Original Contributions
Evaluation of the Paediatric Canadian Triage and Acuity Scale in a pediatric ED

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Abstract

The aim of this study was to compare the performance of the Paediatric Canadian Triage and Acuity Scale (Paed CTAS) to a previous triage tool with respect to the percentage of admissions, the diagnostic and therapeutic interventions, and the mean pediatric risk of admission (PRISA) score in a pediatric tertiary center emergency department. Data were prospectively collected for 4 months before the Paed CTAS introduction (PRE group) and for 4 months after its implementation (Paed CTAS group). Both groups were similar in chief complaints, distribution of triage levels, and mean PRISA score. In the Paed CTAS group, more patients were triaged in the higher acuity levels (53% vs 36%, P < .05), but the percentage of admission for these patients was comparatively lower (13% vs 27%, P < .05). The ability to predict admission was greater for the PRE tool as compared to the Paed CTAS tool (AUC: 0.82 vs 0.69, P = .001). The ability to predict requirements for interventions such as blood culture and intravenous fluid bolus was similar for both triage tools.

Introduction

Triage is a crucial step in the emergency department (ED) functioning especially with the tendency for increased ED use and overcrowding. The main role of triage remains to assign priority to patients who need care that is more urgent and to predict the nature and scope of care likely to be required [1].

The use of widely varying triage scales among different EDs throughout the world makes comparisons in the functioning of different EDs difficult (eg, with respect to severity of patient load). To aid appropriate distribution of resources, the availability of a uniform triage scale is important. Such a tool will enable the provision of reliable information on department acuity, differences in EDs with regards to case mix, and serve as a measure of workload and performance indicator [1].

In an attempt to unify different triage scales, a single national 5-level triage acuity scale was proposed by the Australian Medical Committee [2]. This 5-level triage scale was reported to have high interobserver agreement rates for adult patients [3], [4].

In 1997, the Canadian Association of Emergency Physicians (CAEP) with the National Emergency Nurses' Affiliation (NENA) developed the 5-level Canadian ED Triage and Acuity Scale (CTAS) [5]. It has since become mandatory to use the CTAS in the EDs of most Canadian provinces.

More recently, the CAEP in collaboration with the NENA and the Canadian Pediatric Society proposed a 5-level triage scale derived from the adult CTAS for the pediatric patients: The Paediatric Canadian Triage and Acuity Scale (Paed CTAS) [6]. Before the development of the Paed CTAS, there was previously no widely accepted tool for the triage of pediatric patients. The intent of the Paed CTAS is to both measure case mix and ensure timely access to intervention. The Paed CTAS is based on a physiological assessment (appearance, neurological, respiratory rate, heart rate, and perfusion) and uses presenting symptom complexes to assign triage levels. Such as the adult CTAS, the Paed CTAS also outlines 5 triage levels, each consisting of degree of illness and acuity, time objectives to medical assessment and intervention, and examples of usual clinical presentation and sentinel diagnoses.

Before its widespread use for the prediction of resource and funding allocation and the need to divert patients from the ED, the validity of a triage tool needs to be adequately evaluated. Such an assessment will assure that the triage will properly identify and classify the patients by their level of severity limiting the occurrence of false-positive and false-negative assignments to a reasonable extent.

The performance of the newly developed Paed CTAS is yet to be assessed. Thus, the major objective of the present study was to assess the performance of the latter in comparison with a previously used triage tool with respect to the prediction of outcomes such as admission, requirement for medical interventions, and pediatric risk of admission (PRISA) score.

Section snippets

Study design

A before-and-after prospective study was conducted.

Setting

The study was conducted in a university-affiliated children's hospital ED with an annual census of approximately 65 000 patient visits. The ED is staffed with part-time and full-time pediatricians, board-eligible/board-certified (BE/BC) pediatric emergency physicians (PEPs), clinical fellows, residents, medical students, and registered nurses (RN).

The triage evaluation was performed by the RNs who had a minimum of 1 year of experience in our ED.

Results

During the above-described study periods, a total of 807 patients were triaged using the preexisting triage tool (PRE group) from which 63 (7.8%) left before being seen by a physician. A total of 560 patients were triaged using the Paed CTAS tool (Paed CTAS group) of which 23 (4.1%) left before seeing a physician. As shown in Table 1, Table 2, the 2 comparison patient populations were similar with respect to the admission rates, diagnostic categories, and type of interventions carried out. A

Discussion

The major objective of the present study was to evaluate the functioning of the newly developed Paed CTAS in a pediatric ED and to compare it with a previously developed triage tool. The results of our study indicate that by and large, the Paed CTAS does not perform better than the previous tool, and for some outcomes, the predictive ability of the previous tool seems more adequate.

Specifically, the Paed CTAS appears less accurate for the prediction of the need for admissions with fewer

Conclusions

With the introduction of Paed CTAS guidelines, we do have to realize that a patient assigned to a triage level might not have the same level of severity for a similar level of triage of a previous tool. Therefore, in a busy ED, the flow of patients might change by adopting the new guidelines.

The notion of a gold standard for the best triage tool remains elusive. It is probably inappropriate to develop a common triage tool for all the different types of ED (rural, urban, university affiliated,

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Results presented in part at the Canadian Association of Emergency Physicians annual meeting in Hamilton, Canada, April 2002, and at the Society of Academic Emergency Medicine annual meeting in St Louis, May 2002.

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