An adapted triage tool (ETAT) at Red Cross War Memorial Children’s Hospital Medical Emergency Unit, Cape Town: An evaluation

Abstract

Objective. To evaluate the efficacy of an adapted Emergency Triage Assessment and Treatment (ETAT) tool at a children's hospital. Design. A two-armed descriptive study. Setting. Red Cross War Memorial Children's Hospital, Cape Town, South Africa. Methods. Triage data on 1 309 children from October 2007 and July 2009 were analysed. The number of children in each triage category red (emergency), orange (urgent or priority) and green (non-urgent)) and their disposal were evaluated. Results. The October 2007 series: 902 children aged 5 days -15 years were evaluated. Their median age was 20 (interquartile range (IQR) 7 -50) months, and 58.8% (n=530) were triaged green, 37.5% (n=338) orange and 3.8% (n=34) red. Over 90% of children in the green category were discharged (478/530), while 32.5% of children triaged orange (110/338) and 52.9% of children triaged red (18/34) were admitted. There was a significant increase in admission rate for each triage colour change from green through orange to red after adjustment for age category (risk ratio (RR) 2.6; 95% confidence interval (CI) 2.2 -3.1). The July 2009 cohort: 407 children with a median age of 22 months (IQR 7 -53 months) were enrolled. Twelve children (2.9%) were triaged red, 187 (45.9%) orange and 208 (51.1%) green. A quarter (101/407) of the children triaged were admitted: 91.7% (11/12) from the red category and 36.9% (69/187) from the orange category were admitted, while 89.9% of children in the green category (187/208) were discharged. After adjusting for age category, admissions increased by more than 300% for every change in triage acuity (RR 3.2; 95% CI 2.5 -4.1). Conclusions. The adapted ETAT process may serve as a reliable triage tool for busy paediatric medical emergency units in resourceconstrained countries and could be evaluated further in community emergency settings.

Triage - keep it simple, swift, safe and scientific

“…[2] Their evaluation of ETAT implied that the inclusion of physiological parameters was superfluous and, in the triage of a paediatric patient, was 'time-consuming to perform and, if manually and hastily undertaken, could be incorrect' . Summarily doing away with an entire aspect of medical evaluation has a sense of throwing the baby out with the bathwater.…”

“…The SATS tool -which is in its third version and has now combined the best of both SATS and ETAT -allows for rapid movement of patients into resuscitation as the first emergency sign is found (the ABCccD of ETAT), bypassing measurement of TEWS at triage. For children less obviously ill, but nevertheless as ill, the TEWS acts as a safety net, catching 'red' patients who slip through the clinical signs net, adding finesse and increasing sensitivity from 57% to 91%, [6] at the cost of a maximum extra 2 -4 minutes per patient (although the ETAT study [2] is the first to report such times: over 100 other sites use the SATS, including resource-constrained sites such as Médecins Sans Frontières field hospitals, and we have not recorded such lengthy processes, nor inaccurate triage due to excessive speed, in any of them). If this cost in time is not deemed feasible, doing away with the weighing of patients at triage is recommended -a routine practice and part of the adapted ETAT for Red Cross Hospital, but as yet unproven in effectiveness as a triage component -rather assessing respiratory rate and pulse within the time frame.…”

“…There can be no question regarding the value of physiological measures in the assessment of acuity. [3][4][5] There is agreement on the problems related to blood pressure measurement, which is why it was removed from the Triage Early Warning Score [1] and the RCCH group state that 'it was believed that an ETAT-based process would be more appropriate than … SATS' , [2] this study neither compared the two tools nor proved 'appropriateness' of one over the other; rather it showed the effect and validity of the introduction of the ETAT tool/framework into a 'triage-naïve' setting. There is no argument against the superiority of almost any kind of triage system over no systematic prioritisation, and ETAT has been shown, unsurprisingly, to be a better system than no system at all.…”

Editor's Choice

“…In a recent multi-country trial of fluid therapy for severely ill children, an anticipated mortality of up to 20% was reduced to 10%, probably because of ETAT. [5] Recently adapted for use at Red Cross War Memorial Children's Hospital (RCH) in Cape Town, [6] the tool correctly identified many critically unwell children and differentiated those most likely to require admission from those likely to be able to go home. While it was confirmed as an appropriate tool for RCH, its usefulness in children presenting to district, regional and community emergency settings requires further evaluation.…”

An adapted triage tool (ETAT) at Red Cross War Memorial Children’s Hospital Medical Emergency Unit, Cape Town, South Africa: An evaluation

“…To the Editor: In the March issue of SAMJ, an article on the emergency triage of children, [1] of which we were the senior co-authors, appeared in association with an editorial by Professor Elizabeth Molyneux. [2] We need to clarify three points.…”