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Accuracy of triage for children with chronic illness and infectious symptoms
Nienke Seiger1, Mirjam van Veen, Ewout W Steyerberg
1Department of Pediatrics, Room Sp 1540, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, PO Box 2060, 3000 CB Rotterdam, Netherlands. h.a.moll@erasmusmc.nl.
Insights
The Manchester Triage System (MTS) shows lower accuracy in identifying urgent needs for children with chronic illnesses presenting with infections. This highlights a risk of undertriage for these vulnerable pediatric patients.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Triage Systems
- Infectious Diseases in Children
Background:
- The Manchester Triage System (MTS) is widely used in emergency departments (EDs) to prioritize patient care.
- Children with chronic illnesses may present differently during infectious episodes, potentially impacting triage accuracy.
- Assessing the validity of triage tools in specific pediatric populations is crucial for patient safety.
Purpose of the Study:
- To evaluate the accuracy of the Manchester Triage System (MTS) in children under 16 presenting to the ED with infectious symptoms.
- To compare the MTS performance between children with and without chronic illnesses.
- To identify potential undertriage or overtriage risks associated with chronic conditions in pediatric infectious disease presentations.
Main Methods:
- A prospective observational study included children (<16 years) with dyspnea, diarrhea/vomiting, or fever presenting to a university hospital ED.
- Chronic illnesses were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes.
- MTS urgency categories were compared against a reference standard including vital signs, diagnosis, resource use, and follow-up. Sensitivity, specificity, and diagnostic odds ratios were calculated.
Main Results:
- Of 8592 children, 35% had a chronic illness. Undertriage was higher in children with chronic illnesses (16%) versus those without (11%, P < .001).
- Sensitivity for the MTS was lower in children with chronic illnesses (58%) compared to those without (74%).
- Specificity did not differ between groups, but diagnostic odds ratios were lower for children with chronic illnesses (4.8) than without (8.7).
Conclusions:
- The Manchester Triage System demonstrates reduced performance in assessing the urgency of infectious symptoms in children with chronic illnesses.
- There is a significant risk of undertriage for pediatric patients with chronic conditions in the ED setting.
- Healthcare providers should exercise heightened awareness and vigilance regarding undertriage in this specific patient group.
Objective:
This prospective observational study aimed to assess the validity of the Manchester Triage System (MTS) for children with chronic illnesses who presented to the emergency department (ED) with infectious symptoms.
Methods:
Children (<16 years old) presenting to the ED of a university hospital between 2008 and 2011 with dyspnea, diarrhea/vomiting, or fever were included. Chronic illness was classified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes. The validity of the MTS was assessed by comparing the urgency categories of the MTS with an independent reference standard on the basis of abnormal vital signs, life-threatening working diagnosis, resource utilization, and follow-up. Overtriage, undertriage, and correct triage were calculated for children with and without a chronic illness. The performance was assessed by sensitivity, specificity, and diagnostic odds ratios, which were calculated by dichotomizing the MTS into high and low urgency.
Results:
Of the 8592 children who presented to the ED with infectious symptoms, 2960 (35%) had a chronic illness. Undertriage occurred in 16% of children with chronic illnesses and in 11% of children without chronic illnesses (P < .001). Sensitivity of the MTS for children with chronic illnesses was 58% (95% confidence interval [CI]: 53%-62%) and was 74% (95% CI: 70%-78%) for children without chronic illnesses. There was no difference in specificity between the 2 groups. The diagnostic odds ratios for children with and without chronic illnesses were 4.8 (95% CI: 3.9-5.9) and 8.7 (95% CI: 7.1-11), respectively.
Conclusions:
In children presenting with infectious symptoms, the performance of the MTS was lower for children with chronic illnesses than for children without chronic illnesses. Nurses should be particularly aware of undertriage in children with chronic illnesses.
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