Irish Childrens Triage System (ICTS) Project Presented by Ruth - PowerPoint PPT Presentation

Irish Children’s Triage System (ICTS) Project Presented by Ruth Devers CNM3 Children's University Hospital Temple St Mary Tumelty CNM3 National Children's Hospital, Tallaght Bridget Conway CNM3 Our Lady's Children's Hospital, Crumlin National Emergency Medicine Programme Seminar February 10th 2016

What is ICTS • Irish Children’s Triage System (ICTS) is a quality improvement initiative, the aim of which is to standardise a formal, comprehensive triage tool that would improve consistency between users and be suitable for triaging children in all emergency departments with paediatric attendances in Ireland.

Objectives of ICTS • Provide an evidence- • To develop a specific based approach to the triage tool to clinically triage of children assess children attending that supports clinical EDs that facilitates the prompt recognition of decision making acuity for ill or injured • Develop a National children. Standard for • Develop a tool tailored to Children’s Triage include clinical elements which ensures that such as, physiological vital signs, pain management, children receive the temperature and other same standard and special guidelines specific quality of care to the needs of children. regardless of where in • the country they present for treatment.

Project Design • ICTS project steering • Training package group convened in 2011 developed & delivered (Chair M.Forde, Nurse by CNM3s from three Lead EMP) Paediatric EDs • Literature review of • ‘Champions’ identified in existing international 6 pilot sites to support triage tools staff & identify and • Flowchart design base on resolve any MTS & existing tools issues/concerns developed locally in highlighted during pilot paediatric EDs in Dublin phase

General Discriminators Definition Triage categories General discriminators Colour Red Airway compromise Triage category 1 Inadequate breathing Meaning of triage category Immediate Exsanguinating haemorrhage Recommended time to be seen Immediate (ongoing Currently seizing by doctor/reassessment assessment) Age related abnormal pulse and respiratory rate * GCS ≤ 12 Oxygen saturations ≤ 90% Colour Orange Severe pain (pain score 7-10) Triage category 2 Uncontrollable major haemorrhage Meaning of triage category Very urgent GCS 13 or 14 ≤ 10 minutes Recommended time to be seen Age related abnormal pulse and by doctor/reassessment respiratory rate * Signs of compensated shock Oxygen saturations ≤ 92% Colour Yellow Moderate pain (pain score 4-6) Triage category 3 Uncontrollable minor haemorrhage Meaning of triage category Urgent Age related abnormal pulse and ≤ 60 minutes Ideal time targets respiratory rate * History of unconsciousness Colour Green Mild pain (Pain score 1-3) Triage category 4 Problem <48 hours Meaning of triage category Standard ≤ 120 minutes Ideal time targets Colour Blue Problem > 48 hours Triage category 5 Meaning of triage category Non urgent ≤ 240 minutes Ideal time targets

Vital Signs Reference Grids Respiratory Rate Values Table 1. Age ≤ - 2 S/D - 1 S/D Normal + 1 S/D + 2 S/D > + 2 S/D 0 – 3 months 21 – 30 60 – 70 70 – 80 < 20 30 - 60 > 80 4 – 6 months 20 – 30 30 – 60 60 – 70 70 – 80 < 20 > 80 17 – 25 25 – 45 45 – 55 55 – 60 7 -12 months < 17 > 60 1 – 3 years 15 – 20 20 – 30 30 – 34 35 – 40 < 15 > 40 4 – 6 years 12 – 16 16 – 24 24 – 28 28 – 32 < 12 > 32 10 – 14 14 – 20 20 – 24 24 – 26 > 7 years < 10 > 26 Heart Rate Values Table 2. ≤ - 2 S/D - 1 S/D Normal + 1 S/D + 2 S/D > + 2 S/D Age 0 – 3 months 65 – 90 90 – 180 180 – 205 205 – 230 < 65 > 230 4 – 6 months 63 – 80 80 – 160 160 – 180 180 – 210 < 63 > 210 60 – 80 80 – 140 140 – 160 160 – 180 7 -12 months < 60 > 180 1 – 3 years 58 – 75 75 – 130 130 – 145 145 – 165 < 58 > 165 4 – 6 years 55 – 70 70 – 110 110 – 125 125 – 140 < 55 > 140 45 – 60 60 – 90 90 – 105 105 – 120 > 7 years < 45 > 120 Colour Triage category Red Triage category 1 Orange Triage category 2 Yellow Triage category 3 White Triage category not determined by pulse or respiration rate

Data Collection Pilot Phase • Champions in each pilot site collected data: – % of each category patient presenting to ED – Admission rates per triage categories – Triage categories of all patients admitted to PICU • Staff satisfaction questionnaire completed by staff at pilot sites • Feedback from champions informed revision of ICTS flowcharts.

Audit Results

Attendance rate per triage category ( across 6 pilot hospitals Mar-May 2012 & 2013 ) Attendance rates per triage category March- May 2012 Attendance per triage category March - May 2013 70 70 60 60 Category 1 50 Category 1 50 Category 2 Category 2 40 Category 3 40 Category 3 30 Category 4 Category 4 30 Category 5 20 Category 5 20 10 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6

Admissions as an overall % of admissions per triage category Mar- May 2012 & 2013 Admissions as an overall admission % per triage category 2012 Admissions as an overall admission % per triage category 2013 70 70 60 60 Category 1 Category 1 50 50 Category 2 Category 2 40 40 Category 3 Category 3 % % 30 30 Category 4 Category 4 20 20 Category 5 Category 5 10 10 0 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6

Admission rate per triage category Mar- May 2012 & 2013 Admissions per triage category 2012 Admissions per triage category 2013 100 100 90 90 80 80 Category 1 Category 1 70 70 Category 2 Category 2 60 60 % 50 Category 3 % 50 Category 3 40 40 Category 4 Category 4 30 30 Category 5 Category 5 20 20 10 10 0 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6

Patients admitted to PICU Triage categories of patients admitted to PICU 2012 Triage categories of patients admitted to PICU 2013 0% 0% 0% 0% 7% 6% Category 1 Category 1 31% 45% Category 2 Category 2 Category 3 Category 3 Category 4 Category 4 49% 62% Category 5 Category 5

National Implementation Plan • Pilot sites request • CNM3s delivered to continue using Train the Trainer ICTS education sessions in 5 locations • Support for around the country national roll out in 2014 from Centre of Children's Nurse Education

Successes & Challenges • No dedicated funding for a • 10 out of 18 EDs have coordinator for a national implemented some ICTS rollout training as result of ‘Train the trainer’ programme • Skill mix / RCN’s not available on each shift in • 6 sites (3 PEDs) already all EDs trained & available to support other sites • Time constraints on trainers due to poor • ED staff enthusiastic & staffing levels willing to use a child specific triage tool • Crowding & trollies • Electronic version ICTS in • Inconsistent access to IT IPMS supported EDs

Next Steps • Continue to work through identifying the barriers at sites who currently do not have ICTS • Resource additional train the trainer day(s) • Publish & launch National EMP ICTS document