Rev. paul. pediatr. vol.34 número3

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REVISTA

PAULISTA

DE

PEDIATRIA

www.rpped.com.br

ORIGINAL

ARTICLE

CLARIPED:

a

new

tool

for

risk

classification

in

pediatric

emergencies

Maria

Clara

de

Magalhães-Barbosa

a,∗

,

Arnaldo

Prata-Barbosa

a

,

Antonio

José

Ledo

Alves

da

Cunha

b

_,

_Cláudia

_de

_Souza

_Lopes

c

a_Instituto_D’Or_de_Pesquisa_e_Ensino_(Idor),_Rio_de_Janeiro,_RJ,_Brazil

b_Departamento_de_Pediatria,_Faculdade_de_Medicina,_Universidade_Federal_do_Rio_de_Janeiro_(UFRJ),_Rio_de_Janeiro,_RJ,_Brazil c_Instituto_de_Medicina_Social_(IMS),_Universidade_do_Estado_do_Rio_de_Janeiro_(Uerj),_Rio_de_Janeiro,_RJ,_Brazil

Received13October2015;accepted29December2015 Availableonline27June2016

KEYWORDS

Triage;

Emergencymedical services;

Pediatrics

Abstract

Objective: Topresentanewpediatricriskclassificationtool,CLARIPED,anddescribeits devel-opmentsteps.

Methods: Development steps: (i) first round of discussion among experts, first prototype; (ii)pre-testofreliability,36 hypotheticalcases;(iii) secondroundofdiscussiontoperform adjustments;(iv)teamtraining;(v)pre-testwithpatientsinrealtime;(vi)thirdroundof dis-cussiontoperformnewadjustments;(vii)finalpre-testofvalidity(20%ofmedicaltreatments infivedays).

Results: CLARIPEDfeaturesfiveurgencycategories:Red(Emergency),Orange (veryurgent), Yellow(urgent),Green(littleurgent)andBlue(noturgent).Thefirstclassificationstepincludes themeasurementoffourvitalsigns(VIPEscore);thesecondstepconsistsintheurgency dis-criminationassessment.Eachstepresultsinassigningacolor,selectingthemosturgentone forthefinalclassification.Eachcolorcorrespondstoamaximumwaitingtimeformedicalcare andreferral tothemostappropriate physicalarea for thepatient’s clinicalcondition. The interobserver agreementwassubstantial (kappa=0.79)andthefinalpre-test, with82 medi-caltreatments,showedgoodcorrelationbetweentheproportionofpatientsineachurgency categoryandthenumberofusedresources(p<0.001).

Conclusions: CLARIPEDis anobjectiveandeasy-to-usetool for simple riskclassification,of which pre-testssuggestgoodreliability andvalidity.Larger-scalestudies onitsvalidityand reliabilityindifferenthealthcontextsareongoingandcancontributetotheimplementation ofanationwidepediatricriskclassificationsystem.

∗_{Corresponding}_author.

E-mail:[email protected](M.C.Magalhães-Barbosa).

http://dx.doi.org/10.1016/j.rppede.2016.02.002

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PALAVRAS-CHAVE

Triagem; Servic¸osmédicos deemergência; Pediatria

CLARIPED:umnovoinstrumentoparaclassificac¸ãoderiscoememergências pediátricas

Resumo

Objetivo: Apresentarumnovoinstrumentodeclassificac¸ãoderiscopediátrico,oCLARIPED,e descreverasetapasdeseudesenvolvimento.

Métodos: Etapas do desenvolvimento:(i) primeira rodada de discussão entre especialistas, primeiroprotótipo;(ii)pré-testedeconfiabilidade,36casoshipotéticos;(iii)segundarodada dediscussãoparaajustes;(iv)treinamentodaequipe;(v)pré-testecompacientesemtempo real;(vi)terceirarodadadediscussãoparanovosajustes;(vii)pré-testefinaldevalidade(20% dosatendimentosdecincodias).

Resultados: O CLARIPED apresenta cinco categorias de urgência: Vermelha (emergência), Laranja (muitourgente), Amarela (urgente), Verde(poucourgente) eAzul (sem urgência). A primeira etapa da classificação inclui a aferição de quatro sinais vitais (escoreVIPE); a segunda etapaconsistenaavaliaçãodediscriminadores deurgência.Cada etaparesulta na atribuiçãodeumacor,selecionando-seademaiorurgênciaparaaclassificaçãofinal.Cadacor correspondeaumtempomáximodeesperapeloatendimentomédicoeaoencaminhamentoà áreafísicamaisadequadaàcondiçãoclínicadopaciente.Aconcordânciainterobservadorfoi substancial(kappa=0,79)eopré-testefinal,com82atendimentos,evidenciouboacorrelação entreaproporçãodepacientesemcadacategoriadeurgênciaeonúmeroderecursosusados (p<0,001).

Conclusões: OCLARIPEDéuminstrumentoparaclassificaçãoderiscosimples,objetivoede fácil uso,cujospré-testessugerem boaconfiabilidadeevalidade. Estudosem maiorescala sobresuavalidadeeconfiabilidadeemdiferentescontextosdesaúdeestãoemcursoepodem contribuirparaaadoçãodeumsistemadeclassificaçãoderiscopediátricoemâmbitonacional. ©2016SociedadedePediatriadeSãoPaulo. PublicadoporElsevier EditoraLtda.Este éum artigoOpenAccesssobumalicençaCCBY(http://creativecommons.org/licenses/by/4.0/).

Introduction

Inthe lasttwodecades,amajorchallengein healthcare hasbeentofindsolutionstotheincreasedovercrowdingin emergencyservicehospitals.Oneofthestrategiesadopted inmanycountriestodealwiththisproblemwasthe imple-mentationoftriagesystemsusedtoclassifyeachpatient’s degree of clinical urgency shortly afterhis/her arrival to theEmergencyDepartment(ED),establishingawaitinglist basedonclinicalrisk,andnotinorderofarrival,toundergo medicalevaluationandtreatment.

The Australian Triage Scale (ATS), Canadian Triage & AcuityScale (CTAS),ManchesterTriageSystem (MTS),and EmergencySeverity Index(ESI) arethe tools for triagein emergencyservicesmostusedworldwide,allwithfivelevels ofurgency.1,2

In Brazil, the risk classification system developed by the Ministry of Health in the Qualisus Program has only fouremergencycategories,doesnotaddress thepediatric grouppeculiarities,andhasnotachievedsignificantnational adherence.3,4_On_the_other_hand,_those_developed_in_Europe,

North America, andAustralia arecomplex,which hinders large-scaleadoptionina heterogeneoushealth contextas theBrazilian.Moreover,thereareinsufficientliteratureon thevalidityandreliabilityofthepediatricversionsofthese triagesystems.

Theaimofthisstudyistopresentanewriskclassification tool,theCLARIPED,forpediatricemergenciesanddescribe the steps of its development. The intent is to obtain a

reliableand validtool thatis best suitedtothe Brazilian healthcontext.

Method

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chartsreview.ThestudywasapprovedbytheInstitutional Review Board of the Instituto D’Or de Pesquisa e Ensino (IDOR),underthenumber209075/2013.

Results

A group of experts (three doctors and two nurses) with extensiveexperiencein pediatricemergencieswas assem-bledinordertochooseandtestariskclassificationtoolfor thepediatricemergencydepartment.Afterextensive liter-aturereview,itwasconcludedthatthefourtriagesystems designedinNorthAmerica(CTASandESI),UnitedKingdom (MTS),andAustralia (ATS)werenotsuitablefor our coun-try,astheyareextensive,complexorlackspecific-pediatric features.TheSouthAfrican TriageScale (SATS),5 _although

simplerandmoreadaptabletotheBrazilianhealthcontext, onlyhadfourlevelsofurgency,insufficientstratificationof pediatricagegroups,inadditiontohavingfewstudiesofits useinchildren.Itwasdecided,therefore,todesignanew triagesystemspecificforpediatricemergencies.

TheCLARIPEDsystem

CLARIPED comprises five urgency categories: Red (immi-nent life threat), Orange (very urgent), Yellow (urgent), Green(littleurgent)andBlue(noturgent). Eachcategory isassignedamaximumwaitingtimeformedicalevaluation andreferraltoanappropriateserviceareaofadequatecare tothepatient’slevelofurgency,asfollows:red,immediate careintheressucitationroom;orange,carewithin10minin theobservationroom;yellow,upto30min,waitingroom;

green,upto90min,waitingroom;andblue,upto180min, waitingroom.Theriskclassificationshouldstartina max-imumof 10min after patient’s arrival and registration; it shouldbeperformedbyanurseandlast2---5min.

Thefirststepstartswithsixquestionsaboutcomplaints, drugallergies,regular pediatric care, associated morbidi-ties,usingmedicationsand lastmeasured weight.Nextis theevaluationoffourvitalsigns:respiratoryrate(RR),heart rate(HR), oxygensaturation(SpO2),andskintemperature

(Temp).Eachvitalsignmeasuredisassignedavaluefrom0 to4,which willcomposethePediatricVitalSignals(VIPE) scorethatrangesfrom0to12,consistingofthesumofthe firstthreeparametersvaluessubtractedfromthe temper-aturevalueincaseof increasedHR(RR+HR+SpO2-Temp,if

increasedHR).TheVIPEscoreshouldthenbeassociatedwith oneof fivecolors: score 0=Blue; 1---2=Green; 3---5=Yellow; 6---9=Orange;≥10=Red(Table1).

The second stepis toconsult the tablesof discrimina-tors categorized by type or organ system involved (lines) and by urgency levels (columns). Assessment of five gen-eraldiscriminators(pain,generalappearance,feverreport, age, and return to the ED) is mandatory for all patients (Table2). The other discriminators are evaluated accord-ingtothepatient’scomplaint(Table3).Itisnotnecessary toconsultall linesandcolumns ofthe second table,only therelevantlinesassociatedwiththereportedcomplaints andthecolumnscorrespondingtolevelsofurgencyhigher thantheassignedbytheVIPEscore.Ifthereisa discrimi-natorcorrespondingtoahigherlevelofurgencythanthat assignedbytheVIPEscore,thehigherlevelofurgencywill

determinethefinalclassification.Theurgencydetermined bytheVIPEscoremaynotbedecreased,onlyincreasedfrom theevaluationofthediscriminators.

Inthe presence ofdiscriminators indicating risk of life threatening,suchassseizures,impairedlevelof conscious-ness,apnea,cyanosis,andothers,thepatientmustbesent for rapid or immediatemedical care before any adminis-trative procedure. The risk classification process is then performedretrospectively.

Pre-teststudies

Thehypotheticalclinicalscenariosdesignedbyexpertsfor training had the following distribution of urgency levels: Red11%,Orange42%,Yellow31%,Green8%,andBlue8%. Theoverallkappaformultipleobserversresultingfromthe firstpre-testwith36hypotheticalclinicalscenarioswas0.79 andkappaforeachurgencycategory was0.93(Red);0.82 (Orange);0.73(Yellow);0.65(Green),and0.93(Blue),with astandarddeviationof0.03andp<0.001,whichrepresented substantialreliability.

The second pre-test, performed with patients in real time, determined changes for the treshholds and values attributedtothephysiologicalparametersandforsome dis-criminators(newborn,returninlessthan24h,feverreport, abdominalpain,andcranialtrauma).

The final validity pre-test, included the retrospective analysisof95medicalcharts,selectedbyasystematic samp-ling of 20%of the cases attendedin thefirst fivedays of December2013. The aimwastoevaluate thedistribution ofthelevelsofurgencyandtheirassociationwithan out-come, which could work as a proxy of urgency, such as the numberofdiagnostic andtherapeutic resourcesused. The distributionofthelevelsofurgencywas: Blue(4.2%); Green(34.7%);Yellow(41%);Orange(6.3%),andRed(0%). NoneoftheattendancesclassifiedasBlueusedadiagnostic and/ortherapeuticresourceintheemergencydepartment; onethirdoftheGreenattendances,halfoftheYellowones usedoneresourceand20%usedtwoormoreresources;over 80%oftheOrangeonesusedtwoormoreresources(Table4;

p<0.001).

Discussion

The proposal todevelop asimple, objective, andeasy to use tool for risk classification in pediatric emergencies, appropriate toa Brazilian health context, resulted in the CLARIPED.Brazil’scontinentalmagnitudeand heterogene-ity make it difficult to adopt a risk classification system nationwide. The option to develop a new instrument, insteadofusingother triagesystemsalreadyevaluated, is justified. The most commonly used systems in the world weredevelopedincountriesinNorthAmerica,6,7 _Europe,8

andAustralia.9_The_health_context_of_these_countries_is_quite

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Table1 VIPEscorecalculation(vitalsignsinPediatrics).

Newbornto2monthsold

4 2 1 0 2 3 4

RR <16 16---19 20---29 30---60 61---80 81---90 >90 HR <81 81---90 91---110 111---149 150---179 180---189 >189 SpO2 <90 90---92 93---94 95---100

3monthsto11monthsold

4 2 1 0 2 3 4

RR <16 16---19 20---24 25---50 51---70 71---80 >80 HR <71 71---80 81---100 101---139 140---169 170---179 >179 SpO2 <90 90---92 93---94 95---100

1yearto4yearsold

4 2 1 0 2 3 4

RR <13 13---15 16---19 20---40 41---60 61---70 >70 HR <61 61---70 71---90 91---119 120---149 150---169 >169 SpO2 <90 90---92 93---94 95---100

5yearsto12yearsold

4 2 1 0 2 3 4

RR <11 11---14 15---17 18---24 25---36 37---50 >50 HR <51 50---60 61---70 71---109 110---129 130---149 >149 SpO2 <90 90---92 93---94 95---100

>12years

4 2 1 0 2 3 4

RR <10 10 11 12---16 17---22 23---29 >29 HR <41 41---50 51---60 61---99 100---119 120---139 >139 SpO2 <90 90---92 93---94 95---100

Assessmentofaxillarytemperature(regardlessofage) IfHRisincreased(score2,3or4)Subtract:

0 −1 −2

AxT 36---37.4 37.5---38.5 >38.5

VIPEscore(0---12)isthesumofthepointsassignedtoeachvitalsign.However,ifheartrateisincreased(score2,3or4);−1shouldbe subtractedfromthefinalscoreiftheaxillarytemperatureisbetween37.5and38.5◦_C_and

−2iftheaxillarytemperature(AxT)is>38.5◦C. Urgencyclassification:Blue(0),Green(1---2),Yellow(3---5),Orange(6---9),andRed(≥10).

Table2 CLARIPEDgeneralandmandatorydiscriminators.

Discriminator Red Orange Yellow Green Blue Maximum

waitingtime

Immediate 10min 30min 90min 180min General

appearance

Criticallook Looksveryill Looksill Lookslittleill Verygood Importantprostration Mildtomoderate

prostration

Noprostration Doesnot looksick Pain(level)a _Strong_(7---10) _Moderate_(4---6) _Mild_(1---3) _No_pain₍₀₎

Fever(axillary temperature)b

Feverreport≥38.5◦_C

in<3months

Feverreport≥37.5◦_C

in<3monthsold Feverreport≥38.5◦_C

in<3yearsold

Feverreport≥39.5◦Cat

anyage

Age Newborn(≤28days)

Return 1returnin<24h

2returnsin<72h

a _The_level_of_pain_should_be_evaluated_by_appropriate_scales_for_the_patient’s_age,_such_as_FLACC_Scale_or_Faces_Scale_(<5_years)_and

VisualAnalogicScale(>5years).

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Table3 CLARIPEDdiscriminatorsaccordingtoreportedcomplaints.

Discriminator Red Orange Yellow Green Blue Levelof

consciousness

Unconscious(coma) Altered (drowsinessand stupor)

Airway/breathing Cyanoticlips Dyspneaa _Tachypneab _Coryza_and/or

sneezing Apnea Stridorc _Hoarsenessd

in<2years

Cough

Cardiovascular Absentpulses Weakpulses Cyanoticextremities Capillaryrefill>2s. Neurological Seizureatthetimeof

care

Acutefocaldeficit Seizureinthepast 12h

Postictalstate CBG:e_40---60

(≤1year)or60---80

(>1year) CBG:e_<40

(≤1year)or<60

(>1year) Gastrointestinal

andgenitourinary

Signsof dehydrationf

Currentseizureor reportof

persistent vomiting

Historyofvomiting and/ordiarrheain thepast72h

Urinaryretention withpalpable bladder

>5bowel

movements/dayor bloodydiarrhea Scrotalpain

and/orswelling

Currentand persistent abdominalpain Intermittent abdominal pain<2years Trauma Polytraumag _TBI_with_report

oflossof consciousness and/orvomiting

TBIwith<12hand noreportofloss ofconsciousness orvomiting

TBIwith>12h withoutlossof consciousnessand withoutvomiting Openfractureor

deformity Highenergy mechanismh

Suspectedfracture orlimbdislocation Bleedingor

woundi

Uncontrolledbleeding Profusebleeding Controlled moderatebleeding

Smallbleeding Minorinjury withoutbleeding Extensiveinjury Moderateinjury Smallwoundwith

mildbleeding Burnj _Face_and/or_inhalation _Moderate>20% _Mild<10%

Electricalor circumferentialor chemicalburn Exogenous

intoxication

Present(reported)

Skin Urticarial_with_stridor

andsignificant respiratorydifficulty

Urticarial_with

faceedema

Extensive urticarial

Rashwithout petechiae

Impetigoorlocal abscess

Purpurak _Edema_without

hypertension

Localurticaria

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Table3 (Continued)

Discriminator Red Orange Yellow Green Blue Locomotor Claudication+fever

Acutegaitdisorder Foreignbody Present

Unspecific Unabletostand Inconsolablecrying Behaviorchange Irritability

Suspectedabuse Comorbidities Diabetes,withsevere

hypoglycemia (CBG<20)e

Diabeteswith hypo-orhyperglycemia: CBGe_<60_or>400

DiabeteswithCBGe

between250and400

Immunosuppression withfever

Neuromuscular diseasesm

Immunosuppressionn

withoutfever Suspecteddengue

(alwaysmeasure BPo_lying_and

sitting)

Signsofshock Presenceofwarning signsp

Absenceofwarning signsp

Signsofrespiratory failure

a _Dyspnea:_respiratory_distress_with_presence_of_intercostal_retractions. b _Tachypnea:_increased_RR_according_to_the_VIPE_table_(RR_score>0).

c _Stridor:_noise_during_inspiration_with_varying_degrees_of_respiratory_distress. d _Hoarseness:_hoarse_cry_or_voice_or_cough,_without_stridor_or_respiratory_distress.

e _Capillary_blood_glucose_(CBG_mg/dL):_perform_the_test_in_all_patients_with_altered_level_of_{consciousness,}_recent_or_current_seizure,

lethargyorprevioushistoryofdiabetes.

f _Signs_of_dehydration:_dry_mouth,_sunken_eyes,_not_urinating_in_the_last_12h,_decreased_skin_turgor. g _Polytrauma:_patients_with_traumatic_injury_in_two_or_more_organs.

h _High_energy_mechanism_(in_the_absence_of_information,_consider_any_traffic_accident_as_high_energy_mechanism):_(a)_motor_vehicle

accident>60km/h(beltcollision);>40km/h(unbeltedcollision);>30km/h(motorcycle),and>10km/h(runover);(b)afallfromhigher than1m.

i _Wound:_(a)_mild: _abrasions_and _contusions_requiring _no_suture; _(b)_moderate: _contusions_requiring _sutures,_but_with_controlled

bleeding;(c)severe:extensivecontusionsrequiringsutures,profuseandcontinuousbleeding.

j _Burn:_Rule_of_nines.

k _Purpura:_presence_of_petechia_and/or_ecchymosis.

l _Urticaria:_unlike_other_skin_rashes;_hyperemia_and_elevated_plaques,_usually_very_itchy,_but_not_always. m _{Neuromuscular}_diseases:_chronic_{encephalopathy,}_myopathy,_{myelomeningocele,}_{hydrocephalus.}

n _{Immunosuppression:}_after_{chemotherapy,}_nephrotic_syndrome_in_activity,_chronic_use_of_{corticosteroids.}

o _Blood_pressure_(BP):_Always_measure_in_case_of_altered_level_of_{consciousness,}_recent_or_current_seizure,_suspected_dengue_fever,

edemaofthelowerlimbsorgeneralized(anasarca).

p _Warning _signs _in _dengue _(presence _of _one _or _more _signs): _abdominal _pain, _persistent _vomiting, _respiratory _distress, _postural

hypotensionordizziness,drowsiness,and/orirritability,spontaneousbleeding,decreasedurineoutput,suddendropintemperature, hypothermia,edema.

Table4 Pilotpre-testofvalidity:useoftreatmentresourcesinaccordancewiththelevelofriskclassification. Frequency

n(%)

0resource

n(%)

1resource

n(%)

2resources

n(%)

≥3

resources

n(%)

Total

n(%)

p-valuea

Blue 4(4.2) 4(100) 0 0 0 4(4.9) <0.001 Green 33(34.8) 17(51.5) 14(42.4) 1(3) 1(3) 33(40)

Yellow 39(41.0) 9(23) 17(43.6) 12(30.8) 1(2.6) 39(47.6) Orange 6(6.3) 0 1(16.6) 2(33.3) 3(50) 6(7.3)

Red 0 0 0 0 0 0

Missing 13(13.7)

Totaln(%) 30(36.6) 32(39) 15(18.3) 5(6) 82(100)

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thecountryasSouthAfricanTriageScale(SATS). CLAR-IPEDkeptthetwo-stepslogisticsoftheSATStriageprocess, consisting of mesurement of physiological parameters, followedbyassessmentofdiscriminators.However,several modificationswereperformedinbothstepsandaredetailed below.

AlthoughSATShasfivecolors,strictlyspeakingithasonly fourlevelsofurgency,astheBlueleveldoesnotreferto non-urgentpatients,buttopatientswhoaredeadonarrival.In theBrazilianhealthcontext,thereisalargeinfluxof outpa-tientstotheemergencyservices.3,4_Thus,_the_existence_of

alevelfornon-urgentpatientsisjustified,similartoother systemssuchastheMTS,8_ESI-4,6_PaedCTAS,7_and_ATS.9_The

triagetoolswithfiveemergencycategories showedhigher reliabilityandvaliditythantoolswithfewercategories.13

InCLARIPED,weoptedforthestratificationintofiveage groups,insteadofthethreegroupsusedbySATS.Thisoption isinagreementwiththevitalsignstablesrecommendedby pediatric textbooks14,15 _and _other _triage _instruments _that

usefourormoreagegroups.6,7_However,_there_is_a_lack_of

studiesthatvalidatethestratificationofagegroupsforvital signsinPediatrics.TheBedsidePediatricEarlyWarning Sys-temScore---BedsidePEWSScore),atooldesignedtodetect early clinical deterioration of hospitalized children, was derivedfromstatisticalmethods andrecentlyvalidated.16

ThestratificationintofiveagegroupsofCLARIPEDwasbased onBedsidePEWSScore.

Althoughthereisnotyetaninternationalconsensuson theparameterstobeincludedinatriagetool,thereis evi-dencethatvitalsignsshouldbeanintegralpartofasafety risk classification process, particularly in children.5,17,18

However,vitalsignmeasurementscanbeextremelydifficult inemergencyscenarios,particularlyinsmallor uncoopera-tivechildren.Selectingthemostobjectiveparametersthat represent an effective contribution to the discrimination of emergency is crucial toachieve the goals of timeand processimprovement.InSATS,thefirststepincludes eval-uationofsevenparameters:RR,HR,systolicbloodpressure (SBP),Temp,levelofconsciousness,mobility,andpresence oftrauma.The pediatricrevised versionofSATS excluded theSBPassessment.ThePaedCTAS7_recommends_the

mea-surementofHR,RR,andSpO2_as_first_order_modifiers,_while

theESI-46_recommends_the_measurement_of_the_same_three

vitalsignsonlyincertaincircumstances.TheATS19_leaves_at

thediscretionofthetriageprofessionaltheneed to mea-surevitalsigns. InCLARIPED, thefourselectedvitalsigns andthescoreassignedtoeachofthemarebasedonstudies addressingthe developmentof twoinstrumentsthat used statisticalmethodstoassesstheabilityofsome physiolog-icalparameterstopredict clinical outcomes:the Bedside Pews16_and_Pediatric_Emergency_Assessment_Tool_(PEAT),20_a

multivariatemodeltopredictthreelevelsofcarerequired forpediatricpatientsintheemergencydepartment.

TheinclusionofSpO2inVIPEscorewasbasednotonlyon

useofthisparameterinothervalidatedinstruments,suchas theESI-4,6 _PaedCTAS,7 _and_Bedside_Pews_Score,16 _but _also

onevidence that patients withlow SpO2 usually have no

increasedrespiratory rate and that itsmeasurement may generatesignificantchangesinthemanagementofanumber ofpatientsattendedatpediatricemergencyservices.21,22

Theexclusionofblood pressuremeasurementfromthe VIPE score wasbased on evidence that the benefitof its

mandatory assessment in pediatric patients in the emer-gency department is limited.23 _On _one_hand, _hypotension

is a late sign of shock in children and, on the other hand,thetriageofchildrenwithhypertensioninthe emer-gency department may result in high prevalence of false positives.24 _Other _triage _tools,_such _as_MTS,8 _Paed_CTAS,7

ESI-4,6 _and_ATS,19 _do_not_include_mandatory_measurement

ofbloodpressure,butonlytheinitialassessmentofclinical signsofshock,suchasthinpulses,delayedcapillaryrefill, sweating,andpallor.

HRcorrectedbythedegreeoffeverisauniqueaspectof CLARIPEDandwasbasedonthefactthattachycardiaisone ofthesystemicinflammatoryresponsesyndrome(SIRS)and sepsisparameters.25 _A_recent_study_proposes_a_similar

cor-rectionintheevaluationofchildrenwithacuteinfection.26

Noothertriagesystemconsidersthiscorrection.The assess-ment of the degree of fever is further considered in the discriminatorsstep,accordingtoageandfollowsthe guide-lines of the American College of Emergency Physicians.27

However,unlikeothertriagesystems,CLARIPEDtakesinto accountnotonlythecurrentfever,butthereportoffever inthelast24h.

In CLARIPED, the evaluation of patient’s level of con-sciousnessandpresenceoftraumaweremovedtothestep of discriminators assessment. Instead of considering the involvementofthepatient’slevelofconsciousnessintofour categories(awake,responsetopain,responsetovoice,and non-responsive),asrecommendedinSATS,11_CLARIPED

con-sidersthatthepresenceofanyimpairmentofconsciousness placesthe patientat theOrangelevel (veryurgent).This strategy is already used in MTS,8 _ESI-4,6 _PaedCTAS,7 _and

ATS.19

InCLARIPED,traumaisassessednotonlyforitspresence orabsence,asrecommendedinSATS,butaccordingtothe aspectsofmechanism,extension,locationandpresenceof symptoms.Themechanismandtraumaseverityassessment isalsousedinotherinstruments.PaedCTAS7_and_ATS19_assess

the presence of a high energy mechanism, regardless of clinical symptoms,toclassifypatients intohigherurgency categories.InMTS,8 _there_is_a_specific_flowchart_for_major

traumainwhichpatientsareclassifiedinemergencylevels one,two,oratleastthree,dependingonclinical manifes-tations.

Finally, the table of discriminators used in the second stepofCLARIPEDisverydifferentfromthatusedinSATS,in termsofcontentandorganization.AsinPaedCTAS,7

discrim-inators aregroupedby organsystems.The Canadiantool, however, is much more extensive and complex, covering 167complaintsgroupedinto17organsystems.

A recent study of the SATS5 _demonstrated _that _in

pediatric triage the combination of the two steps, the evaluation of physiological parameters followed by the assessment of clinicaldiscriminators, increasedsensitivity (91%), compared with the use of each step alone (57.1% and75.6%,respectively).InCLARIPED,itisconsideredthat theVIPEscorecalculationhasalowerweightinthetool’s sensitivity, although this hypothesis has not been tested yet.

Thefinalpre-testwithasampleof82attendancesfounda distributionofemergenciessimilartootherstudies.28---30_The

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Some limitationsmaybeidentifiedin thedevelopment oftheCLARIPEDsystem.Thefirstreferstothemethodology forconsensusontheproposedmodificationsandthechoice andorganizationofdiscriminators.ADelphimethod assur-ing the participating experts anonymity, interaction with controlled feedback, and statistical analysis of responses tosuccessiveroundsofinteractionwouldbethepreferred methodtominimizebiasand noiseandensure the preva-lence of the majority opinion. On the other hand, the tooldevelopmentprocessinseveralstepsensuredthe pro-cess systematization and a broad participation of the ED professionalsin thedevelopmentandimprovementof the instrument up to its last version. The second limitation relatesto the use of CLARIPED in other health care sett-ings.Itcanbearguedthatthespecificcontextinwhichthe CLARIPED was conceived limitsits application elsewhere. Morespecificdiscriminatorsrelatedtoophthalmologicalor psychiatricemergencies,for example,areabsentin CLAR-IPED.However,thesearchforthesimplicity,objectivity,and trainingfacility oftheinstrumentcanmakeitsadaptation anddisseminationviable inother less developedBrazilian regions by including more comprehensive and/or specific discriminators suitable to different settings. The concern in refining the discrimination between intermediate lev-els of urgency (Yellow [urgent] vs. Green [little urgent]) alsomakesthetool theoreticallyapplicable to intermedi-ateandlowurgencycareservices.Howevertheinstrument is not suitablefor pre-hospitaltriageduring criticalmass events.Specificinstrumentsfocusingontriageofcritically illpatientsinnon-hospitalsettingsareneededforthis pur-pose.

Itcan beconcludedthatthedevelopmentofCLARIPED for risk classification in pediatric emergenciesresulted in asimple,objective,andeasytousetool,whose pre-tests suggestagoodreliabilityandvalidity.Larger-scalestudies ofitsvalidity,reliability,andapplicationindifferenthealth contextsareunderway andmaycontributetotheuseofa pediatricriskclassificationsystemnationwide.

Funding

CNPq(Conselho Nacionalde Desenvolvimento Científico e Tecnológico, REF. No.: 448855/2014-3). Faperj (Fundac¸ão CarlosChagasFilhodeAmparoàPesquisadoEstadodoRio deJaneiro,REF.No.:E-26/010.000196/2015).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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