Volume 194 - Issue 4
Using the CEC paediatric calling criteria in emergency department triage
Authors: Charles H Pain, Clifford F Hughes, Marino Festa, Jodie Ekholm and Matthew O’Meara
Med J Aust 2011; 194 (4): 210-211. || doi: 10.5694/j.1326-5377.2011.tb03784.x
Published online: 21 February 2011
Published online: 21 February 2011
To the Editor: O’Leary and Major1 have opened debate on the issues raised by the New South Wales-wide introduction of the Clinical Excellence Commission Between the Flags (BTF) observation charts, which incorporate escalation thresholds for vital signs and other criteria. In the BTF charts, “yellow” zone criteria trigger a clinical review and “red” zone criteria, a rapid response.2 Evidence shows that deterioration can be recognised early, reducing serious consequences.3,4 O’Leary and Major trialled a subset of the draft BTF paediatric calling criteria in the context of triage in an emergency department, applying them retrospectively and comparing the actual triage decision with the one that would have been made using the BTF criteria alone. They also examined patient disposition for patients falling within the yellow and red zones. They concluded that “the physiological parameters ... are not suitable as a triage tool in the paediatric emergency department, do not replace an experienced triage nurse, and are a poor predictor of disposition”.1
We are not surprised by this conclusion.
The Australasian Triage Scale is designed to assess a patient’s urgency based on presenting problem and general appearance, possibly combined with physiological observations.5 Trialling a subset of vital signs, on their own, against the triage process, although interesting, is unlikely to demonstrate a strong correlation in decision making for the following reasons.
The BTF vital signs observations are designed for use in the context of a “track and trigger system” in a general ward, to monitor trends, not as a substitute for the triage process.
Vital sign observations on their own contribute little to triage decisions.
Triage decisions are poor predictors of disposition (eg, up to 67% of triage Category 2 patients are discharged home from the emergency department) (Sydney South West Area Health Service emergency department data for July 2010, for Campbelltown, Liverpool and Royal Prince Alfred hospitals).
On their own, we would expect vital signs to be poorer predictors of disposition outcome than triage decisions, which have the benefit of information on presenting problem and general appearance. Context for vital sign observations has a major influence on their interpretation.
We recommend that more work be done on the value of the BTF vital signs criteria as a complement, not alternative, to triage processes.
Competing interests
Charles Pain and Clifford Hughes hold executive positions at the Clinical Excellence Commission. Marino Festa is an unpaid member of the Clinical Excellence Commission BTF Expert Advisory Committee and co-editor of the DETECT Junior Manual that will accompany the BTF program.
References
- O’Leary FM, Major JI. Using the paediatric calling criteria in emergency department triage. Med J Aust 2010; 193: 373-374. <eMJA full text>
- Clinical Excellence Commission. Between the Flags — keeping patients safe. Sydney: CEC, 2009. http://www.cec.health.nsw.gov.au/programs/between-the-flags.html (accessed Nov 2010).
- Jacques T, Harrison GA, McLaws ML, Kilborn G. Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting. Resuscitation 2006: 69; 175-183. 0_i1095854
- Chen J, Bellomo R, Flabouris A, et al. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009: 37; 148-153. 0_i1095856
- Australasian College for Emergency Medicine. Guidelines on the implementation of the Australasian Triage Scale in emergency departments. Revised Aug 2005. Melbourne: Australasian College of Emergency Medicine, 2005. http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation__ATS.pdf (accessed Nov 2010).