Outcomes of Chengdu Pediatric Emergency Triage Criteria: A Retrospective Study of 198,628 Pediatric Patient Records

Introduction

In pediatric emergency medicine, triage is a key step in the alleviation of Emergency Department (ED) crowding that takes into account the severity and urgency of patients’ health conditions. Its aim is to rationally allocate medical resources and identify which treatment and nursing methods are the most appropriate during resource restrictions. Triage accuracy is associated with the quality of treatment and care provided to patients [1]. Triage is an essential practice owing to the acute onset and seasonality of pediatric diseases and potentially excessive numbers of pediatric patients being admitted to hospital during “peak season” [2]. Owing to the limited capacity of outpatient registration and lack of nighttime outpatient service, patients who cannot be registered in the Outpatient Department will enter the ED, leading to ED crowding [3]. Pediatric patients’ parents hope their children receive timely treatment and often make pressing demands for emergency nursing, thereby adding to the stress experienced by pediatric emergency triage nurses. In the previous survey of our hospital’s emergency nurses’ degree of willingness in carrying out their responsibilities, we found that triage received the lowest score.

Our hospital’s emergency triage decisions have been formed through the following stages: the triage nurse’s own knowledge and experience; the triage criteria for adults; and, the Chinese and foreign countries’ pediatric emergency triage criteria. Our hospital’s triage recording system has evolved through 3 stages: manual registration, electronic medical record entry, and then the current electronic triage system. In December 2020, a pediatric emergency triage criteria suitable for our hospital, called the Chengdu pediatric emergency triage criteria, was developed at our hospital using the Delphi method. This triage criteria were informed by internationally recognized triage criteria, such as the Emergency Severity Index and Canadian Triage Acuity Scale, as well as the pediatric emergency triage criteria used in some hospitals in China. Chengdu pediatric emergency triage criteria is a 4-level triage tool. Its maximum waiting time for treatment under different triage levels are as follows: level 1, immediate treatment; level 2, within 10 min; level 3, within 30 min; and level 4, within 240 min (Table 1) [4]. The reliability and validity of the Chengdu pediatric emergency triage criteria was verified in 2021 [5]. This retrospective study included 198 628 patient records that were triaged between January and May 2022 using the Chengdu pediatric emergency triage criteria and aimed to evaluate outcomes from levels 1 to 4 of this triage criteria.

Material and Methods

ETHICS APPROVAL:

This study was conducted in accordance with the Declaration of Helsinki. All research methods were conducted in accordance with the relevant guidelines and regulations. This study was approved by the Medical Ethics Committee of West China Second University Hospital, Sichuan University (2022 Medical Scientific Research for Ethical Approval No. 138). Because this was a retrospective study based on patient records, the Medical Ethics Committee of West China Second University Hospital, Sichuan University approved the waiver of informed consent in this study.

STUDY DESIGN:

A total of 198 628 records of cases that were triaged in the ED of our hospital during January to May 2022 using the Chengdu pediatric emergency triage criteria were included in this study (level 1: 128 cases; level 2: 1164 cases; level 3: 14 560 cases; and level 4: 182 776 cases).

A self-designed survey form was used to collect pediatric ED patients’ general data, including age, sex, and chief concern, and clinical data, including triage level, whether the patient had died, whether the patient was admitted to our hospital, case mix index (CMI) at admission, and waiting time for treatment in the ED. The above-mentioned data were extracted from our hospital’s health information system. Data accuracy was checked by multiple researchers, and data entry was checked by 2 researchers to ensure appropriate integrity and accuracy of data.

QUALITY CONTROL:

Our hospital’s triage research group developed the Chengdu pediatric emergency triage guidelines and criteria and have conducted relevant training for triage nurses, including point-by-point explanation, case analysis, and situational simulation, so that the triage nurses could thoroughly understand the triage criteria and pass the relevant examination. The research group members provided follow-up guidance for triage nurses within the first month after the triage criteria were put into service to ensure triage nurses’ correct manipulation of the triage criteria. Each triage nurse at our hospital must possess at least 3 years of ED work experience before being permitted to work independently in the triage position.

STATISTICAL ANALYSIS:

SPSS 23.0 was used for statistical analysis. Measurement data were presented as mean±standard deviation. Enumeration data were expressed in the forms of frequency and component ratio. The chi-square test was used to compare the waiting times for treatment and hospital admission rates under different triage levels.

Results

PATIENTS’ GENERAL DATA:

A total of 198 628 patients visited the ED during January to May 2022. Patients’ general data are presented in Table 2.

COMPARISON BETWEEN TRIAGE LEVELS AND WAITING TIME FOR TREATMENT:

The Kruskal-Wallis H test results show that statistically significant differences existed between the different triage levels and the waiting time for treatment (P=0.000). The Kruskal-Wallis one-way analysis of variance results showed that no statistically significant difference existed between patients triaged to levels 1 and 2 (P=0.420), whereas statistically significance differences existed between patients triaged to other levels (P=0.000; Tables 3, 4).

COMPARISON BETWEEN TRIAGE LEVELS AND HOSPITAL ADMISSION RATES:

The chi-square test results showed a statistically significant difference between triage levels and hospital admission rates (P=0.000). The pairwise comparison results showed the hospital admission rate of patients triaged to level 1 was higher than the rates of patients triaged to levels 2, 3, and 4; the hospital admission rate of patients triaged to level 2 was higher than that of patients triaged to levels 3 and 4; and, the hospital admission rate of patients triaged to level 3 was higher than that of patients triaged to level 4. In summary, statistically significant differences were found between hospital admission rate by triage level (P<0.05; Tables 5, 6).

COMPARISON BETWEEN TRIAGE LEVELS AND ADMISSION CONVERSION RATES:

For the patients triaged to different levels, the chi-square test results showed that statistically significant differences existed between the admission conversion rates (proportion of patients receiving hospital admission letters and accepting admission; P=0.000). Among the patients who were triaged to levels 1 and 2 and received hospital admission letters, the pairwise comparison results showed no statistically significant difference in the admission conversion rates between them (P=0.994); by contrast, the admission conversion rates of patients triaged to levels 1 and 2 were higher than those of the patients triaged to levels 3 and 4, and the admission conversion rate of patients triaged to level 3 was higher than that of patients triaged to level 4. In summary, statistically significant differences were found between admission conversion rate by triage level (P=0.000) (Tables 7, 8).

COMPARISON BETWEEN TRIAGE LEVELS AND CMI VALUES AT ADMISSION:

The Kruskal-Wallis H test results showed that statistically significant differences existed between the CMI values at admission in the patients at different triage levels (P=0.000). The Kruskal-Wallis one-way analysis of variance results showed that no statistically significant differences existed between CMI values either in patients triaged to levels 1 and 2 (P=0.360) or in patients triaged to levels 3 and 4 (P=0.463). However, statistically significant differences existed in CMI values at admission between patients triaged to other triage levels (P<0.05) (Tables 9, 10).

Discussion

LIMITATIONS:

It should be noted that this study was conducted in the ED of only a single grade A tertiary hospital in China. A multi-center study is needed to further evaluate the outcomes using the triage criteria. Moreover, the criterion-related validity indicators selected for this study were insufficient; further predictive research should consider other variables, including death rate, Pediatric Intensive Care Unit admission, and the provision of medical resources on site. More criterion-related validity indicators should be included to further test the outcomes using the triage criteria.

Conclusions

The Chengdu pediatric emergency triage criteria developed and applied within our hospital appears to be characterized by good validity. Equipped with this triage criteria, triage nurses are more capable of determining the severity and emergency of the pediatric ED patients’ health conditions and effectively triaging the patients. Internationally recognized triage tools generally consist of comprehensive triage implementation guidelines. However, to improve the suitability of Chengdu pediatric emergency triage criteria, the triage criteria should be refined and, where appropriate, corresponding implementation guidelines should be imported.