Overview
Definition:
After-hours triage protocols are systematic approaches designed to assess the urgency of pediatric medical complaints presenting outside of regular clinic hours, enabling efficient allocation of healthcare resources and ensuring timely, appropriate care.
Epidemiology:
Pediatric emergency departments and urgent care centers experience significant patient volume during after-hours periods, with common complaints including fever, respiratory distress, abdominal pain, and injuries
Effective triage is crucial for managing this influx.
Clinical Significance:
Robust after-hours triage protocols are vital for differentiating between true emergencies requiring immediate intervention and non-urgent conditions that can be managed conservatively or with follow-up
This improves patient safety, reduces unnecessary ED visits, and optimizes clinician workload.
Common Complaints And Initial Assessment
Fever:
Assess duration, highest temperature, associated symptoms (lethargy, irritability, rash, respiratory symptoms), and immunization status
Red flags: fever >3 months, dehydration, stiff neck, focal infection signs.
Respiratory Distress:
Evaluate respiratory rate, retractions, nasal flaring, grunting, cyanosis, and work of breathing
Auscultate for wheezes, crackles, or diminished breath sounds
Assess oxygen saturation
Red flags: stridor, paradoxical breathing, inability to speak.
Vomiting And Diarrhea:
Characterize emesis (bilious, non-bilious) and stool (bloody, watery)
Assess for signs of dehydration (dry mucous membranes, decreased urine output, sunken fontanelles, poor skin turgor)
Red flags: hematemesis, severe abdominal pain, lethargy.
Abdominal Pain:
Localize pain, assess character, severity, and associated symptoms (fever, vomiting, diarrhea, constipation, urinary symptoms)
Palpate for tenderness, guarding, rebound tenderness, or masses
Red flags: peritonitis, intussusception, appendicitis symptoms.
Injuries And Trauma:
Obtain mechanism of injury
Assess for deformities, swelling, bruising, open wounds, neurological deficits, and signs of abuse
Check range of motion and pain with movement
Red flags: head trauma with altered mental status, suspected fractures, significant bleeding.
Triage Scoring And Decision Making
Pediatric Triage Scales:
Utilize validated scales like the Manchester Triage System (MTS) or Emergency Severity Index (ESI) adapted for pediatrics to assign a priority level based on symptom severity and urgency
Scores typically range from 1 (resuscitation needed) to 5 (non-urgent).
Assessment Parameters:
Key parameters include vital signs (heart rate, respiratory rate, blood pressure, temperature, oxygen saturation), level of consciousness, hydration status, pain assessment, and presence of specific red flag symptoms.
Decision Tree Approach:
Follow standardized algorithms for each complaint, guiding the triage nurse through a series of questions and observations to arrive at an appropriate disposition: immediate physician assessment, routine physician assessment, or referral for primary care follow-up.
Resource Allocation:
Triage decisions dictate the immediacy of physician evaluation, need for specific investigations (e.g., labs, imaging), and patient flow within the healthcare setting
Higher acuity patients are prioritized for evaluation and intervention.
Management Pathways Based On Acuity
Immediate Assessment And Intervention:
Patients triaged as immediate need (e.g., severe respiratory distress, shock, altered mental status) require prompt physician evaluation, stabilization, and critical interventions such as airway management, oxygen therapy, or intravenous fluid resuscitation.
Urgent Assessment Within Timeframe:
Urgent cases (e.g., moderate fever with lethargy, significant dehydration) need to be seen by a physician within a defined timeframe (e.g., 15-30 minutes) for further diagnosis and management, potentially including medications or closer observation.
Routine Assessment And Follow Up:
Less acute conditions (e.g., mild fever without concerning symptoms, minor injuries) may be managed with symptom relief, parental education, and clear instructions for follow-up with their primary care physician within 24-48 hours.
Discharge And Referral Criteria:
Establish clear criteria for discharge home with follow-up instructions versus referral to a higher level of care or specific specialist, based on initial assessment and potential for deterioration.
Age Specific Considerations
Neonates And Infants:
Fever in neonates (<3 months) is always a concern and requires immediate evaluation due to the risk of serious bacterial infection
Infants have less predictable vital signs and may present with non-specific symptoms.
Toddlers And Preschoolers:
Communication can be challenging
reliance on parental observation and objective signs of distress is key
Common issues include febrile seizures, gastroenteritis, and upper respiratory infections.
School Aged Children And Adolescents:
May be able to articulate symptoms better but can also be stoic
Appendicitis, asthma exacerbations, and musculoskeletal injuries are frequent after-hours presentations.
Documentation And Communication
Accurate Record Keeping:
Thorough documentation of triage assessment, vital signs, parent concerns, triage score, and disposition is essential for continuity of care and legal protection.
Clear Handover:
Effective communication of the triage assessment and rationale to the evaluating physician is critical for seamless patient management
A structured handover process should be in place.
Patient And Parent Education:
Provide clear, concise verbal and written instructions regarding follow-up care, warning signs to watch for, and when to seek further medical attention
Empower parents to be active participants in their child's care.
Key Points
Exam Focus:
Understand the principles of pediatric triage, common pediatric complaints presenting after hours, and red flags for each
Know how to interpret vital signs and assess hydration
Differentiate acuity levels.
Clinical Pearls:
Always trust parental instinct when they express significant concern
A thorough and systematic approach is crucial, even under time pressure
Never underestimate a young infant with fever
Age-appropriate vital signs are paramount.
Common Mistakes:
Missing red flags for serious conditions
Inadequate assessment of hydration status
Relying solely on temperature without considering other symptoms
Poor or incomplete documentation
Failure to communicate effectively with the physician.