Sistemas de triagem em emergência pediátrica

Artigos publicados entre 1999 e 2019, obtidos por meio de busca nos bancos de dados Medical Literature Analysis and Retrieval System Online (Medline), Embase e PubMed usando as palavras-chave “pediatric triage”, “pediatric assessment tools” e “emergency department triage”, com ênfase em estudos que avaliaram a validação e a confiabilidade desses sistemas.

Síntese dos dados:

Foram avaliados 105 artigos sobre sistemas de triagem na emergência pediátrica de 12 países. Os sistemas de triagem foram divididos em dois grupos: estratificados por cores e de alerta. Os sistemas de triagem com estratificação por cores incluídos nesta revisão foram: Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), Emergency Severity Index (ESI) e Australian Triage Scale (ATS). Os sistemas de alerta incluídos foram: Paediatric Observation Priority Score (POPS), Pediatric Early Warning Score (PEWS) e Pediatric Approach Triangle (PAT). Há evidências que corroboram a validade e a confiabilidade do MTS, PedCTAS, ESI v.4, PEWS, POPS e PAT em serviços de emergência de pediátricos.

Conclusões:

Os sistemas de triagem são ferramentas fundamentais para o atendimento de pacientes que procuram serviços de emergência. Nem todos os sistemas de triagem foram avaliados para validação e confiabilidade nem se aplicam a todas as regiões do mundo. Para a aplicação de sistemas de triagem no Brasil, devem ser feitos adaptação cultural e treinamento do estafe de saúde local, bem como estudos de validação e confiabilidade em nosso país, dado o seu contexto social e cultural diferente daquele dos países onde essas ferramentas foram desenvolvidas.

Palavras-chave:
Triagem; Medicina de emergência; Validação; Confiabilidade

Author and year	Objective	Population	Study type	Conclusions
Gouin et al.⁶6. Gouin S, Gravel J, Amre DK, Bergeron S. Evaluation of the Paediatric Canadian Triage and Acuity Scale in a pediatric ED. Am J Emerg Med. 2005;23:243-7. https://doi.org/10.1016/j.ajem.2004.02.046 https://doi.org/10.1016/j.ajem.2004.02.0... 2005	Performance comparison between PaedCTAS and PRISA.	1281	Prospective	More patients were classified as high severity with PaedCTAS with a high level of acuity but with less ability to predict admissions. The ability to predict interventions was similar in both.
Gravel et al.²¹21. Gravel J, Fitzpatrick E, Gouin S, Millar K, Curtis S, Joubert G, et al. Performance of the Canadian Triage and Acuity Scale for children: a multicenter database study. Ann Emerg Med. 2013;61:27-32. https://doi.org/10.1016/j.annemergmed.2012.05.024 https://doi.org/10.1016/j.annemergmed.20... 2013	Association between triage levels of CTAS and surrogate markers validity for real-life children triaged in ED.	550,940	Retrospective cohort	There was a strong association between triage level and multiple markers of severity that suggests validity of CTAS for children.
Gravel et al.⁵⁰50. Gravel J, Gouin S, Bailey B, Roy M. Reliability of a computerized version of the pediatric Canadian triage and acuity scale. Acad Emerg Med. 2007;14:864-9. https://doi.org/10.1197/j.aem.2007.06.018 https://doi.org/10.1197/j.aem.2007.06.01... 2007	Evaluation of inter-evaluator agreement.	29 nurses	Experimental in two phases	The computerized version showed statistically significant improvements in agreement between nurses.
Bergeron et al.²²22. Bergeron S, Gouin S, Bailey B, Amre DK, Patel H. Agreement among pediatric health care professionals with pediatric Canadian Triage and Acuity Scale. Pediatr Emerg Care. 2004;20:514-8. https://doi.org/10.1097/01.pec.0000136067.07081.ae https://doi.org/10.1097/01.pec.000013606... 2004	Assessment of inter-evaluator agreement, between nurses and emergency pediatricians.	29 nurses 15 pediatricians	Cross-sectional	The study sent 55 scenarios to physicians and nurses. The level of agreement and accuracy was moderate between physicians and nurses and did not vary according to each group’s experience and occupation.
Ma et al.²³23. Ma W, Gafni A, Goldman R. Correlation of the Canadian Pediatric Emergency Triage and Acuity Scale to ED resource utilization. Am J Emerg Med. 2008;26:893-7. https://doi.org/10.1016/j.ajem.2008.02.024 https://doi.org/10.1016/j.ajem.2008.02.0... 2008	Assessment of the correlation between PaedCTAS levels and the use of resources.	1618	Prospective	PaedCTAS levels correlated well with the use of resources by pediatric ED patients.
Gravel et al.²⁴24. Gravel J, Gouin S, Goldman R, Osmond MH, Fitzpatrick E, Boutis K, et al. The Canadian Triage and Acuity Scale for Children: a prospective multicenter evaluation. Ann Emerg Med. 2012;60:17-7. https://doi.org/10.1016/j.annemergmed.2011.12.004 https://doi.org/10.1016/j.annemergmed.20... 2012	Assessment of inter-evaluator agreement and validation of the triage level and severity markers.	1464	Prospective	The study found good agreement between nurses in a pediatric ED and good association with severity markers.

Author and year	Objective	Population	Study type	Conclusions
Roukema et al.²⁸28. Rokeuma J, Steyeberg EW, Meurs AV, Ruige M, Lei J, Moll HA. Validity of the Manchester Triage System in paediatric emergency care. Emerg Med J. 2006;23:906-10. https://doi.org/10.1136/emj.2006.038877 https://doi.org/10.1136/emj.2006.038877... 2006	Validation in a pediatric ED	1065	Prospective	The MTS showed moderate validity in pediatric ED.
Van Veen et al.²⁷27. van Veen M, Steyerberg EW, Ruige M, Meurs AH, Roukema J, Lei J, et al. Manchester Triage System in paediatric emergency care: prospective observational study. BMJ. 2008;337:a1501. https://doi.org/10.1136/bmj.a1501 https://doi.org/10.1136/bmj.a1501... 2008	Validation in a pediatric ED	13,554	Observational, prospective	The MTS showed moderate validity in pediatric ED. Triage was more difficult for younger patients and those with medical problems.
Van der Vulp et al.⁵¹51. Wulp I, Baar ME, Schrijvers AJ. Reliability and validity of the Manchester triage system in a general emergency department patient population in the Netherlands: results of a simulation study. Emerg Med J. 2008;25:431-4. https://doi.org/10.1136/emj.2007.055228 https://doi.org/10.1136/emj.2007.055228... 2008	Validation and assessment of reliability of triage systems	50 scenarios	Prospective	Assessment of emergency scenarios and reassessment 19 days later. Moderate and substantial inter-evaluator reliability and high test/retest reliability were observed.
Van Veen and Moll¹1. van Veen M, Moll HA. Reliability and validity of triage systems in paediatric emergency care. Scand J Trauma Resusc Emerg Med. 2009;17:38. https://doi.org/10.1186/1757-7241-17-38 https://doi.org/10.1186/1757-7241-17-38... 2009	Validation and assessment of reliability of triage systems.		Literature review	The MTS was a valid pediatric emergency triage system with good reliability.
Van Veen et al.⁵²52. van Veen M, Walle VF, Steyerberg EW, Meurs AH, Ruige M, Strout TD, et al. Repeatability of the Manchester Triage System for children. Emerg Med J. 2010;27:512-6. https://doi.org/10.1136/emj.2009.077750 https://doi.org/10.1136/emj.2009.077750... 2010	Assessment of the repeatability of the MTS in children	20 scenarios	Prospective	The MTS showed good to very good repeatability in pediatric ED.
Mirhaghi et al.²⁹29. Mirhaghi A, Mazlom R, Heydari A, Ebrahimi M. The reliability of the Manchester Triage System (MTS): a meta-analysis. J Evid Based Med. 2017;10:129-35. https://doi.org/10.1111/jebm.12231 https://doi.org/10.1111/jebm.12231... 2017	Assessment of the reliability of the MTS.		Meta-analysis	The MTS showed an acceptable level of overall reliability in a pediatric ED.
Magalhães-Barbosa et al.¹⁵15. Magalhães-Barbosa MC, Robaina JR, Prata-Barbosa A, Lopes CS. Reliability of triage systems for paediatric emergency care: a systematic review. Emerg Med J. 2019;36:231-8. https://doi.org/10.1136/emermed-2018-207781 https://doi.org/10.1136/emermed-2018-207... 2019	Assessment of the reliability of pediatric emergency triage systems		Systematic review	There was some evidence of MTS reliability, but most studies were limited to the countries where the scale was developed.

Author and year	Objective	Population	Study type	Conclusions
Tanabe et al.⁵⁴54. Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams JG. Reliability and validity of scores in Emergency Severity Index version 3. Acad Emerg Med 2004;11:59-65. https://doi.org/10.1197/j.aem.2003.06 https://doi.org/10.1197/j.aem.2003.06... 2004	Evaluate ESI v.3 reliability and validation in ED.	403	Retrospective	Excellent level of reliability and correlation with resource utilization and length of stay in the ED.
Baumann et al.⁵³53. Bauman MR, Strout TD. Evaluation of Emergency Severity Index (version 3) triage algorithm in pediatric patients. Acad Emerg Med. 2005;12:219-24. https://doi.org/10.1197/j.aem.2004.09.023 https://doi.org/10.1197/j.aem.2004.09.02... 2005	Assessment of ESI v.3 reliability and validity in children.	510 (at the validation stage)	Study in two phases: 1. Retrospective 2. Observational prospective	Excellent level of agreement between evaluators. Demonstrated validity in the task of triage and resource utilization.
Van Veen and Moll¹1. van Veen M, Moll HA. Reliability and validity of triage systems in paediatric emergency care. Scand J Trauma Resusc Emerg Med. 2009;17:38. https://doi.org/10.1186/1757-7241-17-38 https://doi.org/10.1186/1757-7241-17-38... 2009	Validation and reliability of the ESI v.3 triage system.		Literature review	ESI v.3 was a valid pediatric emergency triage system with good reliability.
Durani et al.³⁰30. Durani Y, Brecher D, Walmsley D, Attia MW, Loiselle JM. The Emergency Severity Index version 4. Reliability in pediatric patients. Pediatr Emerg Care. 2009;25:751-3. https://doi.org/10.1097/PEC.0b013e3181b0a0c6 https://doi.org/10.1097/PEC.0b013e3181b0... 2009	To measure ESI v.4 reliability and agreement between evaluators and between physicians and nurses.	20 scenarios	Prospective	The ESI v.4 showed high reliability and agreement (83%) between emergency personnel and nurses.
Travers et al.³¹31. Travers DA, Walker AE, Katznelson J, Agans R. Reliability and validity of the Emergency Severity Index for pediatric triage. Acad Emerg Med. 2009;16:843-9. https://doi.org/10.1111/j.1553-2712.2009.00494.x https://doi.org/10.1111/j.1553-2712.2009... 2009	Evaluation of reliability of ESI v.4 and its validation in pediatric EDs for all age groups.	40 scenarios 1671 patients	Prospective	Moderate reliability. The study identified scenarios in which nurses had difficulty in performing triage consistently.
Green et al.³²32. Green NA, Durani Y, Brecher D, DePiero A, Loiselle J, Attia M. Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage. Pediatr Emerg Care. 2012;28:753-7. https://doi.org/10.1097/PEC.0b013e3182621813 https://doi.org/10.1097/PEC.0b013e318262... 2012	Assessment of ESI v.4 reliability and validation in pediatric ED.	780	Study in two phases: 1. Retrospective 2. Prospective cohort	High agreement between nurses and physicians. ESI v.4 predicted hospital admission, length of stay, and use of resources in pediatric ED.
Jafari-Rouhi et al.³³33. Jafari-Rouhi AH, Sardashti S, Taghizadieh A, Soleimanpour H, Barzegar M. The Emergency Severity Index, version 4, for pediatric triage: a reliability study in Tabriz Children Hospital, Tabriz, Iran. Int J Emerg Med. 2013;6:36-40. https://doi.org/10.1186/1865-1380-6-36 https://doi.org/10.1186/1865-1380-6-36... 2013	Assessment of ESI v.4 reliability and validation in pediatric ED.	20 scenarios 1104 patients	Study in two phases: 1. Retrospective 2. Prospective cohort	There was agreement between nurses and physicians and reliability when performed by experienced professionals.
Magalhães-Barbosa et al.¹⁵15. Magalhães-Barbosa MC, Robaina JR, Prata-Barbosa A, Lopes CS. Reliability of triage systems for paediatric emergency care: a systematic review. Emerg Med J. 2019;36:231-8. https://doi.org/10.1136/emermed-2018-207781 https://doi.org/10.1136/emermed-2018-207... 2019	Assessment of the reliability of pediatric ED triage systems		Systematic review	There is some evidence supporting the reliability of ESI v.4, but most studies were limited to the countries where the scales were developed.

Author, year, and scale	Objective	Population	Study type	Conclusions
Roland et al.³⁷37. Roland DT, Lewis G, Fielding P, Hakim C, Watts A, Davies F. The Pediatric Observational Priority Score: a system to aid detection of serious illness and assist in safe discharge. Open J Emerg Med. 2016;4:38-44. https://doi.org/10.4236/ojem.2016.42006 https://doi.org/10.4236/ojem.2016.42006... 2016 – POPS	Validation of the POPS as a triage tool.	936	Observational prospective	The POPS demonstrated an ability to help healthcare professionals make decisions.
Cotterill et al.³⁸38. Cotterill S, Rowland AG, Kelly J, Lees H, Kamara M. Diagnostic accuracy of PAT-POPS and ManChEWS for admissions of children from the emergency department. Emerg Med J. 2016;33:756-62. https://doi.org/10.1136/emermed-2015-204647 https://doi.org/10.1136/emermed-2015-204... 2016 – POPS	Investigation of the ManchEWS and POPS ability to predict hospital admission.	2068	Prospective cohort	The POPS was a more accurate predictor of risk for hospital admission in EDs than the ManchEWS. The POPS appeared to be clinically appropriate for use in pediatric ED.
Roland et al.³⁹39. Roland D, Arshad F, Coats T, Davies F. Baseline characteristics of the Pediatric Observation Priority Score in emergency departments outside its centre of derivation. BioMed Res Int. 2017;9060852:1-5. https://doi.org/10.1155/2017/9060852 https://doi.org/10.1155/2017/9060852... 2017 – POPS	To examine the utility of the POPS in a pediatric ED and determine its performance.	3323	Prospective cohort	It is feasible to implement the POPS in EDs; it had performance characteristics similar to those of the original development site.
Riaz et al.⁴⁰40. Riaz S, Rowland A, Woby S, Long T, Livesley J, Cotterill S, et al. Refining and testing the diagnostic accuracy of an assessment tool (PAT-POPS) to predict admission and discharge of children and young people who attend an emergency department: protocol for an observational study. BMC Pediatr. 2018;18:303. https://doi.org/10.1186/s12887-018-1268-7 https://doi.org/10.1186/s12887-018-1268-... 2018 – POPS	To refine and test the diagnostic accuracy of the PAT-POPS in predicting admission and discharge of children in ED.	16,000 Minimum estimated sample	Observational retrospective	This predictive tool can help in hospitalization and discharge decisions for children and youth in ED.
Bradman et al.⁴²42. Bradman K, Maconochie I. Can paediatric early warning score be used as a triage tool in paediatric accident and emergency? Eur J Emerg Med. 2008;15:359-60. https://doi.org/10.1097/MEJ.0b013e3283026208 https://doi.org/10.1097/MEJ.0b013e328302... 2008 – PEWS	To determine whether the PEWS can identify children requiring hospitalization during triage	424	Observational prospective	The PEWS showed low sensitivity in predicting the need for hospitalization
Seiger et al.⁴³43. Seiger N, Maconochie I, Oostenbrink R, Moll HA. Validity of different pediatric early warning scores in the emergency department. Pediatrics. 2013;132:e841-50. https://doi.org/10.1542/peds.2012-3594 https://doi.org/10.1542/peds.2012-3594... 2013 – PEWS	To compare PEWS performance in EDs to predict hospital or ICU stays	17,943	Prospective cohort	The discriminatory ability of the PEWS was moderate to good for predicting ICU admission and poor to moderate for predicting hospital admission.
Gold et al.⁴⁴44. Gold DL, Mihalov LK, Cohen DM. Evaluating the Pediatric Early Warning Score (PEWS) system for admitted patients in the pediatric emergency department. Acad Emerg Med. 2014;21:1249-56. https://doi.org/10.1111/acem.12514 https://doi.org/10.1111/acem.12514... 2014 – PEWS	To determine whether the PEWS predicts the need for ICU admission	12,306	Observational prospective	High scores were associated with the need for ICU admission. The study did not demonstrate that the PEWS could determine hospital discharge or predict deterioration.
Horeczko et al.⁴⁶46. Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. J Emerg Nurs. 2013;39:182-9. https://doi.org/10.1016/j.jen.2011.12.020 https://doi.org/10.1016/j.jen.2011.12.02... 2013 – PAT	To determine the reliability and accuracy of the PAT as applied by nurses.	528	Observational prospective	The PAT quickly and reliably identified acute pediatric patients and their pathophysiological conditions.
Fernandez et al.⁴⁷47. Fernández A, Ares MI, Garcia S, Martinez-Indart L, Mintegi S, Benito J. The validity of the Pediatric Assessment Triangle as the first step in the triage process in a pediatric emergency department. Pediatr Emerg Care. 2017;33:234-8. https://doi.org/10.1097/PEC.0000000000000717 https://doi.org/10.1097/PEC.000000000000... 2017 – PAT	To evaluate the association between PAT findings in triage and severity markers of patients in pediatric ED.	302,103	Retrospective cohort	PAT findings were an independent risk factor for hospital admission, ICU admission, and length of ED stay. It is a valid tool to identify more severe patients as a first step in the triage process.
Paniagua et al.⁴⁸48. Paniagua N, Elosegi A, Duo I, Fernandez A, Mojica E, Martinez-Indart L, et al. Initial asthma severity assessment tools as predictors of hospitalization. J Emerg Med. 2017;53:10-7. https://doi.org/10.1016/j.jemermed.2017.03.021 https://doi.org/10.1016/j.jemermed.2017.... 2017 – PAT	To assess the performance of the PAT in predicting hospitalization, ICU admission, and length of stay at the ED in children with asthma exacerbation.	14,953	Retrospective cohort	PAT is a good predictor of hospital admission. Abnormality in PAT is an independent risk factor for hospital admission and length of stay.

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[1] *Corresponding author. E-mail: hanyjr@uol.com.br (H. Simon Junior).