A Validation Study of the Paediatric Non-Urgent Risk Assessment Management and Nurse Escort Assessment (PaNURAMA)...

Decision support tools improve risk assessment in critical paediatric inter-hospital transfers (IHT), however, data on non-critical transfers of unwell children is limited. This study assessed the validity and reliability of a novel risk stratification tool, paediatric non-urgent risk assessment management and nurse escort assessment (PaNURAMA), designed to improve the quality of non-critical IHT for paediatric patients. Developed through expert multidisciplinary consultation, PaNURAMA provides three-tiered risk stratification to determine consultation, treatment, and escort needs: (i) Red (retrieval team co-ordination, medical escort considerations), (ii) Amber (specialist consultation, potential nurse escort) and (iii) Green (standard referral, no escort required).

PaNURAMA's accuracy in predicting risk stratification and nurse escort needs was evaluated utilising a randomised sample with de-identified data from 175 children that underwent IHTs (2019-2020). A blinded expert reviewer applied the tool to a pre-referral dataset, assigning predicted risk and escort requirements. Review and risk stratification of the post-arrival dataset was also completed. Sensitivity and specificity were assessed using an exact binomial test, targeting 80% sensitivity and 75% specificity.

Of all cases, 68% were stratified as Amber, with 26% requiring an escort. Overall risk stratification agreement between pre- and post-transfer classifications was 94% (range 62% Red to 98% Amber). Intra-rater reliability was strong (κ = 0.83, 95% CI: 0.74-0.92). Escort allocation had 97% specificity for true negatives and 82% for true positives. Discrepancies reflected clinical improvements or additional findings post-referral.

PaNURAMA demonstrates strong validity and reliability in risk stratification and escort allocation supporting its use in transfer decision making for non-critical paediatric IHTs.