Pediatric Triage: A Review of Emergency Education Literature PDF

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CLINICAL PEDIATRIC TRIAGE: A REVIEW OF EMERGENCY EDUCATION LITERATURE Authors: Susan McDaniel Hohenhaus, MA, RN, FAEN, Debbie Travers, PhD, RN, FAEN, and Nancy Mecham, RN, MSN, Chapel Hill, NC, and Salt Lake City, Utah C hildren represent about a fourth of the population pediatric triage often are l...

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Pediatric Triage: A Review of Emergency Education Literature Susan Hohenhaus Journal of Emergency Nursing

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CLINICAL

PEDIATRIC TRIAGE: A REVIEW OF EMERGENCY EDUCATION LITERATURE Authors: Susan McDaniel Hohenhaus, MA, RN, FAEN, Debbie Travers, PhD, RN, FAEN, and Nancy Mecham, RN, MSN, Chapel Hill, NC, and Salt Lake City, Utah

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hildren represent about a fourth of the population treated each year in US hospital emergency departments.1 This means that approximately 30 million children enter the emergency health care system and undergo a triage assessment by a nurse. Pediatric triage involves rapid recognition of seriously ill or injured children, assigning an acuity rating level, and anticipating appropriate emergency care and referral. Acuity rating levels are used to prioritize patients for care and typically involve assigning a numeric score to patients, such as level 1 (most acute) to level 5 (least acute). Although no standard system for triage acuity rating exists in the United States, ENA and the American College of Emergency Physicians have recommended that emergency departments use a valid, reliable 5-level acuity system.2 Two such systems are the Emergency Severity Index (ESI) and the Canadian Triage and Acuity Scale (CTAS). Both systems recommend that triage nurses undergo general triage education in addition to acuity system-specific education. Furthermore, ENA and the ESI and CTAS materials recommend that triage be performed only by experienced ED nurses.3-5 Children often present with subtle signs and symptoms of illnesses and injuries, and emergency nurses must possess strong pediatric assessment skills to perform prompt, accurate triage of children. The pediatric triage process is critically important and may even warrant recognition as a specialty within emergency nursing. Yet, with the exception of a few programs, current pediatric emergency education resources include only a brief definition of what it is rather than on how to actually do it. Courses that have some focus on

pediatric triage often are limited to describing specific disease states or categories such as trauma or medical resuscitation. This article is part of a larger project to improve pediatric triage acuity rating in ED settings. We sought to perform a comprehensive review of the literature to identify best practices and the best evidence that is relevant to pediatric triage. Our goal was to identify existing resources that we could recommend as a foundation for ED nurses, upon which we would provide education specific to pediatric triage acuity rating processes.

Susan McDaniel Hohenhaus, Pennsylvania Chapter, is Consultant, Pediatric ESI Triage Project, University of North Carolina, Chapel Hill, NC. Debbie Travers is Assistant Professor, The University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. Nancy Mecham is Clinical Nurse Specialist, Emergency Department and Rapid Treatment Unit, Primary Children’s Medical Center, Salt Lake City, Utah. For correspondence, write: Susan Hohenhaus, MA, RN, FAEN, 6 Willard Ter, Wellsboro, PA 16901; E-mail: [email protected]. J Emerg Nurs 2008;34:308-13.

Results: Themes Identified in the Literature

Available online 6 February 2008. 0099-1767/$34.00 Copyright © 2008 by the Emergency Nurses Association.

Methodology

The project team searched for educational programs and texts that included content on either pediatric triage specifically or pediatric emergencies in general. Key words used were pediatric triage, pediatric emergency care, and pediatric emergency education. Current print and Web materials sponsored by national professional organizations were included. Excluded were commercial products not specifically endorsed by a national body of experts. Relevant courses and textbooks that met the inclusion criteria were identified and collected by the study team. Two masters-prepared pediatric emergency nursing experts reviewed all of the literature. Each review was structured to identify information that was pertinent to ED triage of pediatric patients, including general pediatric assessment and vital signs information as well as triage-specific pediatric scenarios (short vignettes that described the initial ED presentation of ill and injured children).

Eleven educational courses and 9 additional textbooks met the inclusion criteria and were reviewed by the 2 pediatric nursing experts. Table 1 includes the courses, and Table 2 lists the textbooks that were reviewed. Several themes emerged from the literature review regarding best practices for pediatric triage and care in emergency situations, although we found little scientific evidence to support practice. ASSESSMENT

doi: 10.1016/j.jen.2007.06.022

All programs consistently focused on the assessment of the “ABCs” of airway, breathing, and circulation, although not

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TABLE 1

Emergency courses with pediatric-specific content reviewed Course

Emergency Nurse Pediatric Course (ENPC)

Primary assessment

PAT; ABCDE

Pediatric Advanced “General Assessment”; Life Support (PALS) PAT; ABCDE; rapid cardiopulmonary assessment Advanced Pediatric Initial assessment Life Support (APLS) (PAT; ABCDE) Pediatric Education Initial assessment for Pre-hospital (PAT; ABCDE; Professionals (PEPP) transport decision)

Canadian Triage Acuity System (CTAS—Pediatric) Advanced Trauma Life Support (ATLS)

Level of consciousness, respiratory rate and effort, heart rate and perfusion; (PAT) ABC

Trauma Nurse Core ABCD Course (TNCC) Advanced Cardiac ABCD (D = defibrillate) Life Support (ACLS) Emergency Severity Index (ESI)

Canadian Triage Acuity System (CTAS—General)

Across the room assessment and chief complaint; ESI algorithm Primary survey (rapid assessment); chief complaint

Secondary assessment

Vital signs

Learning scenarios

Tables of normal and abnormal vital signs (reference Proehl); palpate central and peripheral pulses Focused medical history Tables of normal vital signs (reference for using the SAMPLE BP and HR) mnemonic and a thorough head-to-toe physical examination SAMPLE; Table of normal vital “danger signs” signs (reference “Sheperd”) Additional assessment Table normal vital signs; attempt BP ×1; (focused history; palpate antecubital detailed physical examination, ongoing fossa for pulse assessment) Yes (reference to 2- to 5-minute Canadian Pediatric interview; the triage history; and the triage Society) physical assessment Table of normal vital Head to toe; brief signs; no reference generic discussion of triage (based on “ABC priorities”) FGHI Tables age based

Scenarios are specific to triage, including assessment and acuity assignment

Focus is cardiac assessment and treatment Based on chief complaint

No

No

Pediatric fever criteria; danger vital signs

Scenarios are specific to triage, including acuity assignment

Secondary survey; FGHI; CIAMPEDS

2- to 5-minute “Expected vital signs” reference “Nades” interview; not a head-to-toe assessment (treatment nurse should complete)

Assessment scenarios focused on respiratory failure and shock

Focus is on diagnosis and management Assessment focused scenarios

Chief complaint focused scenarios

No

No

Chief complaint focused scenarios

ABCD, Airway, breathing, circulation, disability; ABCDE, airway, breathing, circulation, disability, exposure/environmental; BP, blood pressure; CIAMPEDS, chief complaint, immunizations and isolation, allergies, medications, past medical history, events, diet and diapers, symptoms; FGHI, full vital signs, give comfort measure, head-to-toe assessment/ history, inspect posterior surface; HR, heart rate; PAT, Pediatric Assessment Triangle; SAMPLE, signs and symptoms, allergies, medications, past illnesses, last meal, events.

all used the same terminology to describe the process. For example, the Emergency Nurse Pediatric Course (ENPC) calls this approach “primary assessment,” and Pediatric Advanced Life Support (PALS) calls it “rapid cardiopulmonary

assessment.” The courses include mnemonics for the primary assessment. For most courses, “ABCD” refers to airway, breathing, circulation, and disability, but in others, the “D” stands for defibrillation.

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TABLE 2

Pediatric emergency texts reviewed Text

Initial assessment

ENA Core Curriculum PAT ENA Pediatric Core Overall appearance Curriculum (ENPC) (PAT; “rapid primary assessment”) Triage Nursing Secrets PAT (Zimmerman/Herr) Pediatric Triage Guidelines (Murphy)

ABC

Quick Reference to Triage (Grossman)

ABC

Triage: Meeting the Challenge (ENA)

ABC

Making the Right Decision (ENA)

Across the room assessment; ESI Algorithm; ABCD Ability to walk; ABC

JumpSTART

Secondary assessment

Vital signs

Triage-specific scenarios

ABCD with history focus No CIAMPEDS No

No No (discussion of acuity lists 3 levels)

Recommends ENPC assessment and CIAMPEDS General head-to-toe assessment; recommends ENPC assessment Recommends ENPC assessment and CIAMPEDS DEFGHIJ; CIAMPEDS; “PEARLS” for history taking DEFGHIJ SAMPLE

Discussion of normal vital signs

Chief complaint

Level of consciousness only

No

Tables of normal vital Chief complaint signs (reference PALS)

Tables of normal and abnormal vital signs (no reference) No

Chief complaint

No

Scenarios are specific to triage-including acuity assignment Triage scenarios are specific to disaster/ mass casualty incident

Sample chief complaint guideline

ABC, Airway, breathing, circulation; ABCD, Airway, breathing, circulation, disability; CIAMPEDS, chief complaint, immunizations and isolation, allergies, medications, past medical history, events, diet and diapers, symptoms; DEFGHI, disability, expose, fahrenheit, get vital signs, head-to-toe assessment, inspect the back and isolate; PALS, Pediatric Advanced Life Support; PAT, Pediatric Assessment Triangle; SAMPLE, signs and symptoms, allergies, medications, past illnesses, last meal, events.

Information regarding vital signs is not standardized in the literature, and we noted variations in normal vital signs parameters by age. For example, some of the courses and textbooks reported normal vital signs criteria by broad age categories (eg, 0-3 months, 3 months to 2 years, 210 years, >10 years), whereas others had as many as 12 different age categories. The upper and lower normal limits for vital signs also varied among the literature reviewed; for example, the upper heart rate limit for newborns was 160, 170, or 180, depending on the source. While most sources list citations for the vital signs parameters they recommend, these citations often were described as modifications from the original sources. ENA’s ENPC has perhaps the most comprehensive approach to the practice of pediatric triage.2 It is specifically designed for emergency nurses caring for pediatric patients in the emergency department. Many of the other resources

reviewed referred to the ENPC system of assessment, especially the “CIAMPEDS” (Chief complaint, Immunizations and Isolation, Allergies, Medications, Past medical history, Events, Diet and Diapers, Symptoms) mnemonic. Full chapters are dedicated to describing the triage of children, pediatric developmental issues, and the assessment of children. Each chapter is well referenced, and training materials include written materials as well as classroom lectures and skills stations that are specific to pediatric triage. Case-based scenarios are used by instructors to illustrate and highlight key concepts for care, including specific triage scenarios. ENA’s Core Curriculum for Pediatric Emergency Nursing has chapters regarding pediatric assessment (and references the ENPC CIAMPEDS mnemonic), age-appropriate approaches to pediatric assessment, and the use of the ABCDEF method of further assessment.6 There is further discussion regarding a head-to-toe assessment. A relatively short chapter on pediatric triage includes a discussion of

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disposition, documentation, and types of triage systems. The Curriculum also has a section on pediatric telephone triage, with appendices for protocols that address pediatric fever and respiratory distress. No case scenarios are included. The American Academy of Pediatrics’ Advanced Pediatric Life Support (APLS)7 course focuses on a comprehensive approach to pediatric assessment that includes the use of the Pediatric Assessment Triangle (PAT), developmental considerations, and further assessment utilizing the ABCDE method. The course includes a very brief discussion of 5-level triage acuity ratings, as well as a few other areas with specific triage guidelines such as burns and disasters. Case scenarios are provided but are focused primarily on treatment recommendations. A table describing potentially dangerous signs such as lethargy, poor feeding, or bulging fontanel is included, which could be very useful in triaging pediatric patients. Tables, referenced to the Pediatric Education for Prehospital Professionals (PEPP) course, also are included that list normal ranges for pediatric vital signs. The American Heart Association’s Pediatric Advanced Life Support Course (PALS) focuses on a rapid cardiopulmonary assessment and prevention of deterioration of the pediatric patient.8 Although this program utilizes many scenarios that elicit a response to how sick a child is, these scenarios are not specific to ED triage. The foundation of the materials is on the primary survey and intervention of airway, breathing, and circulation. The American Academy of Pediatrics’ PEPP course includes chapters about pediatric developmental issues and assessment. PEPP introduced the PAT.9 The focus of the PAT is to determine whether a child is “sick or not sick.” It includes a follow-up primary and secondary surveys that describe an ABCDE approach. There is a very brief mention of triage in the context of the ongoing assessment for the prehospital setting. The course includes many scenarios that discuss initial assessment and decision making, but none are specific to triage. The pediatric version of the CTAS consists of a 3-step assessment: initial impression of illness severity; evaluation of the presenting complaint; and assessment of behavior and age-related physiological measurements.3 CTAS also lists recommendations for time to treatment based on acuity category and lists recommendations for the reassessment of waiting pediatric patients. Training materials include recommendations about triage definitions, the assignment of triage acuity categories, and the goals of triage, as well as recommendations about when it is permissible to “change” a triage acuity category for waiting patients. This program has been universally endorsed by the major Canadian emergency care organizations as

the standard for triage care in Canadian hospital emergency departments. The American College of Surgeons’ Advanced Trauma Life Support (ATLS) is a course designed for physicians that sets standards for the care of the trauma patient.10 General materials include initial assessment, including a focus on the primary survey of airway, breathing, circulation, disability, and exposure. Assessment and treatment of shock and specific trauma-focused treatment parameters are the focus of the materials. A pediatric trauma chapter is included and describes differences in pediatric physiology, treatment management, and specific treatment parameters for shock and focused injuries. There is no discussion of pediatric triage. The text has a brief section that discusses triage in the context of patient transport and transfer. The American Heart Association’s Advanced Cardiac Life Support (ACLS) course has a focus on adult cardiac assessment and treatment.11 In some emergency departments, this course is the only emergency care education that ED clinicians are required to complete. Prehospital and hospital triage is discussed with the ABC method of initial assessment. The “D” in the assessment focuses on the possible need for defibrillation as soon as possible. The secondary survey steps that are recommended also focus on expanded questions surrounding the ABCD assessment, with the “D” meaning a differential diagnosis or list of potential problems that may be causing the patient’s condition. No specific pediatric cardiac considerations are discussed in the ACLS course. Vital signs are only adult ranges listed within the algorithms. Some casebased teaching scenarios that cover pediatric cardiac arrest and respiratory emergencies are included. The ESI Version 4 Implementation Handbook is specific to the implementation of one type of triage system: ESI.4 Materials include some pediatric-specific practice cases and competency cases. Pediatric patients are referenced specifically regarding fever guidelines, which are based on the American College of Emergency Physicians fever criteria.12 The ESI also includes “danger vital signs” tables broken down by pediatric and adult age groups and addresses upper normal limits for heart rate and respiratory rate and a lower normal limit for oxygen saturation for patients at sea level. The ESI danger zone vital signs criteria are based on the systemic inflammatory response literature.13 ENA’s Trauma Nursing Core Course (TNCC) is a program that provides a standardized approach to teaching trauma nursing care to patients who have sustained injuries.14 The course has a major focus on the adult patient but does include a pediatric trauma chapter. The TNCC course includes a standardized approach to the primary

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cal assessment using ENPC’s ABCDEFGHI system of assessment. “Pearls” for pediatric history taking and a brief mention of legal issues in pediatric emergency care are included. The text is focused primarily at improving triage systems. One of its unique features is that it includes sample policies to review, several of which include reference to pediatric patients.

assessment (to identify life-threatening injuries) and a secondary assessment, which includes an EFGHI mnemonic (Exposure, Full set of vital signs, Give comfort measures, Head to toes assessment and history, and Inspect posterior surfaces of the patient). The pediatric trauma chapter discusses some of the major differences in injury patterns, mechanisms of injury, and pediatric assessment differences. The chapter also includes an age-based vital sign table. No patient scenarios are included in the TNCC provider manual, nor is there any s...