Original contribution
The use of the soterion rapid triage system in children presenting to the Emergency Department

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Abstract—

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system’s reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system’s validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system’s validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281–99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83–0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate–Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.

Introduction

It is estimated that there are over 31 million pediatric visits to Emergency Departments (EDs) each year (1). Inadequately developed communication skills, the subtlety of presenting signs and symptoms, and their unique physiology make the initial assessment of children more difficult, and place the seriously ill child at higher risk of being overlooked.

Triage is the first and most critical step toward the early identification of the sick child and the timely delivery of emergency health care. Without well-defined guidelines, triage is dependent upon the skill, education and experience of the individual performing triage. Many countries have adopted national five-level triage systems due to the recognized need for a more uniform triage tool (2, 3, 4). However, there are few five-level triage systems that have been developed that address the specific needs of the pediatric patient and no studies in this country that have evaluated the effectiveness of five-level triage systems in children (5, 6).

The Soterion Rapid Triage System (SRTS) is a new, computerized five-level triage system that contains both an adult and pediatric clinical decision-making process. We have previously reported on our initial experience using the system in a mixed general patient population (7). The unique aspects surrounding the care of children and the recent emphasis on five-level triage systems prompted the further study of the SRTS in this subgroup of patients. Therefore, this study was undertaken to evaluate the system’s reliability and validity for stratifying acuity levels in children under the age of 13 years.

Section snippets

Methods

The SRTS is a five-level triage acuity scale with the definition of each level based on the Canadian Triage and Acuity Scale (CTAS) (3). The development of the software application has been previously described (7). The overall logic of the system is comprised of three main components: standardized observations made of the patient, the computerized analysis of vital signs, and chief complaint-based algorithms with scripted interview questions directed to the child or the child’s caretaker. The

Characteristics of the Study Subjects

During the time period between April 12, 2003 and December 12, 2003, there were a total of 38,763 ED patient visits. Of those, 7077 (18%) were children under the age of 13 years who were triaged by SRTS. The characteristics of the study subjects triaged by the SRTS are shown in Table 4. There was a significant difference in mean age throughout all triage levels, such that acuity increased as age decreased (p < 0.0001). The mean age was 5 years ± 3.9. The five most common chief complaints were:

Five-Level Triage Systems

Since the mid 1990s, Australia, Canada and England have each adopted national five-level triage systems due to the recognized need for a more uniform triage tool and the demonstration of greater inter-rater reliability with a five-level system as compared with previous three- and four-level systems (10, 11, 12, 13, 14, 15). Recently, the need for a uniform triage tool has been underscored by the American College of Emergency Physicians and the Emergency Nurses Association’s recent approval of

Limitations

This study was performed in an ED with a mixed adult and pediatric population. It is unknown whether similar results would be experienced in a high-acuity pediatric ED. One could contend, however, that the mixed patient population in this study is more representative of EDs in this country, with pediatric EDs comprising less than 10% of the total EDs in this country (29).

Also, there must be continued refinement of the clinical content of the algorithms as more outcome-related data become

Conclusions

This report represents the first study in this country on the use of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age. This system has the characteristics of an ideal triage system, being highly reliable and strongly predictive of clinical outcome and resource utilization.

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  • Cited by (0)

    Drs. Maningas and Hime are partners of Soterion LLC, which developed the software application. Dr. Maningas is the first named inventor of the software, for which Patent No. 6,786,406 B1 has been granted.

    Original Contributions is coordinated by John Marx, md, of Carolinas Medical Center, Charlotte, North Carolina

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