Use of Pediatric Early Warning Score to Prevent Undertriage in Pediatric Patients

Aim: : Ensuring patients are prioritized to appropriate care levels is a critical component to patient outcomes in the emergency department setting. Nurses are the first point of contact for care and are key to successful sorting and subsequent prioritization of arriving patients. The Emergency Severity Index is the recommended five-level triage scale used by nurses to appropriately triage patients. Despite the use of this validated tool, over and under triage can still occur, potentially resulting in increased wait times, reduced hospital performance indicators, and increased morbidity and mortality.

In 2019, we undertook a quality improvement initiative to address inaccurately triaged pediatric patients in our mixed population Emergency Department. To improve triage accuracy, we added the modified Pediatric Early Warning Score to triage assessments for pediatric patients.

Framework:: Our project team went through two PDSA cycles to address accuracy of triage.

Setting:: Mixed population Emergency Department, Level II Trauma Center and teaching hospital in a suburban setting.

Stakeholder Team:: Emergency Department Clinical Coordinator identified the opportunity to improve triage accuracy of pediatric patients. They brought this to the leadership team and support was obtained. The Clinical Coordinator partnered with the Clinical Nurse Specialist to research pediatric specific risk assessments, develop an implementation plan, and conduct ongoing chart assessments for triage accuracy. Clinical Coordinator and Clinical Nurse Specialist partnered with scholarly faculty and statistician to determine clinical significance of data and subsequent project presentation.

Methods: : Aimed to improve the triage accuracy of pediatric patients ten years old and under. We educated and implemented a paper based modified Pediatric Early Warning Score tool to assist with triage. After 6 months, triage accuracy was evaluated, and no improvement was appreciated. Following this first PDSA cycle, we implemented the modified Pediatric Early Warning Score as a required triage assessment for every pediatric patient. For analysis, we included all admitted or transferred patients ten years and under with the exception of patients arriving with the chief complaint of a mental health problem or overdose.

Outcomes:: We included two and a half years of data including 100 patients (including 35 patients pre-implementation and 65 patients post-implementation) showed a statistically significant increase in triage accuracy to 92.5% exceeding the target goal of 85%. Our pre-implementation triage accuracy was 48.6%.

Implications:: The modified Pediatric Early Warning Score was a simple yet effective triage tool to add as an adjuvant to the Emergency Severity Index for triage accuracy. We are currently exploring conducting a more robust research study of the applicability of using the modified Pediatric Early Warning Score in a mixed-population emergency department. We found this is the existing gap in the literature as the majority of research was on the modified Pediatric Early Warning Score in pediatric specific settings only. We feel this is an opportunity for other mixed population Emergency Departments to improve care of the pediatric patient. Since embedding the modified Pediatric Early Warning Score into the Electronic Health Record and establishing ongoing education for onboarding new hires, this process has been quite stable with little intervention required.