Improving triage for children with comorbidity using the ED-PEWS: an observational study

Area of Science:

• Pediatric Emergency Medicine
• Clinical Triage Systems
• Patient Risk Stratification

Background:

• The Emergency Department-Pediatric Early Warning Score (ED-PEWS) is utilized for triage in pediatric emergency departments.
• Assessing the ED-PEWS's efficacy in children with comorbidities is crucial for optimizing care.
• The Manchester Triage System (MTS) is a widely adopted triage tool in emergency settings.

Purpose of the Study:

• To evaluate the performance of the ED-PEWS in triaging pediatric patients with varying degrees of comorbidity.
• To compare the ED-PEWS's accuracy for children with and without comorbidities.
• To determine the added value of incorporating the ED-PEWS into the existing MTS for comorbidity patient groups.

Main Methods:

• A secondary analysis of a prospective cohort study involving over 53,000 pediatric emergency department visits across three European hospitals.
• Utilized a three-category reference standard to represent true patient urgency.
• Assessed the discrimination (c-statistic) and calibration of the ED-PEWS for children with and without comorbidities, and evaluated its combination with the MTS.

Main Results:

• The ED-PEWS demonstrated comparable performance (c-statistic ~0.86) in identifying high-urgency patients across children with no comorbidity, non-complex comorbidity, and complex comorbidity.
• Sensitivity for high-urgency patients was slightly higher in children with comorbidity (0.73-0.75) compared to those without (0.70), with a trade-off in specificity.
• Adding the ED-PEWS to the MTS improved triage performance for children with comorbidity, except in settings with a low prevalence of high-urgency cases.

Conclusions:

• The ED-PEWS is a reliable triage tool for children with comorbidities, performing similarly to its application in children without underlying health conditions.
• The integration of ED-PEWS with the MTS enhances the triage process for pediatric patients with comorbidities, improving accuracy and potentially patient outcomes.
• The study highlights the ED-PEWS's value in diverse emergency department settings, with a caveat regarding its effectiveness in low-volume high-urgency patient scenarios.