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Investigators have found that low-risk reverse triage can provide modest benefits to pediatric hospitals looking to create capacity during patient surges. The approach involves identifying patients who can be discharged early with minimal risks of an adverse outcome, but investigators noted that the unique needs of pediatric patients must be considered.
Hospitals and emergency personnel devote considerable time and energy developing surge plans for when a disaster, mass casualty event, or an infectious disease outbreak pushes hospitals beyond their normal capacity to take care of patients. But what happens when the demand for care primarily comes from pediatric patients?
“There is a fair amount of literature out there [suggesting] that should something happen to a large group of kids, even with a network of hospitals prepared to care for them, [the system] can get overwhelmed fairly quickly,” explains Gabor Kelen, MD, FRCP(C), FACEP, FAAEM, director of the department of emergency medicine and the office of critical event preparedness and response at Johns Hopkins University School of Medicine in Baltimore.
In developing solutions for such scenarios, Kelen and colleagues analyzed data on inpatients from seven pediatric units during 196 mock disaster days over a period of one year to see if reverse triage, a strategy commonly used during surges of adult patients, also could be effective at relieving pressure on hospitals caring for pediatric patients.
In a sampling of 501 inpatients, investigators found that more than 10% were eligible for immediate, low-risk reverse triage, meaning that these patients did not require any critical interventions such as IV medication or invasive procedures during the following four days. Further, investigators found that more than 13% would be eligible for low-risk reverse triage within 96 hours. When investigators applied a standard of accepting moderate risks, they found that reverse triage could expand surge capacity by 50%.1
While the effect of using low-risk reverse triage was modest, investigators concluded that when used with other strategies, it could have a meaningful effect on creating capacity.
The concept of reverse triage is relatively straightforward. It involves devising a way to identify patients who can be discharged earlier than protocols or routine would generally suggest to make room for patients at high risk who need immediate access to hospital resources, Kelen explains. However, making this kind of decision is more complicated with a pediatric population because young patients have unique needs.
“First of all, there is the whole ethical issue that kids can’t truly make decisions for themselves,” Kelen says. “You can’t do shared decision-making directly with a child when you are trying to explain the risks of leaving, so their first need is for a good and responsible parent, guardian, or proxy.”
In addition, Kelen notes that pediatric patients are much more dependent on the judgment of doctors, nurses, and caregivers than adult patients; they rely on others for their needs. “In the pediatric population, you may not be able to send some kids to certain homes, even if they are medically stable because whoever are the responsible people in the home may not be able to do the next step,” he says. “These children may actually have to remain in the hospital a little bit longer until the [responsible adults in the home] are able to take care of the child properly.”
On top of these vulnerabilities, children are physiologically different from adults, Kelen observes. “At different ages, there are different kinds of considerations as to what has to happen for a child to be sent home,” he says.
However, when the unique vulnerabilities of children are accounted for, certain types of patients emerge as good candidates for reverse triage, Kelen says. “Let’s say you have a patient who had some kind of orthopedic surgery and has been receiving IV pain medication and antibiotics,” he says. “That patient could very easily be switched over to oral medications, and a responsible parent could, in fact, monitor the wound and do wound dressings. If the patient was discharged one day earlier than otherwise planned, the risk of something going terribly wrong would be pretty minor.”
Another potential candidate for reverse triage could be a patient suffering from bronchiolitis, asthma, or croup, and who is at the tail end of his treatment. “He could be switched to continuous medications, which can be given at home,” Kelen observes.
Similarly, a child who has been properly treated for diabetic ketoacidosis and is close to achieving the right balance of insulin would be at very low risk under the care of a responsible parent, Kelen adds.
Capacity-freeing tactics such as reverse triage have importance to the ED. When there is a sudden influx of patients, other parts of the hospital must be able to rapidly take in the victims that emergency providers have screened and started treating, Kelen explains. “This is a way to make sure that the victims who need a further level of care have a place to get it,” he says. “Otherwise, the incoming patients will completely clog the ED and take up all of those resources.”
It is not just during disasters and mass-casualty events that such strategies are useful, Kelen stresses. “Many of us who are at these major institutions have experienced crowding to the level of disaster proportions,” he says. “If we had these kinds of protocols to help our inpatient colleagues, the ED could unclog within 24 hours, whereas sometimes the impact of crowding takes three to five days to actually [resolve] because the inpatient services have no real way to approach the early discharge of their patients right now.”
The next step for researchers is to develop prediction rules and risk-scoring for reverse triage, and eventually to offer a live score that continuously updates based on vital signs and lab results from the electronic medical record so that clinicians can predict outcomes safely, including the ability to discharge a patient safely, Kelen explains.
In the meantime, the primary message from this work is that reverse triage is one strategy to consider when a disaster strikes or when ED administrators are developing surge plans, Kelen advises. “Most people don’t think about reverse triage yet, so we want to get the concept out there,” he says. “Hopefully, this will stimulate thinking in ... pediatric hospitals so that even in the absence of a valid risk-scoring system, protocols will be developed.”
At this point, such plans would be based primarily on clinician judgment, but they could be used to create space for patients in immediate need of hospital resources. “That would be at least an interim step, and at this hospital we are doing exactly those kinds of developments now,” Kelen adds.
Financial Disclosure: Physician Editor Robert Bitterman, Author Dorothy Brooks, Editor Jonathan Springston, Nurse Planner Diana S. Contino, and Executive Editor Shelly Morrow Mark report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Editorial Advisory Board Member Caral Edelberg discloses that she is founder, chairman, majority stockholder, and consultant for Edelberg and Associates.