Objective To validate use of the Manchester triage system in paediatric emergency care. Design Prospective observational study. Setting Emergency departments of a university hospital and a teaching hospital in the Netherlands, 2006-7. Participants 17 600 children (aged <16) visiting an emergency department over 13 months (university hospital) and seven months (teaching hospital). Intervention Nurses triaged 16 735/17 600 patients (95%) using a computerised Manchester triage system, which calculated urgency levels from the selection of discriminators embedded in flowcharts for presenting problems. Nurses over-ruled the urgency level in 1714 (10%) children, who were excluded from analysis. Complete data for the reference standard were unavailable in 1467 (9%) children leaving 13 554 patients for analysis. Main outcome measures Urgency according to the Manchester triage system compared with a predefined and independently assessed reference standard for five urgency levels. This reference standard was based on a combination of vital signs at presentation, potentially life threatening conditions, diagnostic resources, therapeutic interventions, and follow-up. Sensitivity, specificity, and likelihood ratios for high urgency (immediate and very urgent) and 95% confidence intervals for subgroups based on age, use of flowcharts, and discriminators. Results The Manchester urgency level agreed with the reference standard in 4582 of 13 554 (34%) children; 7311 (54%) were over-triaged and 1661 (12%) under-triaged. The likelihood ratio was 3.0 (95% confidence interval 2.8 to 3.2) for high urgency and 0.5 (0.4 to 0.5) for low urgency; though the likelihood ratios were lower for those presenting with a medical problem (2.3 (2.2 to 2.5) v 12.0 (7.8 to 18.0) for trauma) and in younger children (2.4 (1.9 to 2.9) at 0-3 months v 5.4 (4.5 to 6.5) at 8-16 years). Conclusions The Manchester triage system has moderate validity in paediatric emergency care. It errs on the safe side, with much more over-triage than under-triage compared with an independent reference standard for urgency. Triage of patients with a medical problem or in younger children is particularly difficult.
Abstract Based on a survey sent to seven Dutch hospitals, we observed an substantial increase in invasive group A streptococcal infections in children in the Netherlands, comparing the pre-COVID-19 pandemic cohort of 2018-2019 to 2021-2022. The most affected age group were children between 0-5 years. Main diagnosis was pneumonia with empyema. Necrotizing fasciitis and streptococcal toxic shock syndrome were also reported in 11% and 7% respectively. A significant number was admitted to the Paediatric Intensive Care Unit. Vigilance is needed.
Background CD64 is expressed on the surface membrane of neutrophils (nCD64) in the presence of bacterial infection. Although initial studies in intensive care settings have been promising, only two small, methodologically flawed studies have been performed in feverish children presenting to the emergency departement (ED), both of which were showing a moderate diagnostic value of nCD64 to detect a serious bacterial infection (SBI). This study aimed to determine the diagnostic value of nCD64 in children presenting with fever to the ED for detecting SBI. Methods In this prospective observational multi-centre study previously healthy children aged 1 month–16 years with fever, presenting to the ED of two hospitals in the Netherlands in 2011–2012 were included. Standardised information on clinical features were collected and nCD64 and CRP were measured routinely. Multivariable logistic regression was used to determine the discriminative ability to detect SBI (ROC-area) of nCD64 compared with CRP. Diagnostic performance measures including sensitivity, specificity and likelihood ratios were calculated. Results In 392 children (45%) with both CRP and nCD64 determined, 52 children (13%) had an SBI. The AUC of the ROC curve for CD64 was 0.62 (95% CI = 0.54–0.70) and 0.75 (95% CI = 0.67-0.83) for CRP. Neither duration of fever nor deviated vital signs influenced the diagnostic performance of nCD64. Conclusion NCD64 expression has poor discriminative value to detect children with an SBI in a general population of febrile children at the ED. It has no superior value compared to CRP in this setting, neither in total nor in sub-populations.
Triage in paediatric emergency care is an important tool to prioritize seriously ill children. Triage can also be used to identify patients who do not need urgent care and who can safely wait. The aim of this review was to provide an overview of the literature on reliability and validity of current triage systems in paediatric emergency care We performed a search in Pubmed and Cochrane on studies on reliability and validity of triage systems in children The Manchester Triage System (MTS), the Emergency Severity Index (ESI), the Paediatric Canadian Triage and Acuity Score (paedCTAS) and the Australasian Triage Scale (ATS) are common used triage systems and contain specific parts for children. The reliability of the MTS is good and reliability of the ESI is moderate to good. Reliability of the paedCTAS is moderate and is poor to moderate for the ATS. The internal validity is moderate for the MTS and confirmed for the CTAS, but not studied for the most recent version of the ESI, which contains specific fever criteria for children. The MTS and paedCTAS both seem valid to triage children in paediatric emergency care. Reliability of the MTS is good, moderate to good for the ESI and moderate for the paedCTAS. More studies are necessary to evaluate if one triage system is superior over other systems when applied in emergency care.
Objective To evaluate compliance and costs of referral of nonurgent children, who present at the emergency department, to the general practitioner cooperative (GPC). Materials and methods In a prospective observational before–after study, during 6 months in 2008, the triage nurse discussed referral to the GPC with parents, when self-referred children with a nontraumatic problem, aged 3 months–16 years were triaged as nonurgent (levels 4 and 5) according to the Manchester Triage System. A telephone follow-up was performed 2–4 days after referral. Real costs were calculated for emergency department consultation (preintervention period) and GPC referral (postintervention period). Compliance of referral was studied for 4 days a week. Results One hundred and forty patients were referred to the GPC, of which 101 out of 140 patients (72%) attended a follow-up. After discharge seven patients (7%) had an unscheduled revisit. No patients were subsequently hospitalized. In total 275 patients were included to study compliance, with 28 (10%) reported missing. Ninety-five out of 247 (38%) patients were referred to the general practitioner and 46 out of 247 parents (19%) refused referral. For 106 out of 247 patients (43%) referral was not initiated by the nurse mainly because of comorbidity. Mean costs per patient were € 106 for the preintervention period and € 101 for the postintervention period. Conclusion Compliance of referring low urgent patients is low, mainly because it was difficult for nursing staff to refer. Total overall cost benefit is minimal. Cost savings may be achieved in different settings, where general practitioner services are colocated and where large numbers can be referred.
In this review Salmonella dublin infections in cattle are discussed. Pathogenic pathways and clinical symptoms in calves and cows are mentioned in addition to diagnostic methods like post mortem examination, bacteriological methods and serology. Epidemiological aspects like carrier state in cows and the survival of the bacteria in the environment are discussed. Without reliable tests to detect carriers, we suggest that control of this infection on farms must be based on prevention, improved hygiene and therapeutic measures. Vaccination can be used to improve the immunity of the herd.
Objectives This multicenter study examines the performance of the Manchester Triage System (MTS) after changing discriminators, and with the addition use of abnormal vital sign in patients presenting to pediatric emergency departments (EDs). Design International multicenter study Settings EDs of two hospitals in The Netherlands (2006–2009), one in Portugal (November–December 2010), and one in UK (June–November 2010). Patients Children (<16years) triaged with the MTS who presented at the ED. Methods Changes to discriminators (MTS 1) and the value of including abnormal vital signs (MTS 2) were studied to test if this would decrease the number of incorrect assignment. Admission to hospital using the new MTS was compared with those in the original MTS. Likelihood ratios, diagnostic odds ratios (DORs), and c-statistics were calculated as measures for performance and compared with the original MTS. To calculate likelihood ratios and DORs, the MTS had to be dichotomized in low urgent and high urgent. Results 60,375 patients were included, of whom 13% were admitted. When MTS 1 was used, admission to hospital increased from 25% to 29% for MTS ‘very urgent’ patients and remained similar in lower MTS urgency levels. The diagnostic odds ratio improved from 4.8 (95%CI 4.5–5.1) to 6.2 (95%CI 5.9–6.6) and the c-statistic remained 0.74. MTS 2 did not improve the performance of the MTS. Conclusions MTS 1 performed slightly better than the original MTS. The use of vital signs (MTS 2) did not improve the MTS performance.
OBJECTIVE: This prospective observational study aimed to assess the validity of the Manchester Triage System (MTS) for children with chronic illnesses who presented to the emergency department (ED) with infectious symptoms. METHODS: Children (<16 years old) presenting to the ED of a university hospital between 2008 and 2011 with dyspnea, diarrhea/vomiting, or fever were included. Chronic illness was classified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes. The validity of the MTS was assessed by comparing the urgency categories of the MTS with an independent reference standard on the basis of abnormal vital signs, life-threatening working diagnosis, resource utilization, and follow-up. Overtriage, undertriage, and correct triage were calculated for children with and without a chronic illness. The performance was assessed by sensitivity, specificity, and diagnostic odds ratios, which were calculated by dichotomizing the MTS into high and low urgency. RESULTS: Of the 8592 children who presented to the ED with infectious symptoms, 2960 (35%) had a chronic illness. Undertriage occurred in 16% of children with chronic illnesses and in 11% of children without chronic illnesses (P < .001). Sensitivity of the MTS for children with chronic illnesses was 58% (95% confidence interval [CI]: 53%–62%) and was 74% (95% CI: 70%–78%) for children without chronic illnesses. There was no difference in specificity between the 2 groups. The diagnostic odds ratios for children with and without chronic illnesses were 4.8 (95% CI: 3.9–5.9) and 8.7 (95% CI: 7.1–11), respectively. CONCLUSIONS: In children presenting with infectious symptoms, the performance of the MTS was lower for children with chronic illnesses than for children without chronic illnesses. Nurses should be particularly aware of undertriage in children with chronic illnesses.
Background: SARS-CoV-2 variant evolution and increasing immunity altered the impact of paediatric SARS-CoV-2 infection. Public health decision making relies on accurate and timely reporting of clinical data.Methods: This nation-wide hospital-based multicentre, prospective cohort study with real-time reporting was active from March 2020 until December 2022. We evaluated longitudinal incident rates and risk factors for disease severity.Findings: We included 564 hospitalized children with acute COVID-19 (n=375) or Multisystem Inflammatory Syndrome in Children (MIS-C) (n=189) from the Netherlands, Curaçao, and Surinam. In COVID-19, 134/375 patients (36%) needed supplemental oxygen therapy and 35 (9·3%) required intensive care treatment. Age above twelve years of age and pre-existing pulmonary conditions were predictors for severe COVID-19. During omicron, hospitalized children had milder disease. During population immunity, the incidence rate of paediatric COVID-19 infection declined for older children but was stable for unexposed children below one year. The incidence rate of MIS-C was highest during the delta wave and has decreased rapidly since omicron emerged. Real-time reporting of our data impacted national paediatric SARS-CoV-2 vaccination- and booster-policies.Interpretation: Our data supports the notion that similar to adults, prior immunity protects against severe sequalae of SARS-CoV-2 infections in children. Real-time reporting of accurate and high-quality data is feasible and impacts clinical and public health decision making. The reporting framework of our consortium is readily accessible for future SARS-CoV-2 waves and other emerging infections.Funding: This study was funded by the #wakeuptocorona crowdfund initiative of the Bontius Stichting and the Leiden University Fund, and by ZonMw (10430072110007).Declaration of Interest: The authors declare no conflict of interest.Ethical Approval: The study was evaluated and approved by the local medical regional ethics committee (METC LDD, reference number N20.043 and NL76177.058.21, protocols can be found at the study website www.covidkids.nl). Informed consent and written approval were obtained from all parents and from children older than 12 years of age.
