CONDUCTING TRIAGE RESEARCH:LESSONS LEARNED IN A PEDIATRIC

EMERGENCY DEPARTMENT

Author: Elizabeth Griffin, RN, CPEN, BS, Raleigh, NCSection Editor: Susan McDaniel Hohenhaus, MA, RN, FAEN

Little has been written about how emergency depart-ment (ED) triage nurses make their decisions. In theUnited States, most hospitals use a three-, four-, or

five-level triage system for acuity assignment. Both theEmergency Nurses Association (ENA) and the AmericanCollege of Emergency Physicians (ACEP) support the useof a valid, five-level triage scale such as the EmergencySeverity Index (ESI), which is what WakeMed Health &Hospitals uses to assign patient acuity.1 The written refer-ence for the ESI system offers general guidelines for patientassessment and acuity assignment. ENA’s EmergencyNurse Pediatric Curriculum (ENPC) includes a chapterdedicated specifically to pediatric triage.2 There are severaltexts that offer guidance as well.3 However, the reality isthat an experienced triage nurse relies largely upon her“gut instinct” or “sixth sense” to determine who is sick ver-sus not sick in many situations.4

Background

The experienced triage nurse must be able to use a com-bination of prior experience, education, and gut instinctto identify high-risk situations. High-risk situations arenot always obvious. The assessment of pediatric headinjuries can be especially challenging even to an experi-enced triage nurse because signs and symptoms of headinjuries in children do not correlate well with the riskof intracranial injuries.5

Approximately 1,500 children per year present to mypediatric ED with head trauma, usually as a result of a fall.Early in my triage career, I realized how challenging thesepatients were to assess and triage. I have seen smilinginfants with skull fractures, and confused, stumbling teen-agers with no detectable injury on computerized tomogra-phy (CT) scan. On the flip side, I have also taken care ofseveral pediatric trauma patients with no detectable headinjury on CT scan but who, because of their age and devel-opmental level, responded to the stress of trauma by shut-ting down and becoming temporarily “unresponsive,”convincing both prehospital providers and some medicalstaff that they had positive loss of consciousness (LOC)and/or altered mental status.

Despite my seven years of experience as a pediatrictriage nurse, I still feel uneasy when I have to triage aninfant who has rolled off a changing table, a toddler whohas dove head first from a shopping cart, or a teenager whohas been hit by a line drive in a baseball game. When ourpediatric ED waiting room is full, I feel the additional pres-sure, knowing that my triage decision is even more criticalbecause anyone I deem nonurgent may wait hours to beseen by a physician. At present, no nursing triage tool existsto aid the triage nurse in assessing and assigning acuity tothe head-injured child.

Searching for Answers

My education and experience have shown me that infantsand children do not react to head injuries in the sameway as adults. History of LOC, degree of vomiting,amnesia and/or headache can be difficult to assess inthe pediatric patient. So what matters when triaging apediatric head-injured patient? I recently attended thepediatric special interest group (SIG) at the 2010 ENAAnnual Conference where we briefly discussed the triageof the head-injured child. Several nurses confirmed thatthey relied largely upon their gut feeling when assigningacuity to these patients. Other nurses, especially in smalleror mixed age EDs, felt uncomfortable triaging head-injured children, so they let almost every head-injured

Elizabeth Griffin is Staff Nurse III in the Children’s Emergency Department,WakeMed Health & Hospitals, Raleigh, NC.

For correspondence, write: Elizabeth Griffin, RN, CPEN, BS, c/o Children’sEmergency Department, WakeMed Health & Hospitals, 3000 New BernAve., Raleigh, NC, 27610; E-mail: elgriffin@wakemed.org.

J Emerg Nurs 2011;37:258-60.

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child bypass triage. One participant (from a mixed-ageED) commented, “we just bring them all back [to see aphysician] right away.”

Two years ago I decided to try to answer my own clin-ical question. After conducting an extensive literaturereview and receiving IRB approval, I embarked on anintensive retrospective chart review of our pediatric EDpatients who were diagnosed with a skull fracture and/orintracranial injury (ICI). I wanted to study not only thepresenting signs and symptoms, but also the mechanismof injury, location of injury, and age of the child to tryto find common high-risk clinical variables. My plan wasto combine the results of the literature review with thechart review to give me and my colleagues solid, evi-dence-based information on which to base our triage deci-sions of head-injured children.

Lessons Learned

The literature review brought more challenges. Most ofthe articles I found were dedicated specifically to physicianassessment and the decision as to whether to CT a child.Additionally, most articles addressed only a specific agegroup: infants, children, or sometimes older childrenand adults. Few addressed the entire patient populationI was trying to study: newborn through age 17. Addingto my frustration was that the studies varied in their ter-minology (ICI, TBI, ciTBI, head injury, minor headinjury) and inclusion criteria (head injury on CT, signifi-cant head injury on CT, trauma patient versus walk-inpatient, hospital admission for concerning symptoms,medical or neurosurgical intervention, death). The studiesalso varied in their results.6-13 Fortunately, an article pub-lished by Kupperman, et al.14 in 2010 described the firstlarge, multicenter study of pediatric head trauma in chil-dren through age 17, the same patient population as inmy pediatric ED. This study by the Pediatric EmergencyCare Applied Research Network (PECARN) and the stu-dies of head-injured infants by Greenes et al.10,11 Schutz-man et al.,12 and Bin et al.13 served as the major resourcesin my literature review.

Falls and Head Injuries: Differences between Children

and Adults

One area of particular interest for me is children who sus-tain significant injuries when falling from lower heightsthan adults. Guidelines for Field Triage of InjuredPatients has set pediatric trauma designations as any fallfrom more than 10 feet or two to three times the heightof the child.15 However, in walk-in head-injury patients,the report of the height of a fall is a rough estimate at

best. Falls out of shopping carts and infants who weredropped from a caregiver’s arms are common mechanismsof injury and have been known to result in skull fractureand/or ICI in the patients studied.

LOC, which is commonly considered a high-risk fac-tor of head injury at any age, was not commonly reported.Vomiting after head injury was difficult to assess in infantswith a history of spitting up at baseline, and parental per-ception of frequency/episodes of vomiting was not consis-tent. Excess sleepiness or “not acting themselves” perparent report was another symptom that was reported,and most alarming was that in some children with skullfracture and/or ICI, the only sign/symptom visible to theparent, triage nurse, or physician was a hematoma.

What Does This Mean for Emergency Nurses?

Children are injured in different ways, and they react dif-ferently to the injuries they sustain. In the ED setting, theemergency nurse is the first encounter for most of thesepatients. The emergency nurse must be skilled at detectingsubtle as well as easily identifiable injuries or illnesses andtriage accordingly. Nurses who assess and triage head-injured children should base their acuity decisions on acombination of factors including the age of the child, themechanism of injury, estimated height of the fall (if applic-able), location of injury, caregiver report/opinion of thechild’s mental status, and the signs and symptoms presentwhen they arrive for care.

Acknowledgment

A special thanks to Tiffany Young, RN, BSN, former WakeMed CED nur-sing supervisor/educator, for being my enthusiastic brainstorming partner;Betty Woodard, RN, PhD, WakeMed Director of Nursing Research and Evi-dence-Based Practice, for teaching me how to answer my own clinical ques-tions through bedside nursing research; and Laurie Cook, RN, CEN,WakeMed CED Nurse Manager, for always offering her unconditional sup-port of my interests and efforts.

REFERENCES1. Emergency Nurses Association. Standardized ED triage scale and acuity

categorization: joint ENA/ACEP statement. Available at: http://www.ena.org/SiteCollectionDocuments/Position%20Statements/STANDAR-DIZEDEDTRIAGESCALEANDACUITYCATEGORIZATION.pdf.Accessed January 25, 2011.

2. Emergency Nurses Association. Emergency nurse pediatric course(ENPC). Des Plaines (Ill): The Association; 2004.

3. Hohenhaus SM, Travers DA, Mecham N. Pediatric triage: a review ofemergency education literature. J Emerg Nurs. 2008;34:308-13.

4. Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR. EmergencySeverity Index, Version 4: Implementation handbook. AHRQ Publica-tion No 05-0046-2. Rockville (MD): Agency for Healthcare Researchand Quality; 2005.

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5. Grant V. Head trauma. In: Baren J, Rothrock S, Brennan J, Brown L,eds. Pediatric Emergency Medicine. Philadelphia: Saunders Elsevier;2008. p. 164-8.

6. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifyingchildren at low risk for brain injuries after blunt head trauma. AnnEmerg Med. 2003;42:493-506.

7. Haydel MJ, Shembekar AD. Prediction of intracranial injury in chil-dren aged five years and older with loss of consciousness after minorhead injury due to nontrivial mechanisms. Ann Emerg Med. 2003;42:507-14.

8. Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-JonesK. Derivation of the children’s head injury algorithm for the predic-tion of important clinical events decision rule for head injury in chil-dren. Arch Dis Child. 2006;91:885-91.

9. Oman JA, Cooper RJ, Holmes JF, et al. Performance of a decisionrule to predict need for computed tomography among children withblunt head trauma. Pediatrics. 2006;117:e238-46.

10. Greenes DS, Schutzman SA. Clinical indicators of intracranial injury inhead-injured infants. Pediatrics. 1999;104:861-7.

11. Greenes DS, Schutzman SA. Clinical significance of scalp abnormalities inasymptomatic head-injured infants. Pediatr Emerg Care. 2001;17:88-92.

12. Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and manage-ment of children younger than two years old with apparently minor headtrauma: proposed guidelines. Pediatrics. 2001;107:983-93.

13. Bin SS, Schutzman SA, Greenes DS. Validation of a clinical score to predictskull fracture in head-injured infants. Pediatr Emerg Care. 2010;26:633-9.

14. Kupperman N, Holmes JF, Dayan PS, et al. Identification of children atvery low risk of clinically-important brain injuries after head trauma: aprospective cohort study. Lancet. 2009;374:1160-70.

15. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage ofinjured patients. Recommendations of the National Expert Panel onField Triage. MMWR. 2009;58(RR-1):1-35.

Submissions to this column are encouraged and may be sent toSusan McDaniel Hohenhaus, MA, RN, FAENSHohenhaus@ena.org

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