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Improving triage for children with comorbidity using the ED-PEWS: an observational study
  1. Joany M Zachariasse1,
  2. Pinky Rose Espina2,
  3. Dorine M Borensztajn1,
  4. Daan Nieboer1,
  5. Ian K Maconochie3,
  6. Ewout W Steyerberg4,
  7. Johan van der Lei5,
  8. Susanne Greber-Platzer2,
  9. Henriette A Moll6
  1. 1Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
  2. 2Division of Pediatric Pulmology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
  3. 3Department of Paediatric Emergency Medicine, Imperial College NHS Healthcare Trust, London, UK
  4. 4Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
  5. 5Department of Medical Informatics, Erasmus MC-University Medical Center, Rotterdam, Netherlands
  6. 6Department of General Paediatrics, Erasmus MC-Sophia Childrens Hospital, Rotterdam, Netherlands
  1. Correspondence to Joany M Zachariasse, Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; j.zachariasse{at}erasmusmc.nl

Abstract

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 j.zachariasse@erasmusmc.nl/secretariaatalkg@erasmusmc.nl; 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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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 j.zachariasse@erasmusmc.nl/secretariaatalkg@erasmusmc.nl; 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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Footnotes

  • Contributors JMZ contributed to the conceptualisation and design of the study, carried out the analyses, drafted the initial manuscript and revised the manuscript based on the coauthors’ feedback. PRE, DMB, IKM and SG-P coordinated the data collection, contributed to interpretation of the data and critically reviewed the manuscript for important intellectual content. DN, EWS and JvdL contributed to the conceptualisation and design of the study, supervised the analyses and critically reviewed the manuscript for important intellectual content. HAM contributed to the conceptualisation and design of the study, contributed to interpretation of the data, critically reviewed the manuscript for important intellectual content and supervised the study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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