Triage of the Pediatric Patient in the Emergency Department:
Are We All in Agreement?
Theresa Maldonado, MD, and Jeffrey R. Avner, MD
ABSTRACT. Objective. To compare triage categorization
as a measure of perceived patient acuity on presentation
to the emergency department by pediatric emergency
medicine (PEM) attending physicians, nurses, and
pediatric residents with their general emergency medicine
(GEM) counterparts.
Methods. A questionnaire that contained 12 pediatric
triage scenarios was sent to all PEM attending physicians,
triage-trained nurses, and pediatric residents and
their GEM counterparts at a large urban hospital with
separate pediatric and general emergency departments.
Participants were asked to use a 3-tier triage system
(emergent, urgent, nonurgent) to assign a triage level for
each patient scenario.
Results. The response rate was 99%. The ␬ level of
agreement was highest (.39) among the PEM physicians.
Significantly more GEM attending physicians triaged the
following scenarios at a higher acuity level as compared
with PEM attending physicians with a trend toward
emergent triage: simple febrile seizure, 50% (95% confidence
interval [CI]: 30%–70%) versus 7.7% (95% CI: 1%–
34%); 18-month-old with fever and bumps on lips, 21%
(95% CI: 9%–43%) versus 0% (95% CI: 0%–23%); and
15-month-old well-appearing child with high fever, 50%
(95% CI: 30%–70%) versus 7.7% (95% CI: 1%–34%). Significant
differences were found between GEM and PEM
triage-trained nurses only in the 15-month-old high fever
scenario and between GEM and pediatric residents in the
15-month-old high fever scenario, the 18-month-old with
fever and bumps on lips scenario, and a fever/limp sce-
nario.
Conclusions. The level of agreement of triage assignment
within each group was only fair. GEM participants
and PEM participants agreed on most scenarios. However,
GEM participants were more likely to triage children
with certain febrile illnesses at higher acuity levels
as compared with their PEM counterparts. Pediatrics
2004;114:356–360; emergency, triage, fever, child.
ABBREVIATIONS. ED, emergency department; PEM, pediatric
emergency medicine; GEM, general emergency medicine; CI, confidence
interval.
B
ecause the priority of care often is based on
triage categorization, consistent and appropriate
triage decision making has important implications
for health care delivery in emergency departments
(EDs). Knowledge and experience with
both common and life-threatening illness are essential
for accurate patient assessment.
Both nurses and physicians use triage categorizations
in patient treatment as an indicator of initial
acuity of illness. For maintaining an efficient flow of
patients through an ED, without compromising patient
care, waiting time at each stage of the evaluation
should take into account patient acuity. This is
especially important for pediatric patients because
their pattern of illness and presenting symptoms often
varies with age. However, most children who
require emergency care are brought to community
hospital EDs because of their availability, rather than
to separate EDs designed and staffed specifically for
children.1 Triage of children who are seen in general
hospital EDs may or may not be performed by general
emergency medicine staff who are experienced
in treating childhood emergencies.
The training and experience of general emergency
medicine staff and pediatric emergency medicine
staff are different. Furthermore, differences in practice
patterns between general emergency medicine
staff and pediatric emergency medicine staff have
been shown in several areas, including time to termination
of resuscitation efforts,2 sedation use,3
treatment of the febrile child,4,5 and management of
febrile seizures.6 These studies focused primarily on
management and did not specifically address the
practitioner’s perception of the severity of the child’s
illness on the basis of the presenting complaint. Our
study was designed to compare triage categorization,
as a measure of perceived patient acuity on
presentation to the ED, by pediatric emergency medicine
(PEM) attending physicians, PEM nurses, and
pediatric residents with their general emergency
medicine (GEM) counterparts. We surveyed these
people to determine whether a difference existed in
the way PEM and GEM staff triage varied pediatric
patients.
METHODS
In our institution, physicians do not triage patients but are
aware of the triage categorization and may reprioritize patient
care at any stage of evaluation. The time to initial physician
contact is based primarily on triage categorization and the time of
presentation.
Twelve triage scenarios were devised by the study investigators
to represent common complaints of pediatric patients who
From the Division of Pediatric Emergency Medicine, Department of Pediatrics,
Albert Einstein College of Medicine, Children’s Hospital at Montefiore,
Bronx, New York.
Received for publication Apr 2, 2003; accepted Jan 26, 2004.
Reprint requests to (T.M.) Division of Pediatric Emergency Medicine, Children’s
Hospital at Montefiore, 111 East 210th St, Bronx, NY 10467. E-mail:
theresamaldo@hotmail.com
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Academy
of Pediatrics.
356 PEDIATRICS Vol. 114 No. 2 August 2004 at 2. Lekarska Fakulta UK on September 3, 2019www.aappublications.org/newsDownloaded from
present to an ED (Table 1). Printed scenarios and the definition of
the hospital’s 3-tier triage system (Table 2) were given to all PEM
attending physicians, PEM triage-trained nurses, pediatric residents,
GEM attending physicians, GEM triage-trained nurses, and
GEM residents at a large urban hospital with separate general and
pediatric emergency services.
We used the 3-tier triage scale not only because this is the scale
that we currently use in our institution and therefore what the
physicians tested are familiar using but also to detect greater
differences in triage categorizations. A 5-tier triage categorization
scale might allow a more specific patient acuity level but would
perhaps be less likely to highlight differences among raters triaging
a group of patients. At the time of survey completion, the
annual ED census was 74 000 adults and 42 000 children. The
majority of the PEM attending physicians surveyed are board
certified (10 of 13) in PEM. The nurses at our institution undergo
a triage training class that includes a 6-hour class and requires
them to triage 100 patients under the supervision of our nurse
educator.
For each printed scenario, the following information was provided
to the participant: chief complaint, a brief history of the
patient’s current illness, vital signs, and general appearance. The
12 cases chosen were not validated but were found to represent
typical cases of the most frequent complaints for each category of
triage. Most patients who are seen in our ED have urgent or
nonurgent complaints, with fever being the most common complaint.
Participants were asked to assign a triage level of emergent,
urgent, or nonurgent for each scenario as well as a brief explanation
as to their triage assignment. The forms were completed
anonymously.
Categorical variables were analyzed with ␹2 and Fisher exact
tests when appropriate. Ninety-five percent confidence intervals
(CIs) were calculated using standard methods. The rate of agreement
within each group was calculated using ␬ statistics. The
following guidelines for interpretation of ␬ statistics were used:
Ͻ.20, poor; between .21 and .40, fair; and Ͼ.41, moderate to
substantial. Similar groups were compared with each other (eg,
attendings with attendings, nurses with nurses, residents with
residents). Although there was no triage gold standard for each
scenario, we compared responses of all groups with those of the
PEM attending physicians. P Յ .05 was considered significant. The
hospital’s Institutional Review Board approved this study.
RESULTS
The response rate was 99% (PEM attending physicians:
13 of 13; GEM attending physicians: 20 of 20;
PEM nurses: 17 of 17; GEM nurses: 38 of 38; pediatric
residents: 60 of 62; GEM residents: 28 of 28). The
average number of years of experience of the different
groups were as follows: PEM physicians: 10.6
years; GEM physicians: 11.4 years; PEM nurses: 12.7
years; GEM nurses: 11.8 years; pediatric residents:
1.5 years; and GEM residents: 2.9 years.
The overall ␬ level of agreement in assigning a
triage level to the case scenarios was .39 for the PEM
physicians, .33 for the GEM physicians, .29 for the
PEM nurses, .26 for the GEM nurses, .26 for the
pediatric residents, and .27 for the GEM residents.
There were no significant differences in triage categorization
between PEM participants and their GEM
TABLE 1. Summary of Patient Scenarios
Chief Complaint Brief History Vital Signs
(T, HR, R, BP)
Physical Appearance
Fever 7-wk-old boy with fever for 1 d 38.6°C, 140, 36, 90/60 Well appearing
Head trauma 3-y-old boy after fall off bed,
no loss of consciousness or
emesis
37°C, 100, 24, 95/65 Comfortable, looking around, small
bump on forehead
Barking cough 18-mo-old girl with cough and
runny nose for 1 d
38.3°C, 130, 40, 88/50,
Sao2 96%
Stridulous, retracting and agitated
Wheezing 7-y-old girl with known asthma 37.1°C, 110, 26, 105/68,
Sao2 95%
Comfortable, mild retractions, slight
expiratory wheeze
Seizure 11-mo-old boy after generalized
tonic-clonic seizure for 5 min
at home
39.1°C, 120, 26, 90/60 Well appearing
Abdominal pain 12-y-old boy with mild
intermittent abdominal pain
for 1 d, emesis ϫ 3 today
37.8°C, 100, 18, 90/65 Comfortable, able to walk
Fever 4-y-old boy complaining of
earache, cough, and fever for
2 d
38.5°C, 130, 30, 96/65 Well appearing and playful
Not drinking 2-y-old girl with 3 d history of
vomiting and diarrhea and
decreased oral intake
38.0°C, 150, 24, 88/50 Alert and active with slightly dry lips
and normal capillary refill time
Fever and decreased
oral intake
18-mo-old boy with 2 d history
of fever, drooling, and
“bumps” on lips
38.5°C, 140, 30, 90/60 A drooling, well-appearing boy with
vesicles on tongue
Chest pain 12-y-old boy complaining of
chest pain for 1 d
37°C, 100, 22, 110/70,
SaO2 ϭ 98%
Comfortable, chest clear and equal
breath sounds, heart regular, no
murmur
Not walking 2-y-old girl who won’t walk
for 1 d
39.7°C, 130, 26, 95/65 Crying but consolable; unable to bear
weight
Fever 15-mo-old with fever for 1 d 41.1°C, 160, 44, 90/60 Crying but easily consolable, well
hydrated
T indicates temperature; HR, heart rate (beats/minute); R, respirations (per minute); BP, blood pressure (mmHg)
TABLE 2. Triage Categorizations
Emergent
Patients with life-, limb-, or sight-threatening illness that, if
not treated immediately, may result in permanent functional
loss or mortality
Urgent
Patients with significant medical problems that, if not treated
within 1–2 hours, have the potential for significant medical
morbidity, pain, or psychological trauma
Nonurgent
Patients whose condition is stable but will require care within
the next 4–6 hours, with no risk of mortality or permanent
functional loss
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counterparts for 8 scenarios: asthma, head trauma,
croup, abdominal pain, otitis, dehydration, chest
pain, and fever in a 7-week-old. For the scenario of a
15-month-old who had high fever for 1 day and was
crying but consolable and well hydrated with an
otherwise nonfocal physical examination, GEM attending
physicians, GEM residents, and GEM nurses
were more likely to assign a higher acuity triage
category as compared with their PEM counterparts
(Table 3). When asked for reasons for the triage level
assignment for this scenario, 11.6% of the GEM participants
listed that a fever Ͼ105°F was “very concerning”
and that “the patient was at risk for seizure
activity.” With regard to the 18-month-old who had
fever, drooling, and bumps on lips and was otherwise
well-appearing, significantly more GEM attending
physicians and GEM residents triaged this child
at a higher acuity level as compared with PEM attending
physicians and pediatric residents (Table 4).
Several of the GEM staff expressed that they were
concerned that the child was drooling (13.3%) and
gave the fear of a potential airway compromise
(8.8%) and/or epiglottitis (2.2%) as an explanation
for their emergent triage assignment, whereas the
PEM staff noted this child as having stomatitis. No
significant differences were found between the nurse
groups for this scenario. The only significant difference
found for the 11-month-old status post a simple
febrile seizure who is now well appearing was between
the attending physician groups (Table 5). For
the 2 year-old with fever and limp scenario, the only
significant difference was found between the resident
groups, with pediatric residents more likely to
categorize the triage level as emergent (45% [95% CI:
33%–58%] vs 39.3% [95% CI: 23%–57%]) and less as
nonurgent (0% [95% CI: 0%–6%] vs 10.7% [95% CI:
4%–28%]).
The percentage of scenarios in which each group
agreed with the PEM attending physicians were as
follows: GEM attending physicians: 75% (95% CI:
53%–89%); GEM nurses: 75% (95% CI: 59%–86%);
GEM residents: 91% (95% CI: 75%–97%); PEM
nurses: 91% (95% CI: 69%–98%); and pediatric residents:
100% (95% CI: 94%–100%).
DISCUSSION
Appropriate triage requires not only the ability to
recognize presenting signs and symptoms that need
to be managed emergently but also the recognition of
symptoms that are likely to represent a benign illness.
It is clear that undertriaging (assigning an inappropriately
low triage level) can lead to delays in
patient care. However, overtriaging (assigning an
inappropriately high triage level) can have a similar
effect. Mixing nonurgent conditions with emergent
conditions results in increased waiting time for the
true emergencies. In addition, variations in triage
practices can affect resource allocation, health care
cost, and, ultimately, patient outcomes. For example,
if a patient’s severity cannot be identified accurately
by triage, then the option to divert a nonurgent patient
to a less expensive venue cannot occur.7
Our data are consistent with the earlier findings
demonstrating great variability among physicians
TABLE3.TriageCategorizationforthe15-Month-OldWithFeverfor1DayScenario
GEMAttendingPhysicians
(nϭ20;95%CI)
PEMAttendingPhysicians
(nϭ13;95%CI)
GEMResidents
(nϭ28;95%CI)
PEDSResidents
(nϭ60;95%CI)
GEMNurses
(nϭ38;95%CI)
PEMNurses
(nϭ17;95%CI)
Emergent50%(30%–70%)7.7%(1%–34%)25%(13%–43%)15%(8%–26%)36.8%(24%–53%)33.5%(16%–57%)
Urgent50%(30%–70%)61.5%(36%–83%)67.8%(49%–82%)45%(33%–58%)57.9%(42%–72%)26.6%(12%–51%)
Nonurgent0%(0%–16%)30.7%(13%–58%)7.1%(2%–22%)40%(29%–53%)5.3%(1%–17%)40%(21%–63%)
Pϭ0.005Pϭ0.006Pϭ0.004
Pvalueϭlevelofsignificanceforeachtable
358 TRIAGE OF THE PEDIATRIC PATIENT IN THE EDat 2. Lekarska Fakulta UK on September 3, 2019www.aappublications.org/newsDownloaded from
and nurses with regard to triage decisions.8 The development
of triaging skills requires knowledge and
experience of both common and life-threatening illness.
Because the intensity of pediatric experience
differs between GEM staff and PEM staff, we tried to
determine whether differences existed in the way
GEM staff and PEM staff triaged pediatric patients.
In our study, GEM participants and PEM participants
agreed on most scenarios, and there was a high
level of agreement of each group with the physicians
who have the most training in PEM, the PEM attending
physicians. However, the scenarios in which
PEM staff differed from GEM staff all involved triage
of a febrile child. GEM participants were more likely
to triage children with certain febrile illnesses as
emergent compared with their PEM counterparts.
This may be attributable to differences in their training,
experience, and/or familiarity with certain common
febrile illnesses in pediatrics. It is interesting
that when compared with the PEM attending physicians,
the GEM residents agreed on more scenarios
(91%) than the GEM attending physicians (75%). This
may be attributable to GEM residents’ having more
recent exposure to pediatric patients at the time of
the questionnaire.
Differences in practice patterns between general
emergency physicians and pediatric physicians in
the management of certain febrile illnesses in children
have been reported. In a survey of 1600 randomly
selected pediatricians, family medicine practitioners,
and emergency physicians, Wittler et al.4
found that although physicians generally agreed in
their treatment of the young febrile infant, there was
considerable variation in the treatment in the older
infant and toddler, with the emergency medicine
physicians being the most aggressive in their treatment.
For example, when surveyed regarding a 16month-old
with a high fever and no clinically apparent
source of infection, emergency physicians were
more likely than pediatricians to obtain a blood culture
and chest radiograph and initiate empiric antibiotic
treatment. In a review of medical records from
a children’s hospital ED and a general ED, Isaacman
et al5 found a number of differences between GEM
physicians and PEM physicians in their treatment of
the young child with fever. Using existing practice
guidelines as a gold standard, the investigators concluded
that GEM physicians were more likely to
order a chest radiograph, perform a lumbar puncture,
and use parenteral antibiotics than their PEM
physician counterparts. Furthermore, specific viral
infections were diagnosed more frequently by PEM
physicians than GEM physicians. The differences in
the triage categorization of children with febrile illness
between the GEM physicians and the PEM physicians
in our study may explain some of the existing
data. Perhaps the GEM physicians consider children
with a febrile illness to be at higher acuity, thereby
resulting in more aggressive management, or perhaps
GEM physicians are accustomed to a higher
level of acuity and therefore triage symptoms differently,
resulting in more aggressive management.
Although we did not assess the potential outcome
of each patient according to his or her level of triage
assignment, our results demonstrate how triage may
affect the way an ED operates. If certain febrile pediatric
patients with common nonurgent illnesses are
being overtriaged, then they may be placed in the
same category as and thereby delay the care of patients
with more emergent conditions. Therefore, the
issue is not just the treatment and outcome of the
child with the nonurgent complaint who is overtriaged
but rather how that action affects the timeliness
of care and outcome of children who present to the
ED at the same time. For example, if a child with a
benign febrile illness is triaged as emergent, then that
may delay the care to a child who has possible meningitis
and was triaged shortly thereafter. Furthermore,
triage categorization may affect patient care
not just during the initial presentation to the ED but
also for additional evaluation by the physician. This
is why we chose to include physicians’ triage categorization
in our study, because their judgment of
patient acuity will affect the order in which patients
are seen inside the ED.
Our study is also consistent with previous data9
showing variability among groups of similar practitioners.
Interobserver agreement as judged by the ␬
statistic was only fair within each group surveyed.
There are a number of limitations to this study.
First, the use of paper scenarios cannot truly substitute
for actual triage practice. We tried to include all
of the essential information generally obtained during
a triage encounter. By providing this information,
we were able to focus on triage categorization
rather than on the clinical ability of the participant to
assess properly whether the child was, for example,
“well appearing” or “well hydrated.” Nevertheless,
TABLE 4. Triage Categorization for the 18-Month-Old With Fever and Bumps on Lips Scenario
GEM Attending
Physicians
(n ϭ 20; 95% CI)
PEM Attending
Physicians
(n ϭ 13; 95% CI)
GEM Residents
(n ϭ 28; 95% CI)
PEDS Residents
(n ϭ 60; 95% CI)
Emergent 21% (9%–43%) 0% (0%–23%) 36% (21%–54%) 5.1% (2%–14%)
Urgent 47.4% (27%–68%) 7.7% (1%–34%) 39% (23%–57%) 32.2% (22%–45%)
Nonurgent 31.6% (16%–54%) 92.3% (66%–99%) 25% (13%–43%) 62.7% (50%–74%)
P ϭ 0.002 P ϭ 0.0001
TABLE 5. Triage Categorization for the 11-Month-Old s/p
Simple Febrile Seizure Scenario
GEM Attending
Physicians
(n ϭ 20; 95% CI)
PEM Attending
Physicians
(n ϭ 13; 95% CI)
Emergent 50% (30%–70%) 7.7% (1%–34%)
Urgent 45% (26%–66%) 77% (50%–92%)
Nonurgent 5% (1%–24%) 15.3% (4%–42%)
P ϭ 0.03
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denying the participants their instinct or gestalt
when actually triaging a patient may bias the results.
We also used a limited number of scenarios, although
we specifically chose scenarios of the more
common illnesses that are seen in our pediatric ED.
The variation in acuity of our scenarios is consistent
with the fact that most patients who are seen in our
ED have urgent or nonurgent complaints. In particular,
the lack of high-acuity scenarios limits our ability
to detect differences for emergent triage com-
plaints.
We chose to use the 3-tier triage system currently
in use at our institution because of its familiarity to
the staff. It is true that some hospitals have adopted
other triage systems, including a 5-tier triage system,
that may have less variation in triage categorization.10
Nevertheless, the focus of our study was on
the perception of patient acuity on the basis of the
presenting symptoms. It was not our goal to assess
the validity or effectiveness of the 3-tier triage system
or to compare it with other systems. We sought only
to use the triage categorization as a gross measure of
perceived patient acuity on the basis of presenting
symptoms.
Our study was not designed to investigate differences
in the training experience of GEM staff. However,
uncovering variability between GEM physicians
and PEM physicians with regard to triaging a
febrile child raises the question as to whether more
GEM training in assessing febrile children is needed.
Differences in management styles are common. Preconceptions,
such as risk of disease prevalence and
reliability of follow-up, may affect attitude toward
assessment of a febrile child. Our intention was not
to investigate whether there is a need for more GEM
training in febrile pediatric patients. Furthermore,
differences in patient assessment and treatment may
not affect final outcome. Therefore, future studies are
needed to assess whether these differences in management
styles affect patient outcome.
In summary, the ␬ level of agreement within each
group was only fair. GEM staff and PEM staff agreed
on the triage level for most scenarios. However,
GEM participants were more likely to triage children
with certain febrile illnesses at higher acuity levels as
compared with their PEM equivalents. This may be
attributable to differences in their training, experience,
and/or familiarity with certain common febrile
illnesses in pediatrics. Future studies are needed to
validate these findings with actual triage practices
and to determine whether differences in experiences
or training are components to variation in triage
categorization between GEM staff and PEM staff for
certain febrile illness.
ACKNOWLEDGMENT
This work was presented in part at the Region II Ambulatory
Pediatric Association Meeting; Philadelphia, PA; March 2002.
REFERENCES
1. American College of Emergency Physicians and the American Academy
of Pediatrics. Care of children in the emergency department:
guidelines for preparedness. Ann Emerg Med. 2001;37:423–427
2. Scribano PV, Baker MD, Ludwig S. Factors influencing termination of
resuscitative efforts in children: a comparison of pediatric emergency
medicine and adult emergency medicine physicians. Pediatr Emerg Care.
1997;13:320–324
3. Krauss B, Zurakowki D. Sedation patterns in pediatric and general
community hospital emergency departments. Pediatr Emerg Care. 1998;
14:99–103
4. Wittler RR, Cain KK, Bass JW, et al. A survey about management of
febrile children without source by primary care physicians. Pediatr Infect
Dis J. 1998;17:271–277
5. Isaacman DJ, Kaminer K, Veligeti H, Jones M, Davis P, Mason JD.
Comparative practice patterns of emergency medicine physicians and
pediatric emergency medicine physicians managing fever in young
children. Pediatrics. 2001;108:354–358
6. Hampers LC, Trainor JL, Listernick R. Setting-based practice variation
in the management of simple febrile seizures. Acad Emerg Med. 2000;7:
21–27
7. Wuerz R, Fernandes CMB, Alarcon J, et al. Inconsistency of emergency
department triage. Ann Emerg Med. 1998;32:431–435
8. Brillman JC, Doezema D, Tandberg D, et al. Triage: limitations in
predicting need for emergent care and hospital admission. Ann Emerg
Med. 1996;27:498–500
9. Bergeron S, Goulin S, Bailey B, et al. Comparison of triage assessments
among pediatric registered nurses and pediatric emergency physicians.
Acad Emerg Med. 2002;9:1397–1401
10. Fernandes CMB, Wuerz R, Clark S, et al. How reliable is emergency
department triage? Ann Emerg Med. 1999;34:141–147
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DOI: 10.1542/peds.114.2.356
2004;114;356Pediatrics
Theresa Maldonado and Jeffrey R. Avner
Agreement?
Triage of the Pediatric Patient in the Emergency Department: Are We All in
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DOI: 10.1542/peds.114.2.356
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Theresa Maldonado and Jeffrey R. Avner
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Triage of the Pediatric Patient in the Emergency Department: Are We All in
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