Quality of the Triage of Children With Anaphylaxis at the Emergency Department

Abstract

Objective Early recognition of symptoms is essential in anaphylaxis management. The Canadian Paediatric Emergency Triage and Acuity Scale prioritizes anaphylaxis to level I or II (resuscitation or emergency). We analyzed the accuracy of pediatric anaphylaxis triage. Methods This was a retrospective review of the triage charts (adaptation of the Canadian Paediatric Emergency Triage and Acuity Scale) of 137 children attended for anaphylaxis at our pediatric emergency department. Per triages' accuracy, charts were divided into TR1 (levels I–II) and TR2 (levels III–V), comparing demographics, initial triage level given by initial assessment (Paediatric Assessment Triangle), vital signs, observations recorded by the staff, and waiting times for physician. Results Forty-six (33.3%) were triaged correctly (TR1 group), and 91 (66.7%) were not. Median ages were similar (TR1: 5 years [interquartile range, 13.1 years] vs TR2: 4.5 years [interquartile range, 14.5 years]; P = 0.837). Initial triage level 5 was given by Paediatric Assessment Triangle to 69.5% of TR1 and 83% of TR2 cases (P = 0.001; likelihood ratio for TR2: 1.985 [95% confidence interval, 1.11–3.49]). Vital signs were normal in 71.7% of TR1 and 94.5% of TR2 patients (P < 0.001; likelihood ratio for TR2: 2.602 [95% confidence interval, 1.22–5.52]). Symptoms suggestive of anaphylaxis (mention of 2 different organs) were recorded in 45.6% of TR1 and 48.3% of TR2 charts (P = 0.08). Median waiting times were 3 minutes (interquartile range, 26 minutes) and 11 minutes (interquartile range, 111 minutes) for TR1 and TR2, respectively (P = 0.001). Conclusions Current triage, based on severity perception, missed most of the cases. Anaphylaxis-defining symptoms were overlooked. Inaccurate triage delayed medical attention. Improving measures, such as emphasizing symptom recognition and defining anaphylaxis risk discriminators, is mandatory to improve their identification.

Triage Grading and Correct Diagnosis Are Critical for the Emergency Treatment of Anaphylaxis

“…Our study shows that less than half of the patients presenting with symptoms evocative of anaphylaxis received a high-priority code, similarly to what happened in a Spanish PED where, among 137 children referred for anaphylaxis, only 56 (33%) were triaged correctly [ 14 ]. However, the Canadian Pediatric Emergency Triage Acuity Scale [ 15 ] suggests that anaphylaxis should be prioritized to level I or II (resuscitation or emergency) and highlights how current triage, which is based on severity perception, has the limit to under-evaluate most of these cases, thus delaying treatment [ 14 ]. Another paper by the same Spanish group investigated the impact of a specific educational intervention (a training lecture to PED triage nurses and design of a reference card highlighting symptoms and risk factors for anaphylaxis).…”

Impact of Specific Training in Anaphylaxis for Triage Nursing Staff in the Pediatric Emergency Department of a Tertiary Hospital

“…Previously, we evaluated how our system prioritized children attended for anaphylaxis in the PEU, noting that 66% were underprioritized and thus experienced delays in receiving their treatment [10]. Other authors have reported similar results [11].…”

“…However, isolated analysis of referred patients showed no differences in the final priority level assigned: 41.7% in G1 and 52.2% in G2 were prioritized correctly (not shown in the Table). We recently analyzed how our hospital's triage system classified a group of children who were subsequently diagnosed with anaphylaxis [10] and found that 66% were undertriaged and that this delayed their medical care.…”

“…Sixty-nine of the patients who had been attended between October 2014 and March 2016 had taken part in our previous study and formed group G1 [10]. In April 2016, we applied the BEI to nursing staff performing triage.…”

“…If skin symptoms are associated with involvement of another organ, priority changes to level II. If nursing staff diagnose anaphylaxis at triage (irrespective of their role assessing other symptoms), patients are assigned to level I priority [7,[8][9][10].…”