ABSTRACT
BACKGROUND: The Manchester Triage System (MTS) determines an inappropriately low level of urgency (undertriage) to a minority of children. The aim of the study was to assess the clinical severity of undertriaged patients in the MTS and to define the determinants of undertriage. METHODS: Patients who had attended the emergency department (ED) were triaged according to the MTS. Undertriage was defined as a 'low urgent' classification (levels 3, 4 and 5) under the MTS; as a 'high urgent' classification (levels 1 and 2) under an independent reference standard based on abnormal vital signs (level 1), potentially life-threatening conditions (level 2), and a combination of resource use, hospitalisation, and follow-up for the three lowest urgency levels. In an expert meeting, three experienced paediatricians used a standardised format to determine the clinical severity. The clinical severity had been expressed by possible consequences of treatment delay caused by undertriage, such as the use of more interventions and diagnostics, longer hospitalisation, complications, morbidity, and mortality. In a prospective observational study we used logistic regression analysis to assess predictors for undertriage. RESULTS: In total, 0.9% (119/13,408) of the patients were undertriaged. In 53% (63/119) of these patients, experts considered undertriage as clinically severe. In 89% (56/63) of these patients the high reference urgency was determined on the basis of abnormal vital signs. The prospective observational study showed undertriage was more likely in infants (especially those younger than three months), and in children assigned to the MTS 'unwell child' flowchart (adjusted OR<3 months 4.2, 95% CI 2.3 to 7.7 and adjusted ORunwell child 11.1, 95% CI 5.5 to 22.3). CONCLUSION: Undertriage is infrequent, but can have serious clinical consequences. To reduce significant undertriage, the authors recommend a systematic assessment of vital signs in all children.
Subject(s)
Child Health Services/standards , Emergency Service, Hospital/standards , Triage/standards , Adolescent , Blood Pressure/physiology , Child , Child, Preschool , Emergencies , Female , Health Resources/statistics & numerical data , Health Services Research , Heart Rate/physiology , Hospitalization/statistics & numerical data , Humans , Infant , Infant, Newborn , Male , Netherlands , Patient Selection , Prospective Studies , Respiratory Rate/physiology , Severity of Illness Index , Triage/methodsABSTRACT
OBJECTIVE: The authors aimed to assess the repeatability of the Manchester Triage System (MTS) in children. METHODS: All emergency department nurses (n=43) from a general teaching hospital and a university children's hospital in The Netherlands triaged 20 written case scenarios using the Manchester Triage system. Second, at two emergency departments (EDs), real-life simultaneous triage of patients (<16 years) was performed by ED nurses and two research nurses. The written case scenarios and the patients included in the real-life simultaneous triage study were representative of children attending the ED, in age, problem and urgency level. The authors assessed inter-rater agreement using quadratic weighted kappa values. RESULTS: The weighted kappa between the nurses, triaging the case scenarios, was 0.83 (95% CI 0.74 to 0.91). In total, 88% (N=198) of the eligible ED patients were triaged simultaneously, with a weighted kappa of 0.65 (95% CI 0.56 to 0.72). CONCLUSIONS: The MTS showed good to very good repeatability in paediatric emergency care.
Subject(s)
Emergency Service, Hospital/standards , Triage/methods , Child , Hospitals, Pediatric/standards , Hospitals, Teaching/standards , Hospitals, University/standards , Humans , Netherlands , Nursing Staff, Hospital , Observer Variation , Reproducibility of Results , Triage/standardsABSTRACT
A 2-week-old boy was presented with prominent cranial fissures. He was diagnosed with malleability post partum.
Subject(s)
Skull/abnormalities , Diagnosis, Differential , Humans , Infant, Newborn , Male , Postpartum PeriodABSTRACT
BACKGROUND: Postoperative analgesia in children may be improved by using tramadol. The pharmacokinetics of rectal tramadol in young children were therefore investigated. METHODS: The pharmacokinetics of rectal tramadol and its active metabolite were studied in 12 young children (age: 1-6 yr) postoperatively. On the basis of these data, a population model was constructed. Using this model, the pharmacokinetics of different doses of tramadol were calculated. RESULTS: The pharmacokinetics of rectal tramadol could be adequately described by a one-compartment model. The pharmacokinetic parameters derived from the model indicate that a low variability was present. Elimination half-life was 4.3 (0.2) h (sem) and the apparent clearance was 16.4 (1.5) litre h(-1) (sem). CONCLUSIONS: The study showed that after rectal administration, tramadol is absorbed at a reasonable rate and with a low inter-individual variability in small children. The data also suggested that a rectal dose of tramadol 1.5-2.0 mg kg(-1) is therapeutic.
