also be used in circulation assessment. Disability can be measured using neurological status or consciousness, activity level and reaction time of patients. Children are curious in nature, silence and inconsolable crying can be indicators that something is wrong (Almond, 2000). Challenges in the Care of Children Emergency preparedness of triage personnel is being further challenged by physiological factors of children that make them more vulnerable during mass casualties and disasters. First, adults have higher levels of strength and stamina that are vital in survival and recovery. Second, children have lighter body mass which makes them prone to heat loss and hypothermia. Third, their cognitive and motor skills may not be fully developed, making it harder for them to recognize danger and escape from it. Fourth, children are also more difficult than adults in terms of airway management, due to smaller airway passages which make it harder to intubate (Lyle, Thompson and Graham, 2009). Studies have shown that even in a stable environment, intubating a child can be hard and unsuccessful (Gausche-Hill, 2003). In order to make sure that a child has proper airway management, a responding triage nurse or EMS should ensure proper positioning of the child, and opt for less invasive methods like bag valve mask. Other physiological differences of a child include open fontanels; immunes systems is not yet fully developed; pliable skeletal system; high baseline pulse and respiratory rates, more prone to dermal absorption of toxins due to thinner skin; and, more prone to dehydration (Lyle, Thompson and Graham, 2009). Treatment and medication dosage in children are being measured through body weight or in kilograms. This method requires a wide range of equipment needed to address children with a variety of body mass. However, in a study constructed by Center for Disease Control, it was said that only 5.5% of American hospitals have a complete list of pediatric equipments, and half of emergency hospitals have pediatric equipments. This list is according to the recommendation of American Academy of Pediatrics and American College of Emergency Physicians (Middleton and Burt, 2006). Triage Systems and Emergency Preparedness in Pediatrics A study measured the accuracy of Pediatric Canadian Triage and Acuity Scale (Paed CTAS) in contrast to the traditional pediatric triage used. The Paed CTAS was measured four months prior to its implementation and four months after its implementation in a university-affiliated children’s hospital. Its efficiency was measured in terms of chief complaints, distribution triage levels and mean pediatric risk of admission (PRISA) score. The results show that using Paed CTAS. The level of distribution in triage levels is higher although admission rates are lower. It also showed that there is no significant difference in terms of diagnostic and therapeutic interventions (Gouin, Gravel, Amre and Bergeron, 2004). A similar study measured the efficiency and accuracy of Soterion Rapid Triage System, a five-tier triage, in pediatric emergency cases. The study was conducted for patients thirteen years and below in a Level II mixed adult and children Trauma Center. Its efficiency and accuracy is measured in terms of admission rate, length of stay, and Current Procedural Terminology (CPT) codes. The results show that Soterion Rapid System is more effective, reliable and valid especially for children thirteen years and below (Maningas, Hime and Parker, 2006). Another study measured the accuracy of Mobile Emergency Triage Abdominal Pain (MET-AP) compared to a physician’s assessment in acute abdominal pain of pediatric patients. The study included patients sixteen years and below experiencing acute but non-traumatic abdominal pain for at least ten days. The results show that MET-AP is 74% accurate in assessing pediatric abdominal pain in contrast to a physician's assessment that is 72% accurate. However, since the difference is relatively low, the study recommended further improvement on the system (Farion, Michalowski, Rubin, Wilk, Correll, et al, 2008). The Emergency Severity Index’s reliability was also measured in a study conducted by Brecher, Wlamsley, Attia, and Loiselle (2007). The reliability was measured in terms of unweighted and weighted kappa. The results show that Emergency Severity Index between physicians and nurses have an agreement rate of 83%, thus it implies that it is a reliable tool when administered by experienced physicians and nurses. A similar study also measured its reliability in patients fourteen years and below. The study has introduced the tool to four physicians and nurses and their assessment was compared to traditional triage systems. The results showed that this tool is reliable even in a pediatric setting (Breacher, 2004). Its reliability in different types of emergency departments (urban, rural, academic and community) was also measured. The results show moderate reliability, where triage nurses may sometimes over rate non-urgent cases and under rate urgent cases (Rosenau, Waller, Trocinski, Travers, Meckam, et al, 2006). A study also measured the emergency preparedness for skin burns in children. Before assessing the degree of the skin burn, the physiological status of the patients should be evaluated first. The airway and inhalation injury should be prioritized during evaluation (Duffy, McLaughlin, and Eichelberger, 2006). Vital signs for airway management include wheezing, tongue swelling, hoarseness, carbonaceous sputum and singed nasal hairs. After assessing airway management, fluid resuscitation must be provided to patients. For minor burns that do not affect the ability of a child to eat or drink, an oral hydration may suffice. If oral hydration is inadequate, a 1 intravenous IV catheter may act as a supplement. Fluid resuscitation is usually composed of formulas like Parkland or Brooke system which contains isotonic crystalloid solution or Ringer’s lactate (Yowler and Fratianne, 2000). The study also focused on non-urgent pediatric cases evaluated the reliability of triage nurse’s assessment in terms of patients’ perception. The study was conducted in an urban hospital, and a telephone interview was used in determining whether the parents followed the triage nurse’s referral and if they think the triage nurse accurately assessed the condition of their child. The results show that since the triage nurse assessed the child’s condition as non-urgent, 79% of the respondents did not follow the referral to a health care provider. Moreover, 81% of the respondents agree that the assessment was accurate (Kuensting, 1995). Effectiveness of triage in patient transportation was also measured, specifically helicopter transport. The study was constructed in an urban Level I pediatric trauma center. The results show that air transport leads to higher survival rates however, 85% of the triage criterion results lead to overtriage (Moront, Gotschall, and Eichelberger, 1996). The compliance to patient transport recommendations were also measured in a study by Morris, Graf, and McPherson (2005). The study included 100 transport calls with specific instructions to referring physicians. Compliance was measured by checking patient’s medical records. The results show that 52% of the transport calls have medical intervention instructions, 76% of which are specific and 24% are vague. However 32% of the instructions were not followed or completed. It also showed that 34% of the recommendations were completed prior to arrival in a hospital. The accuracy of telephone pediatric triage was also measured in a study conducted by Wachter, Brillman, Lewis and Sapien (1999). The assessment by an actual triage nurse and by a telephone triage was compared, and the result showed that there is significant difference the two groups. This implies that although both groups used a standard guideline, results still vary due to the variety of approaches used by health professionals. It may also be caused by the absence of physical contact between patient and triage nurse. The use of pain protocol in improving the timeliness of the provision of treatment (analgesics) in pediatric emergency departments was also evaluated by Fosnotch and Swatson (2007). The study measured the frequency and time of analgesic treatment before and after administration of triage pain protocol. The results show that prior to triage pain protocol, provision of analgesic took 76 minutes while after triage pain protocol, it only took 40 minutes before a patient was given analgesic. The study implies that using pain protocols decreases waiting time for analgesic treatment. Synthesis of Review The study used literatures related to pediatric triage published in academic journals to determine what pediatric triage is, common signs and observation methods used by health care providers in assessing a patients’ condition, how it differs from adult triage and other challenges being encountered by triage nurses and personnel. The study first defined what pediatric triage is, its age criterion and how health care providers should approach pediatric emergency cases. Common vital signs and observational techniques were also explored, emphasizing on the critical areas like airway management and circulation. Differences between adult triage and pediatric triage were also enumerated, especially in terms of physiological differences. The challenges being encountered by health care provider was also analyzed, as well as basic solutions on how these issues can be addressed and improved. The study also looked into a variety of triage systems used in pediatric emergency departments like MET-AP, Soterion, Canadian Triage and Acuity Scale and Emergency Severity Index. These systems were evaluated in terms of accuracy and reliability and how appropriate these systems are in a pediatric setting. The study was able to find out that Emergency Severity Index, although initially for adult triage, can be applied in a pediatric setting as well without compromising its reliability. It also showed that Soterion and Canadian Triage and Acuity Scale are effective, accurate and reliable in pediatric emergency departments. However, MET-AP showed little difference, making its clinical significance questionable. Further studies are recommended to improve the system. Effectiveness of pediatric triage in emergency preparedness, pain protocols and emergency transportation was also measured. The results all showed positive results, increasing preparedness, timeliness and survival rates. Conclusion The study was able to enumerate standard guidelines used in the initial assessment of pediatric triage. Evaluation of the patients’ condition is based on vital signs like weight, pulse rate, temperature, pulse oximetry and blood pressure. It was also shown that unexpected deaths mostly demonstrate deviation from normal vital signs. However, not all vital signs are accurately recorded as shown in the heterogeneity of measuring techniques of body mass, some were not even measured as shown in blood pressure, in emergency departments. It was also emphasized that assessment should not rely on vital signs alone. Health care providers should also utilize observational skills when evaluating the patients’ condition. Audible sounds can be used in assessing airway management, and skin color and temperature in circulation. Challenges experienced by health care providers were also shown to be caused by the differences between adult and pediatric triage. Differences are mostly in terms of physiological factors. Intubation is relatively difficult because children have smaller airway passages in contrast to adults. Children are also more prone to dehydration, hypothermia, and trauma. Children also have pliable skeletal system and less developed immune systems. Majority of the systems reviewed by the study have demonstrated reliability, accuracy and efficacy in a pediatric setting. Only one of the systems reviewed showed relatively low difference and questionable clinical significance. Lastly, the effects of triage in pain protocol, emergency preparedness and emergency transportation was also established. It was shown that timeliness of treatment, preparedness and survival rate can be increased by the use of an effective triage system. References Almond, C. (2000). Issues in pediatric triage. Annals of Emergency Nursing Journal, 3, 12-15. Breacher, D. (2004). Reliability of the emergency severity index in the pediatric population. Journal of Emergency Medicine, 30, 402-18. Breacher, D., Walmsley, D., Attia, M., and Loiselled, J. (2007). The emergency severity index (ver.4). Reliability in Pediatric Patients, 33(3), 333-334. Duffy, B., McLaughlin, P., and Eichelberger, M. (2006). Assessment, triage, and early management of burns in children. Clinical Pediatric Emergency Medicine, 82. Emergency Nurses Association. 2004. Emergency nurse pediatric course. Des Plaines, IL: The Association. Farion, K.,Michalowski, W., Rubin, S., Wilk, S., Corell, R., et al. (2008). Prospective evaluation of the MET-AP system providing triage plans for acute pediatric abdominal pain. International Journal of Medical Informatics, 77, 208-218. Fosnocht, D., and Swanson, E. 2007. Use of a triage pain protocol in the emergency department. American Journal of Emergency Medicine; 25:791-793. Gouin, S., Gravel, J., Amre, D., and Bergeron, S. (2005). Evaluation of the pediatric Canadian triage and acuity scale in a pediatric emergency department. American Journal of Emergency Medicine, 23, 243-247. Graham, C., Steumky, J., and Lera, T. (1993). Emergency medical services preparedness for pediatric emergencies. Pediatric Emergency Care, 9, 329-31. Grauck, K., Nufer, K., and LaValley, J. (2007). Do pediatric and adult disaster victims differ? A descriptive analysis of clinical encounters from four natural disasters DMAT deployments. Prehospital Disaster Medicine, 22, 67-73. Keddington, R. (1998). 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Nachter, D., Brillman, J., Lewis, J., and Sapien, R. (1997). Pediatric telephone triage protocols: Standardized decision-making or a false sense of security. Annals of Emergency Medicine; 33(4), 38. Rosenau, A., Waller, A., Trocinski, D., Travers, D., Mecham, N., et al. (2006). Is the emergency severity index reliable for pediatric triage? Annals of Emergency Medicine, 48(4), 62-63. Shirm, S., Liggin, R., and Dick, R. (2007). Prehospital preparedness national guidelines and recommendations: Findings of an evidence-based consensus process. Biosecur Bioteror, 2, 301-319. Thompson, T., Dick, R., Stanford, K., and Graham, J. (2007). A national of triage practice in pediatric emergency department. Journal of Emergency Medicine, 33(3), 333. Read More