CHAPTER ■ A GENERAL APPROACH TO TRIAGE DEBRA A POTTS, MARY KATE F ABBADESSA, SHANNON M GAINES INTRODUCTION Children are cared for in all emergency departments (EDs) from general EDs that see primarily adult patients, to those general EDs with a separate pediatric section, to pediatric EDs that exist within a pediatric institution In the last two decades there has been a considerable increase in ED visits in the United States, almost a fourth of these visits are by children In 2015, there were 30 million ED visits for children less than 18 years of age As the health burden on emergency services continues to rise, it is critical to have a reliable method of triaging children presenting for services HISTORY OF TRIAGE The term “triage” derived from the French word “trier,” to sort, was first used back in the 18th century to document the severity of injury in warfare Battlefield triage eventually made its way into the American medical system and in 1964 Wasserman et al published the first use of civilian triage in EDs Subsequently many institutions, federal agencies, and emergency medical systems have continued to study and refine triage systems in the United States CURRENT TRIAGE SYSTEMS Pediatric triage requires rapid assessment of those presenting to the ED including determination of severity of illness or injury, assignment of acuity level, and anticipation of appropriate emergency care resources needed With limited resources available, the goal of the triage process is “right patient, right provider, right care, right time,” which demands a standardized approach The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) have recommended that EDs use a reliable and valid fivelevel triage system for prioritizing the care of children presenting to the ED In 2010, the ACEP and ENA, based on expert consensus of currently available evidence, supported the adoption of a reliable, valid five-level triage system such as the Emergency Severity Index (ESI) Following the release of this position statement, the number of EDs using the five-level ESI triage system increased significantly Comprehensive triage has been the dominant model for assigning triage acuity in U.S EDs Triage acuity systems have been based on the nurse’s assessment of vital signs and physical examination along with subjective information including past medical history, medications, allergies, and history of the presenting complaint These systems require the nurse to assign an acuity level by determining how acutely ill the patient is and how long they can wait to be seen by a provider The ESI is a five-level triage system developed by a group of emergency physicians and nurses in the late 1990s The ESI is distinctive in its method of triage as it integrates both acuity and resource utilization This system relies on nursing judgment for the more acutely ill patients (ESI levels and 2), while asking nurses to assign lesser acuities (ESI levels to 5) to the less acutely ill by predicting the number of resources such as diagnostic tests and procedures each patient will need in determining disposition Triage nurses follow an algorithm for determining acuity ( Fig 6.1 ) The nurse answers specific questions for determining the more acutely ill at points A and B Point B takes into consideration special high-risk conditions in pediatrics ( Table 6.1 ) If the child is determined to be less acute, direction is given to what constitutes a resource and nurses are only required to estimate up to two resources ( Table 6.2 ) Multiple studies of general ED populations have validated the ESI triage system with good interrater reliability and the ability to estimate ED resources when triage was performed by trained, experienced ED nurses The ESI tool has continually been validated and improved upon through research ESI version (2012 edition) was born out of the Pediatric ESI Research Consortium’s large, multicenter study on pediatric triage and a comprehensive review of pediatric emergency courses and textbooks Improvements to ESI included a designated chapter on pediatric triage and more pediatric triage case scenarios for educational use In 2009 the American Hospital Association reported that 57% of U.S hospitals were using the ESI triage system Standardization of triage systems across the United States allows for increased sharing of ED data and setting performance metrics for care Establishing a standard for triage acuity assessment further facilitates benchmarking, public health surveillance, and research The National Center for Health Statistics at the Centers for Disease Control and Prevention reports national level data on ED visits The report categorizes patients in five levels on how urgently they need to be seen by a provider and includes immediate (immediately), emergent (1 to 14 minutes), urgent (15 to 60 minutes), semiurgent (1 to hours), nonurgent (2 to 24 hours) While there is no research to support this classification, it allows for sharing of national level data on acuity mix when patients present to the ED A Requires immediate life-saving intervention Respiratory: Intubated / apneic / severe distress OR Cardiac : Pulseless or Shock? OR Neuro: Unresponsive? B YES / Triage \ Level 1f Requires emergent intervention Respiratory: Moderate distress OR Neuro: Confused / lethargic / disoriented? OR Severe pain / distress OR High-Risk Patient YES J \ Triage Level NO c ' How many resources are needed? 11 MANY D ONE NONE Triage Level Triage Level if If indicated, take appropriate VS >r Are any VS high risk? YES Consider Triage , Level , NO Triage Level FIGURE 6.1 ESI triage algorithm Emergency Severity Index (ESI) A Triage Tool for Emergency Department Care Version Implementation Handbook 2012 Edition, AHRQ Publication ... (2012 edition) was born out of the Pediatric ESI Research Consortium’s large, multicenter study on pediatric triage and a comprehensive review of pediatric emergency courses and textbooks Improvements... emergency courses and textbooks Improvements to ESI included a designated chapter on pediatric triage and more pediatric triage case scenarios for educational use In 2009 the American Hospital Association... Consider Triage , Level , NO Triage Level FIGURE 6.1 ESI triage algorithm Emergency Severity Index (ESI) A Triage Tool for Emergency Department Care Version Implementation Handbook 2012 Edition,