A Review of the Roles and Implementation of Pediatric Emergency Triage Systems in China and Other Countries

Background

A growing number of pediatric Emergency Department (ED) patients has become increasingly common in recent years. Forty percent of the ED patients in the United States are children, and children account for 25–30% of the accident and Emergency Department patients in the United Kingdom [1]. The number of pediatric ED patients in China has significantly exceeded the capabilities and resources of the hospitals, but only 20% of them are in true emergencies [2]. An excessive number of the pediatric ED patients who are not in true emergencies not only affects efficiency of triage but also increases patient waiting time, resulting in a delay in medical treatment and an increase in deaths [3]. It is particularly important to use pediatric triage systems to quickly assess the patients’ conditions and determine the patients’ priority in emergency treatment, ensuring timely treatment to critically ill patients and efficient utilization of medical resources. The Canadian Triage and Acuity Scale Paediatric Guidelines (PaedCTAS), Australasian Triage Scale (ATS), Emergency Severity Index (ESI), and Manchester Triage System (MTS) are internationally recognized pediatric triage systems [4]. Studies on pediatric triage systems have also been conducted in many other countries, such as China, South Africa, and Thailand to create a pediatric triage system in line with the situation of their respective countries. The variety of triage tools used in different countries makes it difficult to compare them, but there is an increasing number of studies on pediatric emergency triage in many countries around the world [5]. We aimed to review the roles and implementation of pediatric emergency triage systems in China and other countries.

Current Guidelines on Pediatric Triage Systems

Triage is the first step to every patient’s visit to the ED. It is a key step that can affect the quality of emergency medical services. The commonly used pediatric triage criteria that have been internationally recognized include paedCTAS, MTS, ESI, and ATS. Each of them is a 5-level triage system and has detailed guidelines (Canadian Emergency Department Triage and Acuity Scale [CTAS] implementation guidelines, ATS implementation guidelines, MTS emergency triage, and ESI implementation handbook version 4.0, respectively) to give better triage guidance for nurses. These criteria were developed by working groups or expert teams. Triage nurses received training before these triage criteria were put into use, and the triage criteria and their guidelines were revised for improvement after they were applied in clinical practice. Emergency triage criteria were initially developed for adults, and there are no standardized triage tools for pediatric ED patients that are routinely used. One of the difficulties in establishing a standardized triage tool is the difference in clinical parameters in different age groups. In addition, pediatric ED patients usually have acute conditions with rapid changes and generally have poor ability to describe their own conditions, and they are prone to crying. All of these can affect the accuracy of triage. How to quickly complete the assessment of the pediatric ED patient and make an optimal triage decision in a short time is a problem in pediatric ED triage [6].

Pediatric Triage Systems in China

The Ministry of Health of China published the Guidelines on Classifying Severity of Illness of Emergency Patients in September 2011. Then, classifying severity of illness was incorporated into The Design of Normative Flow of Emergency Department as a directive and was put into practice in September 2012. It states that a triage station using the four-level triage system shall be established in the ED, the diagnosis area in the ED shall be divided into 3 zones (red, yellow, and green), and the triage nurses shall classify the patients into different zones according to the patients’ severity of illness. Since then, the triage system has been implemented in China [7].

The Chinese pediatric triage criteria, developed in 2017 based on the paedCTAS [8], contain objective indicators, symptom/vital signs, and comprehensive indicators that reflect 3 factors of PEWS. The Chinese pediatric triage criteria have 4 level 1 indicators, 36 level 2 indicators (23 of them are the same as the indicators for adults), and 31 level 3 indicators. The pediatric patients are classified into 4 categories: Level 1 (critical, requiring immediate care), Level 2 (emergency, requiring care within 10 min), Level 3 (urgent, requiring care within 30 min), and Level 4 (non-urgent, requiring care within 240 min). It has a high degree of reliability. The Kappa value for agreement among the triage decisions between the triage nurses and the expert team was 0.994 [95% CI (0.987, 1.000)]. It was incorporated into the Emergency Triage (draft for comments) issued by the Medical Administration Bureau of National Health Commission of the People’s Republic of China in April 2021 [9]. This was China’s first national guideline containing information on a pediatric triage system. In the clinical application of Chinese pediatric emergency triage criteria, it was found that there were imperfections in the triage criteria. Therefore, Zhao et al [10] developed the Chengdu pediatric emergency triage criteria using the Delphi method by referring to the internationally recognized triage criteria (such as ESI and paedCTAS) and the existing Chinese pediatric emergency triage criteria. The Chengdu pediatric emergency triage criteria contain symptom/vital signs, objective indicators, and comprehensive indicators, and have 4 level 1 indicators, 51 level 2 indicators, and 23 level 3 indicators; the maximum waiting time to treatment for all triage levels is as follows: level 1 – immediate treatment; level 2 – within 10 min; level 3 – within 30 min; and, level 4 – within 240 min. The Chengdu pediatric emergency triage criteria have good reliability and validity [11] and can promote rapid and effective triage by triage nurses.

Pediatric Triage Systems in North America

ESI, which was promoted in the United States in 2003 and widely used in Europe and Asia [12], was modified and updated in 2012 to give guidance on pediatric emergency triage in the United States. When a patient visits the ED, the triage nurse generally carries out triage as follows: (1) Determine whether the patient will die without immediate life-saving measures; if so, the patient is triaged to level 1. (2) Determine whether the patient can wait. Patients requiring immediate emergency treatment are triaged to level 2. For patients who do not have a life-threatening condition, triage nurses should estimate the types of medical resources needed for diagnosis and treatment; if only 1 type of medical resource is required, the patient should be triaged to level 4; patients who are estimated to need multiple medical resources (2 or more types of medical resources) should be triaged to level 3 if their vital signs are stable; otherwise, they should be triaged to level 2 [13]. Medical resources are divided into 9 categories: electrocardiogram monitoring, consultation with clinical departments, diagnostic tests (electrocardiogram, laboratory tests, plain film X-ray, and special images) and therapeutic procedures (intravenous medication, use of blood products, and mechanical ventilation). Triage nurses estimate the types of medical resources that may be used for diagnosis and treatment based on the above-mentioned provisions, which are detailed in the guidelines [13]. Ghafarypour-Jahrom et al [14] found that ESI is reliable and better than ATS (Kappa: 0.65–0.92, P<0.001); ESI 4.0 is also reliable and effective in children and older patients.

Triage criteria applicable to children have been developed based on CTAS in recent years. In Saudi Arabia, paedCTAS is an important triage tool that can effectively triage pediatric patients in need of priority treatment. The nurses in Saudi Arabia achieved a better effect of using paedCTAS compared with the doctors, and their triage accuracy rate was higher than that of the doctors [15]. The paedCTAS has also been introduced to other countries to develop their own pediatric triage systems. For example, Israel’s pediatric triage guidelines, which were developed based on paedCTAS, can effectively predict the pediatric emergency patients’ hospital admission rate, rate of transfer to intensive care units, and length of stay in the ED [16].

Pediatric Triage Systems in Europe

MTS, which is widely used in the United Kingdom, was also introduced to the Netherlands, Portugal, and Sweden, and a 3rd edition of the MTS has been developed. Information about pediatric triage was added to the MTS when it was modified in 2014. MTS categorizes the patients according to their chief concerns. It contains 55 fixed triage flow charts. Of them, 49 are applicable to pediatric patients. The modified MTS has a significantly improved specificity but maintains a similar sensitivity when used in pediatric Emergency Departments [17]. Zachariasse et al [18] showed that the CTAS, ATS, MTS, and ESI had no differences in high-urgency triage accuracy between children and adults, but had a high degree of variability in sensitivity and specificity in low-urgency triage accuracy between children and adults. Compared with other triage systems, none of them had a better specificity. A meta-analysis [4] has shown that these 4 triage systems have a high level of agreement in pediatric ED; the pooled coefficient for the level of agreement was 0.727 (95% CI: 0.650–0.790); and the Kappa values of ATS, CTAS, ESI, and MTS were 0.25, 0.571, 0.810, and 0.755, respectively. Multiple regression analysis in time and space has shown that CTAS and ESI can be applied in other countries and reliability is increased over time. Campos-Gómez et al [19] found that paedCTAS had been effectively applied in Costa Rica.

Pediatric Triage Systems in Other Countries

As the first internationally recognized 5-level triage system, ATS has had a significant influence on triage systems in other countries, such as Canada, the United Kingdom, and the United States. ATS is based on physicians’ assessments of patients and differs from MTS, paedCTAS, and ESI. Ghafarypour-Jahrom et al [14] showed that ATS is effective in pediatric emergency triage (Kappa: 0.51–0.87), but it has a lower reliability and effectiveness in pediatric emergency triage than in adult emergency triage [12].

Many countries have created their own pediatric triage systems in line with the situation of their respective countries. The Ramathibodi Triage System (RTS) in Thailand uses computers to categorize the patients according to their chief concerns and vital signs: Level 1 triage requires immediate medical treatment, Level 2 triage requires treatment within 30 min, and Levels 3–5 triage require non-urgent treatment [20]. The Singapore Paediatric Triage Scale (SPTS) uses PAT to quickly make an initial assessment on the patient’s severity of illness and then determines the trial level according to the patient’s chief concern, vital signs, and severity of illness: Level 1 (resuscitation), Level 2 plus and Level 2 (non-resuscitation), and Level 3 (less urgent, emergency) [12]. The pediatric South African triage scale (pSATS), which was developed in 2004, is composed of the 4-level triage scale and numeric triage early warning score [21]. South Korea created the Korean Triage Scale based on CTAS in 2012 and developed the Pediatric Korean Triage and Acuity Scale (PedKTAS) in 2016 [22]. Rapid Emergency Triage and Treatment System-pediatric (RETTS-p) in Norway classifies patients into 4 priority levels: red=immediate, orange within 20 min, yellow=within 2 h, green=within 4 h, and blue=no priority [23].

Assessment Tools Used in Pediatric Triage Systems

The Pediatric Assessment Triangle (PAT) is a tool utilizing visual and auditory clues to quickly make an initial assessment of the pediatric patient’s severity of illness within 30–60 s. It has been widely used as the first step in the pediatric emergency triage process and is also used worldwide in different types of emergencies [1]. PAT is composed of 3 components: appearance, work of breathing, and circulation to skin, reflecting the child’s overall physiological status and the status of oxygenation, ventilation, perfusion, and function. The common structured triage system is used to categorize the patients based on their overall assessment. Fernandez et al [1] showed that PAT can facilitate rapid and effective triage of pediatric ED patients. PAT is usually used in conjunction with a triage system; for example, paedCTAS and SPTS use PAT for quick initial assessment.

Pediatric Early Warning Signs (PEWS) is a tool that is commonly used to assess the pediatric patient’s severity of illness. Brown et al [24] found that PEWS can quickly identify critically ill patients at an early stage, provides ongoing evaluation on the patient’s vital status, and helps in decisions regarding discharge to home or admitting the patient to a ward, or even selecting appropriate patients for admission to the pediatric intensive care unit. However, Lillitos et al [25] has shown that PEWS had poor sensitivity in predicting hospital admission (32%) and significant illness (44%) in pediatric emergency triage, so PEWS alone is not suitable for use in triage. McElroy et al [26] reported that using PEWS and CTAS together could identify early signs of deterioration, enhancing the value of pediatric emergency triage.

Future Directions

With the rapid development of artificial intelligence (AI) and big data, machine learning has shown higher prediction ability than a single model established based on triage information. We plan to build and verify an AI-based triage model and research the prognosis of pediatric ED patients based on the AI-based triage system.

Conclusions

The pediatric triage systems developed in different countries are reliable in the ED. Pediatric patients’ vital signs may differ with age and can exhibit non-specific symptoms. Because different triage systems have different performances, it is advisable to study the factors influencing their performance.