Emergency Pediatric Assessment Triangle (PAT) Review PDF

Tørisen et al. BMC Emergency Medicine (2024) 24:158 BMC Emergency Medicine https://doi.org/10.1186/s12873-024-01068-w RESEARCH...

Tørisen et al. BMC Emergency Medicine (2024) 24:158 BMC Emergency Medicine https://doi.org/10.1186/s12873-024-01068-w RESEARCH Open Access Emergency pediatric patients and use of the pediatric assessment triangle tool (PAT): a scoping review Tore A. G. Tørisen1, Julie M. Glanville2, Andres F. Loaiza3,4 and Julia Bidonde5* Abstract Background We conducted a scoping review of the evidence for the use of the Pediatric Assessment Triangle (PAT) tool in emergency pediatric patients, in hospital and prehospital settings. We focused on the psychometric prop- erties of the PAT, the reported impact, the setting and circumstances for tool implementation in clinical practice, and the evidence on teaching the PAT. Methods We followed the Joanna Briggs Institute methodology for scoping reviews and registered the review pro- tocol. We searched MEDLINE, PubMed Central, the Cochrane Library, Epistemonikos, Scopus, CINAHL, Grey literature report, Lens.org, and the web pages of selected emergency pediatrics organizations in August 2022. Two reviewers independently screened and extracted data from eligible articles. Results Fifty-five publications were included. The evidence suggests that the PAT is a valid tool for prioritizing emer- gency pediatric patients, guiding the selection of interventions to be undertaken, and determining the level of care needed for the patient in both hospital and prehospital settings. The PAT is reported to be fast, practical, and use- ful potentially impacting overcrowded and understaff emergency services. Results highlighted the importance of instruction prior using the tool. The PAT is included in several curricula and textbooks about emergency pediatric care. Conclusions This scoping review suggests there is a growing volume of evidence on the use of the PAT to assess pediatric emergency patients, some of which might be amenable to a systematic review. Our review identified research gaps that may guide the planning of future research projects. Further research is warranted on the psycho- metric properties of the PAT to provide evidence on the tool’s quality and usefulness. The simplicity and accuracy of the tool should be considered in addressing the current healthcare shortages and overcrowding in emergency services. Review registration: Open Science Framework; 2022. https://​osf.​io/​vkd5h/ Keywords Pediatrics or paediatric, Pediatric assessment triangle, Children; emergency medicine; review *Correspondence: Julia Bidonde [email protected] Full list of author information is available at the end of the article © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 2 of 14 Background to deliver timely effective emergency treatment. EHWs Emergency medical services (EMS) are crucial to emer- also need to reassure patients and caregivers and bring gency care systems providing effective emergency order to potentially chaotic situations. EHWs who lack medical care to people in need. The World Health specialized training in pediatric emergencies may unin- Organization (WHO) Emergency Care System Frame- tentionally exacerbate stressful situations. Emer- work (see Additional file 1) notes that effective emer- gency pediatric training for healthcare professionals gency care involves a coordinated and integrated system inside and outside of the hospital is essential to ensure of care, including the provision of prehospital care, trans- the best outcomes for critically ill or injured pediatric portation, and emergency department (ED) services. patients [14, 15]. The WHO framework emphasizes the importance of Emergency triage involves quickly identifying patients early recognition of health issues and the timely provi- who require medical attention to prioritize treatment sion of appropriate interventions to reduce morbidity efficiently for those in greatest need. Triage tools and decrease the incidence of death and illness. Pediat- such as the Manchester Triage System and the Emer- ric emergencies, particularly acute injuries and illnesses, gency Severity Index are helpful. The Paediatric generate considerable numbers of ambulance calls and Canadian Triage and Acuity Scale (PaedCTAS) was ED visits in developed countries [3, 4]. developed specifically for pediatric patients , using There is a general understanding that lack of pediatric the Pediatric Assessment Triage (PAT) tool as the first emergency flow (or crowding) may lead to adverse out- step in assessing emergency patients. It includes the “gen- comes for the child. However, the prevalence of pediatric eral impression” stage using the PAT, primary assessment emergencies poses significant challenges to emergency with the airway, breathing, circulation, disability, and healthcare providers [5, 6]. In the UK, pediatric emer- exposure (ABCDE) approach , secondary assessment, gencies represent 5–10% of all emergencies and in the diagnostic assessment, and reassessment. USA, children represent 20% of ED patients. Injuries are the leading cause of morbidity and mortality among The Pediatric Assessment Triangle (PAT) children and adolescents [9, 10]. The PAT is used to quickly identify critically ill or injured Caring for critically ill or injured pediatric patients children needing immediate medical attention. It focuses can be challenging for emergency healthcare workers on three presenting components (“arms”): appear- (EHWs). Patients’ histories may be difficult to obtain ance, work of breathing, and circulation (Fig. 1). It can if the patient cannot provide verbal information or has be used in prehospital or hospital settings for efficient been found alone without a caregiver. Taking vital rapid assessment of the patient’s level of consciousness, signs can be difficult and may not provide accurate infor- breathing, and circulation, without requiring hands- mation due to normal age-based variations. Fur- on assessment or equipment [5, 19]. It can help identify thermore, some EHWs may have not received training in key pathophysiological problems and whether urgent pediatric emergencies, which can be stressful. transport or resources are needed. The PAT assessment Despite these challenges, EHWs need to conduct a takes 30–60 s [5, 19] and it can be performed remotely (a rapid and accurate assessment of the pediatric patient “through the room” assessment). Fig. 1 The Pediatric Assessment Triangle components (arms). Figure adapted from Fuchs S and McEvoy M ] Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 3 of 14 Methods and CINAHL, from 1995 to July 2022, to include publi- Scoping review aim and design cations before the introduction of the PAT in the curric- Give the current shortage of healthcare personnel world- ula of Pediatric Education for Prehospital Professionals wide, and overcrowding of emergency departments, (PEPP) and Advanced Pediatric Life Support (APLS) in gathering of the PAT’s evidence is essential. This review 2000. The database searches were conducted from aimed to identify the available scientific evidence about 24 to 28 July 2022. Fourteen websites of organizations the PAT and its use by EMS. Our objective was to com- involved in policy making in emergency pediatrics were plete a scoping review within the pre-and-hospital care to searched between 6 and 10 August 2022. We searched synthesize: for unpublished (grey) literature using Grey Literature Report (http://​www.​greyl​it.​org/) and Lens.org (https://​ What are the psychometric properties of the PAT www.​lens.​org/). Full searches are presented in additional (e.g., validity, reliability, applicability)? file 3. What are the reported impact(s) of the PAT? (e.g., improved triage, cost, better clinical outcomes) What are the requirements or circumstances for PAT Study selection process implementation in clinical practice? We deduplicated records in EndNote and conducted What is the evidence on the value of teaching EMS double independent screening (TT, AFL-B) in Covidence workers about PAT? (Veritas) against the eligibility criteria (Table 1). Con- flicts were resolved by consensus or arbitrated by a third We followed the Joanna Briggs Institute framework for reviewer (JB). Additional file 4 lists records excluded scoping reviews. The review protocol was registered at full text with reasons. Records reporting the same. The review is reported according to the PRISMA study were grouped and we cite the earliest publication extension for scoping reviews (Additional file 2). while presenting relevant data from any of the related publications. Eligibility criteria Eligible publications (Table 1) reported the use of the PAT with pediatric populations in prehospital, hospital Data collection process or training settings. Eligible outcomes matched our spe- Data were extracted from eligible studies into a Microsoft cific aims as follows: 1) psychometric performance, 2) 365 Excel form which was piloted on a random sample impact(s), 3) implementation of PAT utilization, and 4) of five included studies, and modified as required based evidence on teaching the PAT. on feedback from the team. One reviewer (TT) com- pleted data extraction and a second reviewer (AFL-B) Searches verified the extracted data. Disagreements were resolved We searched MEDLINE (PubMed), PubMed Central (via by consensus or arbitrated by a third reviewer (JB). Risk LitSense), the Cochrane Library, Epistemonikos, Scopus of bias was not assessed. Table 1 Scoping review inclusion and exclusion criteria Inclusion Exclusion Participants/population: Emergency pediatric patients. ‘Emergency’ defined Exclusions: as any medical condition or trauma that requires contact with the health care Non-English language literature unless there was an English abstract, system, prehospital and/or hospital. Pediatric means any patient from 0 to 18 in which case the abstract was data extracted years of age. Emergency health care workers. Pediatric Assessment Triangle Podcasts, recorded lectures etc. (PAT) trainers Incomplete records (i.e., those with no abstracts or where the full text Concept: The PAT for clinical assessment was unavailable after exhausting all possible routes) Context: Prehospital and hospital use. Prehospital includes, but is not limited to, Emergency Medical Services, out of hours clinics, search and rescue services, doctors’ offices, “walk in” clinics, or ambulance services. Hospital use is not limited to emergency departments. In training settings Outcomes: Psychometric properties of the PAT (e.g., validity, reliability, appli- cability), reported impact(s), requirements for PAT implementation, reported conditions of PAT utilization, and evidence on teaching/instructing people to use the PAT Any publication status. Documents at all stages of publication were eligible (e.g., “in review”, “accepted”, “in press”, “published”) Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 4 of 14 Knowledge user (KU)/patient engagement Additional file 5) of which three were books. Sixteen pub- and methodological appraisal lications were in non-English languages, but with English We defined KU/ patient engagement as individuals who abstracts, and of these we retrieved 14 full text publica- may be affected by the research findings. Since this tions (Spanish (n = 9), German (n = 2), French (n = 1), review was time sensitive, we did not recruit knowledge Turkish (n = 1), and assumed Taiwanese Mandarin users or patients. (n = 1)). Of these, there were seven papers that described We did not appraise methodological quality or risk the psychometric properties of the PAT, 18 were about of bias of the included articles, which is consistent with the PAT’s impact, 38 described implementation pros and guidance on scoping review conduct. cons, and 30 provided references to the PAT used in edu- cational/training environments. The publication dates Synthesis ranged from 1999 to 2022, representing 18 countries with The synthesis included quantitative (e.g. psychometric the majority classified as "high income" (World Bank properties) and qualitative analyses (e.g. content analysis) classification) (see Additional file 6). Study designs of the components of the impact, implementation and were diverse: primary research (n = 27, 49.1%), second- teaching. A word cloud was drawn for the impact of the ary research (n = 4, 7.3%), and "other" (n = 24, 43.6%). We PAT using the online program WordClouds. The team identified no randomized controlled trials, systematic members identified, coded, and charted relevant units reviews, or scoping reviews. of text from the articles using a framework established a priori as a guide. The framework was developed through Psychometric properties team discussions upon reviewing the preliminary results. The seven papers reporting psychometric properties Data were grouped by question and overviews are pro- were as follows. Four studies (Table 2) reported sensi- vided using charts and tables generated using Microsoft tivity and specificity, measuring test accuracy [26–29], 365 Excel. of which one study reported an area under the receiver operating characteristic curve (AUROCC) and four Results studies reported likelihood ratios (LR) [26–28, 30]. Search results and publication characteristics PAT sensitivity (Fig. 3) ranged from 77.4% to 97.3% The searches identified 548 records (Fig. 2). Fifty- (four studies) suggesting it can accurately identify a five publications were included (full citations listed in large proportion of patients with the targeted condition Fig. 2 PRISMA flow chart Table 2 Psychometric properties of the Pediatric Assessment Triangle (7 studies) Author (number of Sensitivity Specificity Positive Negative likelihood Odds Ratio Area under the Reliability participants) % (95% CI) % (95% CI) likelihood ratio (95% CI) (95%CI) receiver operating (95% CI) ratio (95% CI) curve Aviles-Martinez 2016 81 (78–84) 87 (84–90) 5.2 (5–7.8) 0.22 (0.18–0.26) 111 (73–168.6) p < 0.001 NR NR N = 1120 children Fernandez 2010 NR (NR) NR (NR) NR (NR) NR (NR) NR (NR) NR 93.6% (Kappa index 0.77 N = 57,617 cases (0.75–0.79) Tørisen et al. BMC Emergency Medicine Fernandez 2017 NR (NR) NR (NR) NR (NR) NR (NR) Abnormal PAT findings NR NR N = 302,103 episodes at triage increased hos- pitalization probability 5.14 (4.97–5.32) p < 0.01 Age adjusted autonomous risk factors for hospitalization: (2024) 24:158 abnormal PAT findings and urgent triage levels I-III: 2.21 (2.13–2.29); triage levels 6.01 (5.79–6.24) p < 0.01 Abnormal appearance or 1 + components of the PAT were associ- ated with admissions: 3.99 (3.63–4.38) p < 0.01; 14.99 (11.99–18.74) p < 0.001 Adjusted age and triage were independent risk factor for intensive care unit admission 4.44 (3.77–5.24) P < 0.001 and longer stay 1.78 (1.72–1.84) P < 0.001 in the pediatric emer- gency department Page 5 of 14 Table 2 (continued) Author (number of Sensitivity Specificity Positive Negative likelihood Odds Ratio Area under the Reliability participants) % (95% CI) % (95% CI) likelihood ratio (95% CI) (95%CI) receiver operating (95% CI) ratio (95% CI) curve Gausche-Hill 2014 77.4 (72.6–81.5) (insta- 90 (87.1–91.5) 7.7 (5.9–9.1) NR NR NR Paramedics used N = 1168 PAT study bility) (instability) (instability) of the PAT in the three forms arms and formed a gen- eral impression with high consistency k = 0.93 (0.91–0.95) Tørisen et al. BMC Emergency Medicine κ = 0.62 (0.57–0.66) (PAT paramedic’s impres- sion and investigators’ retrospective chart review on final diagnosis and disposition) (2024) 24:158 κ = 0.66 (0.62–0.71) (PAT paramedics’ impression and investigator’s impres- sion: stability) Horeczko 2013 Children deemed Children deemed Children Instability (n = 58): 0.12 NR NR Fleiss’ κ (n = 38, 3 raters) N = 528 children instable (n = 58): 97.3 instable(n = 58): 22.9 deemed stable: (0.06–0.25) Appearance = 0.7, (94.6–98.8) (17–30) 0.12 (0.06–0.25) Respiratory dis- (0.51–088) p < 0.001 Respiratory dis- Respiratory dis- Instability tress (n = 290): 0.11 Work of breathing = 0.24 tress (n = 290): 91.1 tress (n = 290): 76.6 (n = 58): 1.2 (0.078–0.17) (0–0.48) p 0.01 (86.6–94.2) (71.1–81.3) (1.2–1.3) Respiratory failure Circulation to skin = 0.32 Respiratory failure Respiratory failure Respiratory dis- (n = 14): 0.8 (0.55–1.06) (0–0.49) p < 0.001 (n = 14): 25.0 (6.7–57.2) (n = 14): 97.9 (96.1–98.9) tress (n = 290): Shock (n = 109): 0.32 Categories of pathophysi- Shock (n = 109): 74.1 Shock (n = 109): 82.2 4 (3.1–4.8) (0.17–0.60) ology (53.4–88.1) (78.5–85.4) Respiratory CNS/ metabolic Stable = 0.70 (0.51–0.88) CNS/ metabolic CNS/ metabolic failure (n = 14): disorder (n = 49): 0.58 p <.001 disorder (n = 49): 46.0 disorder (n = 49): 93.5 12 (4–37) (0.43–0.78) Respiratory distress = 0.16 (30.0–62.9) (90.8–95.4) Shock (n = 109): Cardiopulmonary (0 to 0.49) p 0.08 Cardiopulmonary Cardiopulmonary 4.2 (3.1–5.6) failure (n = 11): 0.25 Respiratory failure = 0.74 failure (n = 11): 75 failure (n = 11): 98.5 CNS/ metabolic (0.046–1.39) (0–1) p <.001 (21.9–98.7) (96.9–99.3) disorder Shock = 0.32 (0–0.49) (n = 49): 7 p <.001 (4.3–11) CNS/metabolic distur- Cardiopulmo- bances = 0.68, (0.51–0.88) nary failure p <.001 (n = 11): 49.1 (20–120) Page 6 of 14 Table 2 (continued) Author (number of Sensitivity Specificity Positive Negative likelihood Odds Ratio Area under the Reliability participants) % (95% CI) % (95% CI) likelihood ratio (95% CI) (95%CI) receiver operating (95% CI) ratio (95% CI) curve Tørisen et al. BMC Emergency Medicine Lugo 2012 NR (NR) NR (NR) NR (NR) NR (NR) NR NR Trained observer N = 157 children and nurse agreement 150/157: k 0.90 (0.91) Concordance ­Indexa Stable and non-urgent patients: k.0.83 (0.85) Stable and semi-urgent: (2024) 24:158 κ: 0.95 (0.96) Respiratory distress and compensated shock with urgencies: κ: 0.79 (0.81) Emergency and respira- tory failure or decompen- sated shock: κ: 0.5 (0.6) Ma 2021 93.24 (NR) 99.15 (NR) NR (NR) NR (NR) NR AUROCC 0.96 Rate of agreement N = 1608 children AUROCC PAT vs PWES: between the PAT 0.96 vs 0.99 x­ 2 0.10 p and the actual situa- 0.74 tion of the sick child The PAT performed bet- was 93.24% ter in assessing non-res- piratory critical diseases (vs. respiratory critical diseases), with values of AUROCC of 0.986 vs 0.930, YI of 0.969 vs 0.858, respectively CI confidence interval, CNS central nervous system, PAT pediatric assessment triangle, PEWS pediatric early warning score, YI Yorden index *Concordance Index – is not typically considered a measure of reliability. In this context it has been used to predict or classify outcomes, the concordance index has been used to evaluate the accuracy of the test’s predictions Kappa interpreted as < 0.20 weak k 0.21 – 0.40, moderate k 0.41 – 0.60, good k 0,61- 0,80 very good Fleiss k coefficient