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Improving triage for children with comorbidity using the ED-PEWS: an observational study


Objective To assess the value of the Emergency Department–Pediatric Early Warning Score (ED-PEWS) for triage of children with comorbidity.

Design Secondary analysis of a prospective cohort.

Setting and patients 53 829 consecutive ED visits of children <16 years in three European hospitals (Netherlands, UK and Austria) participating in the TrIAGE (Triage Improvements Across General Emergency departments) project in different periods (2012–2015).

Intervention ED-PEWS, a score consisting of age and six physiological parameters.

Main outcome measure A three-category reference standard as proxy for true patient urgency. We assessed discrimination and calibration of the ED-PEWS for children with comorbidity (complex and non-complex) and without comorbidity. In addition, we evaluated the value of adding the ED-PEWS to the routinely used Manchester Triage System (MTS).

Results 5053 (9%) children had underlying non-complex morbidity and 5537 (10%) had complex comorbidity. The c-statistic for identification of high-urgency patients was 0.86 (95% prediction interval 0.84–0.88) for children without comorbidity, 0.87 (0.82–0.92) for non-complex and 0.86 (0.84–0.88) for complex comorbidity. For high and intermediate urgency, the c-statistic was 0.63 (0.62–0.63), 0.63 (0.61–0.65) and 0.63 (0.55–0.73) respectively. Sensitivity was slightly higher for children with comorbidity (0.73–0.75 vs 0.70) at the cost of a lower specificity (0.86–0.87 vs 0.92). Calibration was largely similar. Adding the ED-PEWS to the MTS for children with comorbidity improved performance, except in the setting with few high-urgency patients.

Conclusions The ED-PEWS has a similar performance in children with and without comorbidity. Adding the ED-PEWS to the MTS for children with comorbidity improves triage, except in the setting with few high-urgency patients.

  • data collection
  • epidemiology
  • health services research
  • resuscitation

Data availability statement

Data are available upon reasonable request. Individual participant data that underlie the results reported in this article will be made available at request after deidentification, beginning 12 months and ending 10 years following article publication. Data will be shared with investigators who provide a methodologically sound proposal, designed to achieve aims in the approved proposal, or for individual participant data meta-analysis. Proposals should be directed to; to gain access, data requestors will need to sign a data access agreement that will be composed together with the Erasmus MC private knowledge office and the technology transfer office.

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