J. Pediatr. (Rio J.) vol.93 suppl.1

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www.jped.com.br

REVIEW

ARTICLE

Is

this

child

sick?

Usefulness

of

the

Pediatric

Assessment

Triangle

in

emergency

settings

夽

Ana

Fernandez

∗

_,

_Javier

_Benito,

_Santiago

_Mintegi

HospitalUniversitarioCruces,ServiciodeUrgenciasdePediatría,Barakaldo,Spain

Received25May2017;accepted5July2017 Availableonline25August2017

KEYWORDS

PediatricAssessment Triangle;

Pediatricassessment; Pediatricemergency department

Abstract

Objective: ThePediatricAssessmentTriangleisarapidassessmenttoolthatusesonlyvisual

andauditoryclues,requiresnoequipment,andtakes30---60stoperform.It’sbeingused

inter-nationallyindifferentemergencysettings,butfewstudieshaveassesseditsperformance.The

aimofthisnarrativebiomedicalreviewistosummarizetheliteratureavailableregardingthe

usefulnessofthePediatricAssessmentTriangleinclinicalpractice.

Sources: The authors carried out a non-systematic review inthe PubMed®, MEDLINE®,and

EMBASE® databases,searchingfor articlespublishedbetween1999---2016usingthekeywords

‘‘pediatric assessment triangle,’’ ‘‘pediatric triage,’’ ‘‘pediatric assessment tools,’’ and

‘‘pediatricemergencydepartment.’’

Summaryofthefindings: ThePediatricAssessmentTrianglehasdemonstrateditselftobe

use-fultoassesssickchildrenintheprehospitalsettingandmaketransportdecisions.Ithasbeen

incorporated,asanessentialinstrumentforassessingsickchildren,intodifferentlifesupport

courses,althoughlittlehasbeenwrittenabouttheeffectivenessofteachingit.Littlehasbeen

publishedabouttheperformanceofthistoolintheinitialevaluationintheemergency

depart-ment.Intheemergencydepartment,thePediatricAssessmentTriangleisusefultoidentifythe

childrenattriagewhorequiremoreurgentcare.Recentstudieshaveassessedandprovedits

efficacytoalsoidentifythosepatientshavingmoreserioushealthconditionswhoareeventually

admittedtothehospital.

Conclusions: ThePediatricAssessmentTriangleisquicklyspreadinginternationallyandits

clini-calapplicabilityisverypromising.Nevertheless,itisimperativetopromoteresearchforclinical

validation,especiallyforclinicalusebyemergencypediatriciansandphysicians.

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/

4.0/).

夽

Pleasecitethisarticleas:FernandezA,BenitoJ,MintegiS.Isthischildsick?UsefulnessofthePediatricAssessmentTriangleinemergency settings.JPediatr(RioJ).2017;93:60---7.

∗_{Corresponding}_author.

E-mail:ana.fernandezlandaluce@osakidetza.eus(A.Fernandez).

http://dx.doi.org/10.1016/j.jped.2017.07.002

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PALAVRAS-CHAVE

Triângulode

Avaliac¸ãoPediátrica; Avaliac¸ãopediátrica; Departamentode emergência pediátrica

Estacriançaestádoente?UtilidadedoTriângulodeAvaliaçãoPediátrica nasconfiguraçõesdeemergência

Resumo

Objetivo: OTriângulodeAvaliac¸ãoPediátricaéumaferramentadeavaliac¸ãorápidaqueutiliza

apenaspistasvisuaiseauditivas,nãonecessitadeequipamentoselevade30-60segundospara

realizac¸ão.Eletemsidoutilizadointernacionalmenteemdiferentesconfigurac¸õesde

emergên-cia, porém poucos estudos avaliaramseu desempenho. Oobjetivo dessaanálise biomédica

narrativaéresumiraliteraturadisponívelcomrelac¸ãoàutilidadedoTriângulodeAvaliac¸ão

Pediátricanapráticaclínica.

Fontes: RealizamosumaanálisenãosistemáticanasbasesdedadosdoPubMed®_,_MEDLINE®_e

EMBASE®_buscando_artigos_publicados_entre_1999-2016_utilizando_as_{palavras-chave}_{‘‘triângulo}

deavaliac¸ãopediátrica’’,‘‘triângulopediátrico’’, ‘‘ferramentasde avaliac¸ãopediátrica’’e

‘‘departamentodeemergênciapediátrica’’.

Resumodosachados: OTriângulodeAvaliac¸ãoPediátricademonstrouserútilnaavaliac¸ãode

crianc¸asdoentesnaconfigurac¸ãopré-hospitalar enatomadadedecisõesdetransporte.Ele

foiincorporado,como uminstrumentoessencialnaavaliac¸ãodecrianc¸asdoentes,em

difer-entescursosdesuportedevida,apesardepoucotersidoescritosobreaeficáciadeensino

doTriângulodeAvaliac¸ãoPediátrica.PoucofoipublicadosobreodesempenhodoTriângulode

Avaliac¸ãoPediátricanaavaliac¸ãoinicialnodepartamentodeemergência(DE).NoDE,o

Triân-gulodeAvaliac¸ãoPediátricaéútilparaidentificar,natriagem,crianc¸asqueexigemcuidadomais

urgente.EstudosrecentesavaliarameprovaramaeficáciadoTriângulodeAvaliac¸ãoPediátrica

tambémnaidentificac¸ãodospacientescomdoenc¸asdesaúdemaisgravese,eventualmente,

sãointernadosnohospital.

Conclusões: O Triângulo de Avaliac¸ão Pediátrica está se difundindo rapidamente de forma

internacionalesuaaplicabilidadeclínicaémuitopromissora.Contudo,éessencialpromover

pesquisaparavalidac¸ãoclínica,principalmenteparaousoclínicoporpediatrasemédicosde

emergência.

OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.

0/).

Introduction

Isthischildsick?ShouldIbeginanyemergencyintervention? Anyprovidershouldbeabletoanswerquicklythese ques-tionswhenevertheprovidercomesinfrontofachildseeking forurgent medicalattention (intheprehospitalsettingor emergencydepartment[ED]).

Everyday,thousandsofchildrenarebroughttodifferent emergencysettingsworldwide.Childrenaccountforabout one-fourthofthevisitstohospitalEDsintheUnitedStates, andaround30millionchildrenareassessedbygeneral prac-titionersorpediatriciansannually.1_Infants_younger_than₁₂

monthsaretheagegroupwiththehighestpercapitarate ofvisitstotheED(91.3per100infantsin2005).Inthe pre-hospitalsetting,10%to13%ofambulancetransportsarefor children.2_In_Europe,_in_the_UK,_25---30%_of_all_Accident_and

Emergencyattendancesarechildren.3

Inpediatricemergencymedicine,stabilizingthepatient mustbeperformedbeforeestablishingadiagnosis;a prob-lemsolvingapproachisrequired.Itis,therefore,essential tohaveatoolthatallowsarapidinitialassessmentand iden-tifiestheproblemthatmustbesolved.Unfortunately,initial assessmentofacriticallyillorinjuredchildisoftendifficult, even for the experienced clinician. Physical examination and vital signs assessment, the cornerstone of the adult assessment,maybecompromisedwithahands-on evalua-tion.Initialassessmentofthechildpresentingtoemergency shouldideallybeviaan‘‘acrosstheroom’’assessment.4

The

Pediatric

Assessment

Triangle:

definition

In2000,theAmericanAcademyofPediatrics(AAP)published thefirstnationalpediatriceducationalprogramfor prehos-pitalproviders,which introduced a newrapid assessment tool, called the Pediatric Assessment Triangle (PAT). The PATisnotadiagnostictool,itwasdesignedtoenablethe providertoarticulateformallyageneralimpressionofthe child,establishtheseverityofthepresentationandcategory of pathophysiology, and determine the type and urgency ofintervention.5_The _PAT_somehow_summarizes_‘‘gut

feel-ing’’ findings, and promotes consistent communication amongmedicalprofessionalsaboutthechild’sphysiological status.

Intended for use in rapid assessment, the PAT uses onlyvisualandauditoryclues,requiresnoequipment,and takes 30---60s to perform. The three components of the PAT are appearance, work of breathing, and circulation tothe skin (Fig.1). Each component of the PAT is evalu-atedseparately, usingspecificpredefinedphysical, visual, or auditory findings. If the clinician detects an abnor-malfinding,thecorrespondingcomponentis,bydefinition, abnormal.Together,thethreecomponentsofthePATreflect the child’s overall physiologic status, or the child’s gen-eralstateofoxygenation,ventilation,perfusion,andbrain function.2

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Appearance Work of Breathing

Circulation to skin

Figure1 PediatricAssessmentTriangle.

fortreatment,andtheresponsetotherapy.Itreflectsthe adequacyofventilation,oxygenation,brainperfusion,body homeostasis,andcentralnervoussystemfunction.Thisarm ofthePATis delineatedby the‘‘TICLS’’mnemonic:Tone, Interactiveness,Consolability,LookorGaze,andSpeechor Cry.Importantclues suchastheinfant’s tone, consolabil-ity,interactionwithcaregiversandothers,andstrengthof crycaninformtheproviderofthechild’sappearanceas nor-malorabnormal(forageanddevelopment).Theinteraction withtheenvironmentandexpectednormalbehaviorvaries accordingtotheageof thepatient.Knowledgeofnormal developmentinchildhoodisessentialfortheassessmentof theappearance.

The other elements of the PAT provide more specific informationaboutthetypeofphysiologicderangement.

Workof breathingdescribesthechild’srespiratory sta-tus,especiallythedegreetowhichthechildmustworkin ordertooxygenateandventilate.Assessingworkof breath-ingrequireslisteningcarefullyforaudibleabnormalairway sounds(e.g.,stridor,grunting,andwheezing),andlooking forsignsofincreasedbreathingeffort(abnormal position-ing,retractions,orflaringofthenostrilsoninspiration).The typeofabnormalairwaynoiseprovidesinformationabout the location of the disease, while the number and loca-tionof retractions and the position of the patientreport theintensityofrespiratorywork.

Circulationtotheskin reflectsthegeneralperfusionof blood throughout the body. The provider notes the color andcolor pattern of the skin and mucous membranes. In the context of blood loss/fluid loss or changes in venous tone,compensatorymechanismsshuntbloodtovitalorgans suchasthe heart and brain,and awayfrom theskin and theperipheryofthebody. Bynotingchangesinskin color andskin perfusion (suchas pallor, cyanosis,or mottling), theprovidermayrecognizeearlysignsofshock.

An abnormality noted in any of the arms of the PAT denotesanunstablechild;i.e.,achildwhowillrequiresome immediate clinical intervention. The pattern of affected armswithinthePATfurthercategorizesthechildinto1of 5categories:respiratorydistress,respiratoryfailure,shock, centralnervoussystemormetabolicdisorder,and cardiopul-monaryfailure.Thespecificcategorythendictatesthetype andurgencyofintervention.2,6

In 2005, an Emergency Medical Services for Children (EMSC) task force was convened to review definitions andassessmentapproachesfornational-levelpediatriclife support programs and courses. Representatives from the AAP, the American College of Emergency Physicians, the

AmericanHeartAssociationEmergencyNurses Association, the National Association of EMTs, the Children’s National MedicalCenter,andtheNewYorkCenterforPediatric Emer-gency Medicine met to adopt consensus definitions and approaches to pediatric emergency care. The group con-cluded thata standard algorithmfor pediatric emergency assessmentshouldstartwiththePAT.5

Sinceits creation as a rapid assessment tool, the PAT hasbeentaughttoandusedinternationallybyhealth pro-fessionalsinvariousdifferentsettings,althoughtherehave beenveryfewvalidationstudies.

This non-systematicreview aims toupdate the profes-sionals involved in thecare of children in EDsin relation totheliteratureavailableregardingtheclinicaluseofthe PAT.Itwascarriedoutusingthekeywords‘‘pediatric assess-menttriangle,’’‘‘pediatrictriage,’’‘‘pediatricassessment tools,’’ and ‘‘pediatric emergency department’’ in the PubMed®,MEDLINE®,andEMBASE® databases,searchingfor articlespublishedbetween1999---2016(Table1).

PAT

as

a

teaching

tool

The tool has been incorporated, as an essential instru-mentforassessingsickchildren,intodifferentlifesupport courses, including the Advanced Pediatric Life Support (APLS), Emergency Nursing Pediatric Course, Pediatric Advanced Life Support (PALS), Pediatric Education for Prehospital Professionals (PEPP), Special Children’s Out-reachandPrehospitalEducation,andTeachingResourcefor InstructorsinPrehospitalPediatrics.5

TheAPLScourseaimstoimprovetheearlymanagement ofacutelyillandinjuredchildrenthroughtrainingand edu-cationofhealthcareprofessionals.Itisavaluableresource forpediatricresidentsanditispartoftheprogramof con-tinuingeducationofpediatriciansandemergencyphysicians intheUnitedStates.7

The first APLScourse was implemented in 1984 in the UnitedStates.The firsteditionoftheAPLScoursestudent manualwaspublishedbytheAAPandACEPin1989.All edi-tionswereguidedbytheAPLSJointTaskForce,andallwere builtonthefoundation laidby Dr.Brushore-Fallisandher colleagues.8

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Table1 Pediatricassessmenttools.

Authorand

year

Assessment tool/setting

Objective n Studydesign Results/conclusions

Horeczko

etal.6

2013

PAT EDtriage

Todeterminequantitatively thePAT’saccuracy,

reliability,andvalidityas appliedbynursesattriage.

528 Prospective, observational

PATreadilyandreliably identifieshighlyacute pediatricpatientsandtheir categoryofpathophysiology. Mierek

etal.10

2010

PAT Prehospital setting

Todetermineifexperienced providerscanusethe informationgatheredfrom the‘‘viewfromthedoor’’ tomaketransportdecisions onpediatricpatients,andif thatinformationagrees withthePAT.

18video casesof pediatric patients

Ethnographic analysisstrategies todevelop themes.Recorded decision-making processes comparedto standardtriage criteria.

Theprovidersextracted informationfromaremote locationaboutpediatric patientsthatcouldbe organizedintoatoolsimilarto thePATandthatdirectly contributedtotransport decisionsinatime-efficient manner.

Gausche-Hill etal.12

2014

PAT Prehospital setting

Toprovideanevaluationof thePATasanassessment toolforusebyparamedic providersintheprehospital careofpediatricpatients.

Substantialagreement betweenthePATParamedic Impressionandthe investigators’retrospective chartreview.

ThePATshoweda77.4% sensitivityand90%specificity forinstability.

ThePATisarapidassessment toolthatcanbereadilyand reliablyusedbyparamedicsin theprehospitalsetting. Fernandez

etal.22

2017

PAT EDtriage

Toassesstheassociation betweenPATfindingsduring triageandmarkersof severityinapediatricED.

302,103 Retrospective cohortstudy

PATfindingswerean independentriskfactorfor admission(OR,2.21;95%CI, 2.13---2.29);forintensivecare unitadmission(OR,4.44;95% CI,3.77---5.24),andalonger stayinthePED(OR,1.78;95% CI,1.72---1.84).

ThePATappearstobeavalid toolforidentifyingthemost severepatientsasafirststep inthetriageprocess. Paniagua

etal.23

2017

PAT EDtriage

Toassesstheperformance ofthePAT,triagelevel, pulmonaryscore,andinitial O2saturationinpredicting

hospitalizationinpediatric acuteasthma

exacerbations.

14,953 Retrospective cohortstudy

AbnormalPATwasan independentriskfactorfor hospitalization(OR:1.6,95% CI:1.4---1.8)andforalonger LOS(OR:1.5,95%CI:1.3---1.7). AmongthecomponentsofPAT, abnormalcirculationtothe skinwasthebestpredictorof hospitalization(OR:1.8,95% CI:1.2---2.9).

Bradman etal.26

2008

PEWS EDtriage

ToassessifthePEWScould detectchildrenattriage whoneedadmission.

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Table1(Continued)

Authorand

year

Assessment tool/setting

Objective n Studydesign Results/conclusions

Seiger

etal.27

2013

PEWS EDtriage

Tocomparethe

performanceofdifferent PEWStopredictICU admissionorhospitalization inchildrenvisitingthe pediatricED.

17,943 Prospectivecohort study

Thediscriminativeabilityof thePEWS(areaundertheROC curve)weremoderatetogood forICUadmission(range:0.602 0.82)andpoortomoderatefor admissiontothehospital (range:0.562---0.68).At present,thereisnoevidence thatPEWSarebetterthan conventionaltriagesystems. Goldetal.28

2014

PEWS ED

ToexploreifthePEWS assignedintheED(P0at initialassessment;P1at admission)predictsthe needforICUadmissionfrom theEDorclinical

deterioration.

12,306 Prospective, observational study

IntheED,alonethetoollacks sufficienttestcharacteristics todeterminedispositionor predictdeteriorationonthe floor.

Roland etal.29

2016

POPS EDtriage

TovalidatePOPSasatriage tool.

936 Prospective, observational study

POPShasdemonstrateda functionalabilitytoaidhealth careprofessionals’decision making.

Rowland etal.30

2014

POPS ED

Toinvestigatetheabilityof PEWSandPOPStopredict admissiontohospital.

2068 Prospectivecohort study

ThePEWSROCis0.67(95%CI 0.65---0.70),SE0.02,andthe POPSROCis0.72(95%CI 0.69---0.75).POPSisamore accuratepredictorof admissionriskfromtheED thanPEWS,andismore suitabletouseinanEDsetting

PAT,PediatricAssessmentTriangle;PEWS,PediatricEarlyWarningScore;POPS,PediatricObservationPriorityScore;ED,emergency department.

Inaddition, morethan 80% of respondents indicated that theyalwaysusethePATapproachintheirclinicalpractice. AlmostallrespondentsbelievedthattheAPLScourseshould beincludedinthepediatricresidency-trainingprogramand thatitshouldbearequirement.9

PAT

in

the

prehospital

setting

ThePATwasinitiallydesignedtobeusedintheprehospital setting.Thus,firstattemptstovalidatethetoolwerecarried outinthissetting.In2010,Miereketal.publishedastudyin which12EMSproviderswererecruitedtoobservetwovideos ofpediatricpatientsandmakeatransportdecisionbasedon theirobservations. Aftereachcase, theparticipantswere interviewed to determine why they made their decision. Interviewswere thentranscribed and analyzedseparately bythreeresearchers.Theyconcludedthatproviderscould extract information from a remote location about pedi-atric patients that could be organized into a tool similar to the PAT. This remotely-obtained information directly contributedtotransportdecisionsandsupported thatthe toolwasatime-efficientmethodoftriagingpatients.They

statedthatthePAT couldbetaughtwithmoreconfidence andgreateremphasis,andultimately,appliedmorebroadly toprehospitalmedicine.10

In2011,Horeczkoetal.publishedanarticlepresenting thePATtoprehospitalprovidersasatoolfortherecognition andtreatmentoftheacutelyillorinjuredchild.11

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When categorized as stable vs. unstable agreement betweenthePATParamedicImpressionandPATInvestigator Impression,agreementwasalso‘‘substantial’’(=0.66,95% CI:0.62---0.71).ThePATParamedicImpressionforinstability demonstrateda sensitivityof 77.4% (95%CI:72.6---81.5%), aspecificityof90.0%(95%CI:87.1---91.5%),withapositive likelihoodratio(LR+)of7.7(95%CI:5.9---9.1)andanegative likelihoodratio(LR-)of0.3(95%CI:0.2---0.3).The authors concludedthatparamedicsconstructedandappliedthePAT reliably,accuratelypredicting theinstabilityandstability. Further,thePATasusedbyparamedicswasconsistentwith theperformanceofappropriateprehospitalinterventions.12

PAT

and

triage

The aim of triage is to identify patients who are more urgent. Urgency incorporates concepts of risk of deterio-rationandtimelinessinmedicalassessmentandtreatment. Becauseurgencymaydifferbetweenpatientswiththesame diagnosis,triageshouldfocusonthepatient’sconditionat presentation insteadofthe diagnosis. Toidentifypatients withsuchacuteconditions,easyandquickassessmenttools mustbeincorporatedintriagesystems.13

Currently,themostcommonlyusedstructuredtriage sys-tems begin the patient’s classification by an assessment of this general impression regardless of the presenting problem.14---16 _Systems _such _as _the _Manchester _triage

sys-temwidelyusedinEuropeanEDswhichdonotincludethis initialassessment, haveshowntobelessaccuratefor the classificationofthepediatricpatient.17---21

Toassessthisgeneralimpression,knowledgeand experi-encearenecessarybutnotsufficient.Theotherfactorfound tobeimportantisgutinstinctorthesixthsense.15 _As_was

said before, the PAT somehow summarizes ‘‘gut feeling’’ findings,andthismakesittheidealacademictooltoteach thisinitialassessment.

The PAT also appears to be a potentially idealtool to guidetriagedecisionsbecauseitcanbeappliedeasilyand quickly, stratifyingstable andunstable patientsto differ-entcare pathways. The pediatric versionof theCanadian TriageandAcuityScale(PaedCTAs)usesthePATastheinitial assessmenttool.16

Horeczko etal. demonstratedfor the firsttime that a structuredassessment basedonPAT, performed bynurses during patienttriage, rapidlyand reliablyidentifies clini-callyurgentpediatricpatientsandtheirpathophysiological status. They conducted aprospective observational study wheretriagenursesperformedthePATonallpatients pre-senting tothe pediatricED of anurban teachinghospital. Researchersperformedblindedchartreviewusingthe physi-cian’sinitialassessmentandfinaldiagnosisasthecriterion standard for comparison. In their study, the PAT accu-ratelyand reliablyidentifiedacutely illor injuredinfants andchildren intriage, asevidenced bya lownegativeLR for instability. Furthermore, the PAT reliably categorized unstablechildrenbypathophysiology,asevidencedbyhigh positiveLRsfordisease,thusaidinginidentifyingpriorities ofmanagement.6

Inaddition,thePATalsohelpstoidentifythosepatients who, after complete diagnosis and treatment in the ED, have more serious health conditions and are eventually

admittedtothehospital.Inalargesingle-center retrospec-tivestudyincludingaround300,000episodesclassifiedusing thePaedCTAS,Fernandezetal.analyzedthepercentageof children hospitalizedrelated tothe PAT findings made by nursesatthetimeoftriage.As secondaryoutcomes,they alsoanalyzed thepercentage of patientsadmitted tothe pediatricintensivecareunit(PICU),thelengthofstay(LOS) inthepediatric ED(<3hand≥3h),andthepercentageof patientsinwhichbloodtestswereobtainedinrelationtoPAT findingsattriage.ThepresenceofabnormalPATfindingsat triagewasassociatedwithahigherprobabilityof hospital-ization(oddsratio[OR],5.14;95%CI,4.97---5.32)especially inthe case of appearance (OR, 7.87; 95% CI,7.18---8.62). In the multivariate analysis, abnormal PAT findings were confirmedtobeindependentriskfactorsforhospitalization. Regardingsecondaryoutcomemeasures,abnormalPAT find-ings,mainlyappearance,andcombinationsofmorethanone componentof thePAT wereassociatedwithlongerLOS in thepediatricED,andhigherprobabilityofadmissiontothe PICU(ORforabnormalPAT12.75;95%CI,10.86---14.97).22

Morerecently,thesamegroupassessedtheperformance ofthePAT along withthetriagelevel givenby PaedCTAS, a clinical score of asthma (pulmonary score), and oxy-gen saturation, as predictors of admission to a pediatric ED for children with asthma exacerbations. The presence of abnormal PAT findings was an independent risk factor for hospitalization (OR: 1.6, 95% CI: 1.4---1.8) and for a longer LOS (OR: 1.5, 95% CI: 1.3---1.7). Among the com-ponentsof PAT, abnormal circulation tothe skin was the bestpredictorofhospitalization(OR:1.8,95%CI:1.2---2.9), whereasincreasedwork of breathing wasassociated with longerLOS(OR:1.4,95%CI:1.3---1.6).Norelationship was foundbetweenabnormalPATfindingsandPICUadmission. TheauthorsconcludedthatthePATidentifiespatientswho requiremoreurgenttreatment,helpingtooptimizepatient flowwithinthepediatricED,andalsothosemorelikelytobe eventuallyadmittedorrequiringalongerstay.EDmanagers coulduse thisinformation in realtimeto make decisions regardingtheneedforadditionalresources.23

Other more complex initial assessment tools, such as the Pediatric Early Warning Score (PEWS) and the Paedi-atricObservationPriorityScore(POPS),havebeenassessed in the first stepof the triageprocess. These tools incor-poratemeasurementofvitalsigns.Traditionally,vitalsigns wereconsideredanintegralcomponentoftheinitialnursing assessmentandwereoftenusedasadecisionmakingtool, butnewertriagemodelsadvocateselectiveuseof physio-logicalparametersat triage.Vitalsignmeasurementsmay beoperatordependent, andthedefinitionofnormalvital signsvaries according to the referenceconsulted. This is especiallytrueforinfancyandchildhood,periodsof enor-mousphysiologicalanddevelopmentalchange,particularly intheearlymonthsandyears.Thereisalackofconsensusin theliteratureregardingnormalpediatricvitalsign param-eters,and furthermore, most references for normal vital signsderive fromstudies of healthy children. Even under thebest conditions,vital signsare not always reliable or accurate.1,24,25

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status.Thetoolwasdevelopedtodetectclinical deteriora-tioninchildrenadmittedtohospital,ultimatelytoprevent cardiopulmonaryarrest.Currently,severalPEWSarebeing usedin Europe,all ofthembasedonthemeasurementof physiologicalparameters,withlittledifferencebetweenthe scoringsystems.In2008Bradman&Maconochiestudiedthe use ofa PEWS-system asa triage tooltopredict hospital admission from the pediatric ED. They found that PEWS scoring in theED hada low sensitivity andtherefore had alimitedvalueinpredictingtheneedforadmission, proba-blybecausethephysiologicalparametersmeasuredcanbe raisedsecondarilytopain,pyrexia,andanxiety,allcommon presentationsinapediatricED.26

In 2013,Seiger etal. publisheda study comparingthe validityof differentPEWsin a pediatricED. Although the authorsfoundthatPEWScouldidentifypatientsatriskinthe EDforICUadmissionand,toalesserextent,couldidentify patientsatriskforhospitalization,theydidnotadviseusing warningscoresastriagetoolstoprioritizepatients,because atpresent,thereisnoevidencethatPEWSarebetterthan conventionaltriagesystems.27

In2014,Goldetal.exploredwhetherthePEWSutilized inanEDofanurban,tertiarycarechildren’shospital pre-dictedthe need forICU admission fromtheED or clinical deteriorationin admitted patients. Theirstudy confirmed that,actually,anelevatedPEWSisassociatedwithneedfor ICU admissiondirectly fromthe ED and asa transfer,but lacksthenecessarytestcharacteristicstobeused indepen-dentlyintheEDenvironment.Usingtheoptimalcutoffscore topredictdispositionfromtheEDwouldresultinatwo-to four-foldincreaseinintensivecareunitadmissionrate,as wellasincorrectlyplaceroughly25%ofICUpatientsonthe floor.The EDisadynamicenvironment,withpatients fre-quentlyhavingalterationsinphysiologicparametersdueto theacuityof illness or injury,medication,pain,fear,and anxiety.SuchfactorswouldresultinelevatedPEWSscores thatdonotreflectactualillness.28

ThePOPSincludes,inadditiontovitalsigns,subjective observation criteria, and has proven to be more suitable tousein anEDsetting thanPEWS.ThePOPSisabespoke assessmenttoolforuse inpediatricEDsincorporating tra-ditionalphysiologicalparametersalongsidemoresubjective observationalcriteria.Itisaphysiologicalandobservational scoringsystemdesignedforusebyhealth care profession-alsofvaryingclinicalexperience.POPShasdemonstrateda functionalabilitytoaidhealthcareprofessionals’decision makingandhasbeenshowntobeamoreaccuratepredictor ofadmissionriskfromtheEDthanPEWS.29,30

PAT

and

clinical

practice

Beyondthe clinical application of the PAT in triage, arti-clesonitsusefulnessinmedicalpracticewerenotfound.In theaforementionedstudypublishedbyBenitoetal.,most participants in the APLS courses acknowledged that they usedthe PAT approachin clinical practiceand morethan a half assured that their management of the critically-ill patientshadimprovedaftercoursecompletion.Inaddition, 82%statedthatthePATandABCDE(Airway,Breathing, Cir-culation,Disability, Exposure) approaches helped them in thediagnosisandindicationofthemostappropriateinitial

treatment.9_Although_this_study_does_not_give_evidence_on

thedirectimpactofthePATinclinicalpractice,theopinion ofproviderswhohave introducedthistoolinthe manage-mentoftheirpatientsappearstosupportitsusefulness.

Conclusions

The PAT has been incorporated, as an essential instru-mentforassessingsickchildren,intodifferentlifesupport courses,although littlehasbeen written aboutthe effec-tivenessofteachingit.

The PAT has demonstrated to be useful to assess sick children in the prehospital setting and tomake transport decisions.

IntheED,thePATisusefultoidentifychildrenattriage who require more urgent care, and recent studies have assessed and proved theefficacy of the PAT toalso iden-tify those patients having more serious health conditions whoareeventuallyadmittedtothehospital.Littlehasbeen published about performance of the PAT administered by pediatriciansor emergency physiciansin theinitial evalu-ationattheED.

The PAT is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperativetopromoteresearchforclinicalvalidation.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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