viernes, 14 de agosto de 2015

Chapter 6. Use of the ESI for Pediatric Triage | Agency for Healthcare Research & Quality

Chapter 6. Use of the ESI for Pediatric Triage | Agency for Healthcare Research & Quality

AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Emergency Severity Index (ESI): A Triage Tool for Emergency Department

Chapter 6. Use of the ESI for Pediatric Triage

This chapter addresses the use of the Emergency Severity Index (ESI) algorithm for triage of patients less than 18 years of age. The chapter incorporates issues identified during a study conducted by the Pediatric ESI Research Consortium (Travers et al., 2006) and from a review of the pediatric triage literature (Hohenhaus et al., 2008), both of which were funded by the Health Services and Resources Administration (HRSA). The chapter can help general hospital and pediatric nurses quickly and accurately assess children in the ED triage setting. The chapter is meant to serve as guidance for all hospitals regarding use of the ESI for pediatric triage. It is not intended to serve as a substitute for a course on pediatric triage or pediatric emergency care, nor for local policies regarding triage (e.g., whether or not febrile children are treated with anti-pyretics at triage if they go to the waiting room).


In the current emergency department (ED) environment of crowding, emerging infectious diseases, and natural disasters, it is important to have a reliable triage system in place that allows for rapid and accurate assessment of patients. This is particularly important for the most vulnerable ED populations, which include children. Nationwide, there are an estimated 30 million ED visits per year for patients under 18 years of age, accounting for one-fourth of all ED visits (Middleton & Burt, 2006). Children's physiological and psychological responses to stressors are not the same as those of adults, and they are more susceptible to a range of injuries and illnesses, from viruses to dehydration to radiation sickness. Given their often limited ability to communicate with care providers, children can be more difficult to rapidly and accurately assess than their adult counterparts.
Triage tools such as the ESI algorithm are designed to prioritize ED patients for treatment. The earliest version of the ESI was intended for use only with patients greater than age 14 (Wuerz et al., 2000). In 2000, specific pediatric vital sign criteria were added to the ESI version 2; this version is intended for triage of patients of any age (Wuerz et al., 2001). While the ESI has been shown to produce valid, reliable triage of the general ED population, recent studies of its utility for pediatric patients indicate room for improvement. Hinrichs and colleagues (2005) found low intra- and inter-rater reliability among nurses using the ESI for infant triage. In another single-site study of ESI version 3, researchers conducted a retrospective chart review of pediatric triage decisions and found variable reliability among triage nurses, nurse investigators, and physician investigators with a moderate level of agreement (Baumann et al., 2005).
The information in this chapter is based on the results of the multi-center study of pediatric triage and a comprehensive review of the pediatric literature. The Pediatric ESI Research Consortium conducted a large, multi-center study of the ESI for pediatric triage and found that, while the overall reliability of ESI version 4 is good, pediatric cases are more often mistriaged than adult cases (Travers et al., 2006). The study evaluated both reliability and validity of the ESI for children, enrolling 155 nurses and 498 patients in the reliability evaluation and 1,173 patients in the validity evaluation across 7 hospitals in 3 states. The sites included urban, rural, suburban, academic, and community hospitals and two dedicated pediatric EDs. The researchers found that nurses make more accurate ESI ratings for trauma cases than medical cases (Katznelson et al., 2006) and that certain types of pediatric patients are harder to triage, including infants, psychiatric patients, and those with fever, rashes, or respiratory problems (Rosenau et al., 2006).
The Pediatric ESI Research Consortium's comprehensive review of the pediatric literature included 15 emergency courses and pediatric emergency text books, and the goal of the review was to identify best practices and best evidence relevant to ED triage of children (Hohenhaus et al., 2008). The review noted both strengths and areas for improvement in the existing literature. Strengths included the use of case scenarios for teaching and the existence of many courses that facilitate education on pediatric assessment during emergencies. Areas for improvement included a lack of evidence-based normal pediatric vital sign parameters; the need for a standardized, interdisciplinary approach to assessment and history taking; and the need for more pediatric triage-specific case scenarios for educational use.

Pediatric Triage Assessment

Triage Assessment: What Is Different for Pediatric Patients?

The goal of the triage nurse is to rapidly and accurately assess an ill child in order to assign a triage level to guide timely routing to the appropriate emergency department area for definitive evaluation and management. Triage is not a comprehensive assessment of the pediatric patient. The ESI version 4 requires that the triage nurse follow the same algorithm on all patients, pediatric and adult. While the algorithm is the same regardless of age, the decision process in the pediatric patient must take into account age-dependent differences in development, anatomy, and physiology.
The triage nurse needs a good sense of what constitutes "normal" for children of all ages. This knowledge will make it easier to recognize things that should be concerning (e.g., the 6-month-old who is not interested in his or her surroundings or the 2-week-old who is difficult to arouse to feed). The triage nurse must be comfortable interacting with children across the age spectrum and must be well versed in the anatomic and physiologic issues that may put a child at increased risk, as well as certain age-dependent "red flags" that should not be overlooked. The importance of adequate education in pediatrics prior to undertaking the triage of pediatric patients cannot be overemphasized. The following are key points that the triage nurse should keep in mind when assessing a child:
  1. Use a standardized approach to triage assessment of the pediatric patient, such as the 6-step approach described in the next section. Observe skin color, respiratory pattern, and general appearance. Infants and children cannot be adequately evaluated through layers of clothing or blankets.
  2. Infants must be observed, auscultated, and touched in order to get the required information. Their caregivers are critical to their assessment. Using a warm touch and a soft voice will help with the assessment.
  3. Infants over about 9 months of age and toddlers often have a significant amount of "stranger anxiety." Approaching them in a nonthreatening manner, speaking quietly, getting down to the child's eye level, and allowing them to have a trusted caregiver with them at all times, will make the assessment easier. Allowing the child to remain on the caregiver's lap and enlisting that person's help in things like removing clothing and attaching monitors can help ease the child's fears.
  4. Elementary school age and older children can usually be relied on to present their own chief complaint. Some preschoolers may have the verbal skills necessary to do so, but many do not or are simply too shy or frightened. In these cases, the chief complaint and other pertinent information must be ascertained from the child's caregiver.
  5. When assessing school-aged children, speak with them and then include the caregiver. Explain procedures immediately before doing them. Do not negotiate.
  6. Don't mistake an adolescent's size for maturity. Physical assessment can proceed as for an adult, remembering that they may be as afraid as a smaller child and have many fears and misconceptions. Pain response may be exaggerated.
  7. The signs of severe illness may be subtle and easily overlooked in the neonate and young infant. For example, poor feeding, irritability, or hypothermia are all reasons to be concerned in an otherwise well appearing neonate. 8. Cardiac output in the infant and small child is heart-rate dependent - bradycardia can be as dangerous if not more dangerous than tachycardia.
  8. Infants, toddlers, and preschoolers have a relatively larger body surface area than their adult counterparts. This puts them at increased risk for both heat and fluid loss. This is compounded in the neonate, who does not have the fully developed ability to thermoregulate. These patients should not be kept undressed any longer than absolutely necessary and should have coverings replaced after a specific area is examined.
  9. Hypotension is a late marker of shock in prepubescent children. A hypotensive child is an ESI level 1, requiring immediate life-saving intervention.
  10. Weights should be obtained on all pediatric patients in triage or treatment area. The actual, not estimated, weight (in kilograms) is important to the safe care of a child. Methods for estimating a child's weight may be used for critically ill/injured children (e.g. length-based tape). Weights should not be guessed by the nurse, parent, or caregivers.
  11. A hands-on approach to pediatric assessment should accompany the use of technical equipment. As you obtain a child's vital signs, assess skin color, temperature, and turgor. As you auscultate the child's chest with a stethoscope, note the rate and quality of respirations, as well as chest and abdominal movements.
  12. Use appropriately sized equipment to measure children's vital signs.

Standardized Approach to Pediatric Triage Assessment

It is helpful to think about pediatric assessment in a standardized manner. A general approach to pediatric triage is suggested here:
  • Step 1. Appearance/work of breathing/circulation—quick assessment.
  • Step 2. Airway/breathing/circulation/disability/exposure-environmental control (ABCDE).
  • Step 3. Pertinent history.
  • Step 4. Vital signs.
  • Step 5. Fever?
  • Step 6. Pain?
These steps are described below.
Step 1. Appearance, Work of Breathing, Circulation—Quick Assessment. Most triage nurses are comfortable with an "Airway, Breathing, Circulation, and Disability" (ABCD) checklist approach to help determine if a child is "sick" or "not sick." In each of the standardized national pediatric emergency education courses, the ABCD approach is preceded by the Pediatric Assessment Triangle (PAT) (American Academy of Pediatrics, 2005). The PAT uses visual and auditory cues and is performed at the first contact with a pediatric patient. It can be completed in less than 60 seconds. The PAT is an assessment tool, not a diagnostic tool and assists the nurse with making quick life support decisions using appearance, work of breathing, and circulation to skin. A child's appearance can be assessed from across a room and includes tone, interactiveness, consolability, look/gaze, and speech/cry. A child's work of breathing is characterized by the nature of airway sounds, positioning, retractions, and flaring. Circulation to skin is assessed by observing for pallor, mottling, or cyanosis. By combining the three parameters of the PAT, the nurse can get a quick idea of the physiological stability of a child and, in conjunction with the chief complaint, make decisions regarding the need for life support. Some patients may need to be taken immediately to the treatment area to address abnormalities found in the quick assessment. For more stable patients, the nurse will proceed to the next step in the assessment, ABCDE.
Step 2. Airway, Breathing, Circulation, Disability, Exposure/Environmental Control (ABCDE). Following the urgency decision made with the PAT, a primary assessment using the ABCDE checklist can then be performed (Emergency Nurses Association, 2004). This assessment must be done in order and includes assessing for airway patency, respiratory rate and quality, heart rate, skin temperature and capillary refill time, blood pressure (where clinically appropriate, such as a child with cardiac or renal disease), and an assessment for disability or neurological status. A child's neurological status can be obtained by assessing appearance, level of consciousness, and pupillary reaction. Exposure involves undressing the patient to assess for injury or illness, and addressing any immediate environmental needs such as treating fever. Exposure and environmental control may happen at triage or in the treatment area, depending on the patient's condition and factors such as treatment room availability. Any serious finding in the ABCDE assessment indicates a need for immediate treatment and may require deferral of the next steps in the assessment.
Step 3. Pertinent History. Following performance of the initial assessment of a child at triage, a standardized history should be obtained (go to examples in Table 6-1). The history may be deferred to the primary nurse if the triage nurse identifies the need for any life-saving interventions or a high risk situation.
Which method is chosen is not nearly as important as using a consistent method to avoid missing important information.

Table 6-1. Pediatric History Mnemonics

CChief complaintSSigns/symptoms
MMedicationsPPast medical problems
PPast health historyLLast food or liquid
EEvents preceding problemEEvents leading to injury/illness
SSymptoms associated with problem
Step 4. Vital Signs. There is a lack of rigorous studies to support the various vital signs parameters that are included in the major pediatric emergency texts and courses such as Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Support (APLS), Pediatric Education for Prehospital Professionals (PEPP), and Emergency Nursing Pediatric Course (ENPC) (AAP, 2004AAP, 2005AHA 2006ENA, 2004Hohenhaus et al., 2008). The major courses and texts appear to represent consensus recommendations for normal vital signs parameters and include varying age groupings and parameters. Version 4 of the ESI includes parameters drawn from the literature (Wuerz et al., 2000).
The following are recommendations regarding the use of blood pressure and oxygen saturation measurements for ESI decisions (Keddington, 1998):
  • Blood pressure measurement is not a critical factor in assigning acuity, and its measurement should be left to the judgment of the triage nurse.
  • Oxygen saturation should be measured in infants and children with respiratory complaints or symptoms of respiratory distress.
Pulse oximetry values may be interpreted differently at high altitude; EDs in such settings may need to develop local protocols to address this (Gamponia et al., 1998).
It is essential that equipment used in pediatric physical assessment is the correct size. Observations have shown that nurses often use adult-sized equipment for children, which may result in errors in vital signs measurements (Hohenhaus, 2006).
Step 5. Fever. Unlike in adult patients, decisionmaking with the febrile child must take into account both the clinical picture and the child's age. Note D on the ESI version 4 addresses pediatric fever considerations. These considerations are based on published guidelines from emergency physicians (American College of Emergency Physicians, 2003). However, since those recommendations were published, the heptavalent conjugate pneumococcal vaccine has become a routine part of the infant immunization series. With this in mind, many physicians are changing their practice and not routinely ordering blood work (including cultures) on febrile children who do not appear toxic and have completed this immunization series. Thus the current Pediatric Fever Considerations in the ESI version 4 reflect the fact that the fever criteria continue to evolve. The guidelines for children with fever (100.4°F or 38°C or greater) who are in the first 28 days of life are clear--these patients must be rated ESI level 2 as they may have serious infections. The ESI guidelines recommend that triage nurses consider assigning ESI level 2 for infants 1-3 months of age with fever, while taking into consideration practices in their institution. Nurses may have to adjust their fever considerations according to those practices for 1- to 3-month-olds.
Other considerations include exposure to known significantly sick contacts (e.g., diagnosed with influenza, meningococcal meningitis) and immunization status. An immunization history should be ascertained at the time of triage. It may be helpful to post a copy of the Recommended Immunization Schedule for Persons Aged 0-6 Years (Centers for Disease Control and Prevention, 2010) at triage. Febrile children over the age of 2 who have not completed their primary immunization series should be considered higher risk than their immunized counterparts with similar clinical presentations. The triage nurse should consider making these patients at least an ESI level 3 if there is no obvious source of fever.
Step 6. Pain. Section B on the ESI version 4 defines severe pain/distress as determined either by clinical observation or a patient rating of ≥7 on a 0-10 pain scale. Pain assessment for children should be conducted using a validated pediatric pain scale. Pediatric patients who meet the ≥7 criterion should be considered for triage as an ESI level 2. The triage nurse is not required to assign these patients an ESI level 2 rating and should use sound clinical judgment in making the final decision. For example, a child who reports his pain as an 8/10 but is awake, alert, smiling, and in no apparent distress may not warrant triage as a level 2. Neither does the young child with a minor injury simply because they are screaming loudly. There are several validated pediatric pain scores. For example, the FLACC (Face, Legs, Activity, Consolability) score for infants and nonverbal children and the FACES score for those who are not able to understand the 0-10 scale are both validated, easy-to-use scoring systems (Bieri, Reeve, Champion, Addicoat, & Ziegler, 1990Keck, Gerkensmeyer, Joyce, & Schade, 1996Luffy & Grove, 2003Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997).
Each institution should decide for itself which pain scale(s) to use for pediatric patients. What is important is that a validated pediatric pain scale be available and used correctly and consistently by the triage nurse. This may require additional education in pain scales that is outside the scope of this handbook but should be part of an institution's inservice program.
Assessment of Rashes. Analysis of nurses' ratings of pediatric patients with the ESI has found that triage nurses both under- and over-triage rash patients (Travers et al., 2009). During this study, nurses gave feedback that it is sometimes hard to differentiate high-risk rashes (e.g., meningococcemia) from low-risk rashes (e.g., contact dermatitis). When triaging the patient with a rash, the nurse should obtain a thorough history and complete set of vital signs. Other associated symptoms should be ascertained and the overall appearance of the child should be taken into account. The child should be undressed if necessary to adequately visualize the rash. Rashes that should raise an immediate "red flag" and warrant an ESI level 2 include vesicular rashes in the neonate and petechial and purpuric rashes in children of any age. If a child has a petechial rash with altered mental status, they should be rated as ESI level 1; they are at risk of meningococcemia and may be in shock. They will likely need significant IV fluid resuscitation and antibiotics.
Infant Triage. For the purposes of ESI triage, an "infant" is defined as any child who has not yet reached his or her first birthday. This definition is consistent with the ACEP definitions, as well as the PALS guidelines regarding equipment size and cardiopulmonary resuscitation (CPR) standards (ACEP, 2003AHA, 2006).
Of all the patients who present to the emergency department, infants may be the most difficult for the triage nurse to evaluate. These patients' lack of verbal skills, and often subtle signs of serious illness can make an accurate assessment difficult. Parental concerns about signs and symptoms, even those not witnessed by the triage nurse, must be taken seriously. Whether the report is of a physical sign (e.g., fever) or an abnormal behavior (e.g., fussy/irritable), parents are the best judges of their infant, and if they are concerned, they often have a good reason to be.
When assessing an infant, the triage nurse must pay close attention to the history offered by the parents as this may be the only real clue to the problem. The infant's state should be assessed prior to handling. Vital signs must be assessed using appropriate-sized equipment and need to be part of the triage process of any infant who does not immediately fall into the ESI levels 1 or 2. Vital sign abnormalities may be the only outward signs of a serious illness. Infants must be unwrapped and undressed for a hands-on assessment of perfusion and respiratory effort, remembering that they can rapidly lose body heat in a cool environment and should be rewrapped as soon as possible.
Fever guidelines for infants are discussed above. Specific practices for the evaluation of febrile older infants may differ from institution to institution. However, it is universally accepted that neonates (<28 days of age) with a rectal temperature of 38C (100.4F) or greater are considered high risk for a serious bacterial infection and should be triaged accordingly (at least at an ESI level 2). In the clinical policy for children under age 3 with fever, the American College of Emergency Physicians rectally (ACEP, 2003). Infants with rectal temperatures of 38C or higher are likely to need a full sepsis workup including blood, urine, and cerebrospinal fluid cultures) and parenteral antibiotic administration.

Assigning ESI Levels for Pediatric Patients

ESI Level 1

ESI level-1 patients are the highest acuity patients that present to the ED. Because ESI level -1 patients are clinically unstable, decisions on resources needed during the ED stay are not considered. These patients require a physician and a nurse at the bedside to provide life-saving critical care interventions. They cannot wait, even a brief time, for initiation of treatment.

Research has found that the ESI level-1 rating is under-utilized by nurses triaging critically ill children, except for those children who are intubated or in cardiac arrest (Travers et al., 2009). In response to findings from an all-age study, the ESI was modified in version 4 to classify any patient in need of immediate, life-saving interventions as ESI level 1; formerly, these patients were often thought of as "sick level 2s" (Tanabe et al., 2005). Table 6-2 provides examples of ESI level-1 conditions. This is not an exhaustive list.

ESI Level 2

As with assigning an ESI level-1 acuity, assigning an ESI level-2 acuity is based on the clinical condition of the patient, and it is not necessary to consider resource utilization in the decision. ESI level-2 decisions are based on the history and assessment findings indicative of sentinel symptom complexes that signal a high-risk or potentially high-risk situation.Table 6-3 provides examples of patient problems that warrant ESI level-2 ratings. This is not an exhaustive list.

Resource Considerations When Using the ESI for Pediatrics

As with use of the ESI for adult patients, its use for children includes resource prediction as a way of differentiating the three lower acuity levels, ESI levels 3 4, and 5. It is sometimes a challenge to predict resource needs for pediatric patients. The triage nurse may find it especially challenging to differentiate pediatric patients predicted to need two resources (ESI level 3), versus one resource (ESI level 4) or no resource (ESI level 5). One reason for this is that some conditions require different numbers of resources in children than in adults. Research has shown that ESI level 5 is under-utilized for pediatric patients (Travers et al., 2009). These issues will be explored in this section.
Pediatric patients may occasionally warrant a different ESI level than an adult for a comparable problem. For example, adults with lacerations that necessitate suturing are typically classified as ESI level 4. However, some pediatric patients may require sedation for a laceration repair, particularly if they are below school age or appear to be especially agitated or uncooperative. Sedation includes the establishment of IV access, administration of IV medications, and close monitoring; thus, all sedation patients are classified as at least ESI level 3 based on their need for more than one resource. Table 6-4 lists examples of children who are candidates for sedation.

Table 6-4. Examples of Situations That May Warrant Sedation in Pediatric Patients

Fracture/dislocation repair in ED

Complicated lacerations, such as:

Complex facial/intraoral lacerations

Lacerations across the vermillion border

Lacerations requiring a multilayered closure

Extremely dirty or contaminated wounds

CT/MRI procedures or image-guided procedures (e.g., joint aspirations under bedside ultrasound, fluoroscopy)

Lumbar punctures (except in infants)

Chest tube insertions
It is important to remember that the ESI is not a nursing workload measure. Rather, resources are used in the ESI as a proxy for acuity. A child with a small abrasion (ESI level 5) who gets the wound cleansed and a tetanus shot is less acute than a patient with a sprained ankle (ESI level 4) who gets an x ray, ace wrap and crutch-walk instruction; and this patient is less acute than a child with a complex laceration (ESI level 3) who gets suturing and sedation. While the tetanus injection, ace wrap and crutch-walking instruction all require nursing time, they are not considered ESI resources. The purpose of the ESI resource assessment is to sort patients into 5 meaningful acuity categories, not to estimate the nursing workload intensity. EDs are encouraged to use appropriate workload measures to capture nursing resource needs.
Table 6-5 lists patients who need no resources and can be classified as ESI level

Table 6-5. Examples of ESI Level 5

Medication refills

Ear pain in healthy school-age children

Contusions and abrasions

URI symptoms with normal vital signs

2 year-old with runny nose, mild cough and temp of 38°C (100.4°F), active and drinking during triage

Poison ivy on extremities

Special Populations


Trauma patients can be challenging to triage, especially if they have suffered internal injuries without visible external signs of injury. Pediatric trauma patients may be difficult to assess due to compensatory mechanisms that produce vital signs with the appearance of stability. The nurse must be proactive when providing care to the pediatric trauma patient to prevent deterioration and rapid de-compensation. Children who suffer traumatic injuries must be assessed and assigned a triage level based on the mechanism of injury and presenting signs and symptoms, as opposed to basing the ESI rating on the practices of individual triage nurses or mode of arrival to the ED. For example, children should not be assigned an ESI level based on their arrival via Emergency Medical Services (EMS) or the use of back boards and c-collars. Any patient with a high risk mechanism of injury should be classified as ESI level 2, unless their condition requires immediate life-saving interventions that warrant classification as ESI level 1. Vital signs and estimation of resource needs are not needed for ESI level-1 or level-2 determinations. The American Academy of Pediatrics (AAP) has issued guidelines that may be useful in the triage of children with minor head injuries (AAP, 1999). Examples of pediatric trauma patients and ESI ratings are provided in Table 6-6.


Psychiatric emergencies among children present a unique challenge for the triage nurse, who will be required to make a complex clinical decision as to the degree of danger the patient may pose to themselves or others. Patients at high risk may exhibit a variety of symptoms including violent or combative behavior, paranoia, hallucinations, delusions, suicidal/homicidal ideation, acute psychosis, anxiety, and agitation and should be rated ESI level 2. The Mental Health Triage Scale can be used in the assessment of the pediatric psychiatric patient (Smart, Pollard, & Walpole, 1999). Any child presenting as confused, disorganized, disoriented, delusional, or hallucinating should be rated as an ESI level 2. These altered mental states may be attributed to the patient's mental health or medical or neurological complications (ENA, 2004). The amount of distress a child appears to be in, or has reportedly been in, can also classify them as an ESI level 2. The triage nurse should be alert for any behaviors that may indicate the patient is a high risk and needs treatment immediately. A patient's distress should not be limited to physical symptoms but may include situational triggers as well. Therefore, it is important to be aware of the circumstances underlying the current psychological event. In addition to establishing the reason for the exhibited behavior, it is important to capture the type, severity, frequency, and focus (is the behavior directed toward something or someone) of the behavior. In some cases, it may be beneficial to interview older children and adolescents alone. They may be more likely to offer information on sensitive subjects such as risky behaviors, abusive relationships, and drug or alcohol use without the presence of their parents.
Resources will determine whether the patient will fall into ESI level 3, level 4, or level 5. Resources will be somewhat different for the pediatric mental health patient than for the pediatric medical patient and are likely to include things such as psychiatric and social work consults. Table 6-7 provides examples of pediatric psychiatric patients.

Children with Co-Morbid Conditions

Research has found that children with co-morbid conditions are both over-triaged and under-triaged (Travers et al., 2009). Patients with chronic conditions (e.g., spina bifida, seizures, metabolic syndromes, short gut) may require more extensive evaluation and workup than otherwise healthy children with similar complaints. At the same time, children should not be automatically triaged at a higher level due to a co-morbid condition. A good history and input from the child's caregiver can help greatly in this determination. For example, the child with a known seizure disorder who presents with breakthrough seizures needs to be triaged at a higher level than the same child who presents for a medication refill. The febrile 10-year-old with a VP shunt is going to need more extensive evaluation than the otherwise healthy and non-toxic appearing 10-year-old with an isolated fever. However, a child with a sprained ankle likely does not need a higher acuity level simply because the child has a history of congenital heart disease.

Pediatric Patient Case Studies

In addition to this pediatric chapter of the ESI Handbook, several sets of pediatric case studies are available to support pediatric-specific ESI education in locally-developed ESI educational programs. One set was validated as part of a Health Resources and Services (HRSA)-funded ESI study (Katznelson et al., 2006) and is available from the HRSA Web site (HRSA, 2010). This set includes new cases and others adapted from the ESI Handbook (Gilboy et al., 2005). In addition to this set of pediatric-only case studies available through the HRSA Web site, many pediatric case studies are included in Chapter 9 (practice cases) and Chapter 10 (competency cases) of this handbook. There are also additional cases available in Gilboy, Tanabe and Travers (2005).


Assessing the pediatric patient can be a daunting task for both the novice and the experienced triage nurse. Remembering some key developmental differences between pediatric and adult patients can help make the process significantly less stressful for ill or injured children and their caregivers. Applying the ESI algorithm consistently on patients of all ages, while keeping in mind key anatomical and physiological differences in the pediatric population, can simplify the process for the triage nurse.
In order to most effectively triage pediatric patients, the triage nurse must be experienced in caring for the youngest patients. This chapter highlights important factors to keep in mind when triaging the pediatric patient, including the value of using a standardized approach to assessment such as PAT, keeping special populations in mind when determining which patients are high risk, and the importance of communication with the accompanying caregiver.
This chapter was made possible by a grant (# H34MC04371) through the Health Resources and Services Administration, Maternal Child and Health Bureau, Emergency Medical Services for Children (EMSC) Program. The grant supported the work on this chapter by the Pediatric ESI Research Consortium:
  • University of North Carolina at Chapel Hill (Chapel Hill, NC): Anna Waller (principal investigator) Debbie Travers, Jessica Katznelson.
  • Wellspan Health System (York, PA): David Eitel, Suanne McNiff.
  • Primary Children's Medical Center (Salt Lake City, UT): Nancy Mecham.
  • Lehigh Valley Health Network (Allentown, PA): Alexander Rosenau, Valerie Rupp.
  • WakeMed Health and Hospitals (Raleigh, NC): Douglas Trocinsk.
  • Hohenhaus and Associates, Inc (Wellsboro, PA): Susan McDaniel Hohenhaus.

Note: Appendix A of this handbook includes frequently asked questions and post-test assessment questions for Chapters 2 through 8. These sections can be incorporated into a locally-developed ESI training course.


American Academy of Pediatrics (1999). The management of minor closed head injury in children. Pediatrics104(6):1407-1415.
American Academy of Pediatrics (2004). APLS: The Pediatric Emergency Medicine Resource (4th ed.). Boston: Jones and Bartlett.
American Academy of Pediatrics (2005). Pediatric Education for Prehospital Professionals (2nd ed.). Sudbury, MA: Jones and Bartlett.
American College of Emergency Physicians Clinical Policies Committee (2003). Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 42(4):530-545.
American Heart Association (2006). Pediatric Advanced Life Support ProviderManual. Dallas, TX: American Heart Association.
Baumann MR, Strout TD (2005). Evaluation of the Emergency Severity Index (Version 3) triage algorithm in pediatric patients. Acad Emerg Med 12(3):219-224.
Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB (1990). The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for the ratio scale properties. Pain 41(2):139-150.
Centers for Disease Control and Prevention (2010). Recommended immunization schedule for persons aged 0-18.MMWR Weekly 58(51&52):1-4.
Emergency Nurses Association (2004). Emergency Nurse Pediatric Course. Des Plaines, IL: Emergency Nurses Association.
Gamponia MJ, Babaali H, Gilman RH (1998). Reference values for pulse oximetry at high altitude. Arch Dis Child 78:461-465.
Gilboy N, Tanabe P, Travers D (2005). The Emergency Severity Index Version 4: Changes to ESI level 1 and pediatric fever criteria. JEN 31(4):357-362.
Hinrichs J, Dever E, Wojner-Alexandrov A (2005). Emergency severity index intra- and inter-rater reliability in an infant sample: A pilot quality study. JEN 31(5):427.
Hohenhaus SM (2006). Someone watching over me: Observations in pediatric triage. JEN 32(5):398-403.
Hohenhaus SM, Travers D, Mecham N (2008). Pediatric triage: a review of emergency education literature. JEN34(4):308-313.
Katznelson J, Hohenhaus S, Travers D, Agans R, Trcinski D, Waller A (2006). Creation of a validated set of pediatric case scenarios for the Emergency Severity Index triage system [Abstract]. Acad Emerg Med 13(5S):S169.
Keck J, Gerkensmeyer J, Joyce B, Schade J (1996). Reliability and validity of the FACES and Word Descriptor scales to measure pain in verbal children. Journal of Pediatric Nursing 11(6):368-374.
Keddington R (1998). A triage vital sign policy for a children's hospital emergency department. JEN 24(2), 189-192.
Luffy R, Grove SK (2003). Examining the validity, reliability and preference of three pediatric pain measurement tools in African-American children. Pediatric Nursing 29(1):54-59.
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing 23(3): 293-297.
Middleton DR, Burt CW (2006). Availability of pediatric services and equipment in emergency departments: United States, 2002-2003. Advance Data 367:1-16.
Rosenau A, Waller A, Trcinski D, Travers D, Mecham N, Katznelson J, Eitel D. (2006). Is the Emergency Severity Index reliable for pediatric triage? [Abstract]. Ann Emerg Med 48(4S):62-63.
Smart D, Pollard C, Walpole B (1999). Mental health triage in emergency medicine. Australian New Zealand Journal of Psychiatry 33(1), 57-66; discussion 67-9.
Tanabe P, Travers D, Gilboy N, Rosenau A, Sierzega G, Rupp V, Adams JG (2005). Refining Emergency Severity Index triage criteria. Acad Emerg Med 12(6):497-501.
Travers D, Agans R, Eitel D, Mecham N, Rosenau A, Tanabe P. Waller A (2006). Reliability evaluation of the Emergency Severity Index Version 4 [Abstract]. Acad Emerg Med 13(5S):S126.
Travers D, Waller A, Katznelson J, Agans R (2009). Reliability and validity of the Emergency Severity Index for pediatric triage. Acad Emerg Med 16(9):843-849.
Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N (2000). Reliability and validity of a new five-level triage instrument.Acad Emerg Med 7(3):236-242.
Wuerz R, Travers D, Gilboy N, Eitel DR, Rosenau A, Yazhari R (2001). Implementation and refinement of the emergency severity index. Acad Emerg Med 8(2):170-176.
Page last reviewed October 2014
Internet Citation: Chapter 6. Use of the ESI for Pediatric Triage. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.

No hay comentarios: