Safety of a Modification of the Triage Level for Febrile Children 6 to 36 Months Old Using the Paediatric Canadian Triage and Acuity Scale

Objective: The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) stipulates that febrile patients who are 3 to 36 months old should be triaged to the PaedCTAS 3 "urgent" category. To optimize resource use, we implemented a protocol enabling these children to be down-triaged to the PaedCTAS 4 "less urgent" category if there was no sign of toxicity. Our objective was to evaluate the safety of this triage protocol modification.

Methods: This retrospective cohort study evaluated all patients triaged in an urban tertiary pediatric hospital during a 6-month period between November 22, 2005, and May 22, 2006. Data were retrieved from the emergency department (ED) database and rates of hospitalization and intensive care unit (ICU) admission were compared for 4 groups: all patients triaged as urgent (level 3), all febrile patients from 3 to 36 months old triaged as urgent (level 3), all patients triaged as less urgent (level 4) and all febrile patients aged 3 to 36 months old who were down-triaged to less urgent (level 4).

Results: There were 36,285 total ED visits during the study period, including 3477 febrile children who were 3 to 36 months old. Nurses down-triaged 1869 febrile children (54%) to the level-4 (less urgent) category and left 1322 (38%) in the level-3 (urgent) category. Hospitalization rate for down-triaged febrile patients was similar to that seen for all PaedCTAS 4 patients (2.4% v. 2.8%, 95% confidence interval for difference -0.3% to 1.1%). Down-triaged patients had significantly lower admission rates than those remaining in the level-3 (urgent) category (absolute risk reduction 10.7% standard deviation 1.9%, p<0.001). No down-triaged patient died or required ICU admission.

Conclusion: Febrile children aged 6 to 36 months who have no signs of toxicity can safely be down-triaged, based on triage nurse clinical judgement, to the less urgent PaedCTAS 4 category. This modification would affect the triage level of approximately 5% of all pediatric ED visits.