title: Accuracy of triage for children with chronic illness and infectious symptoms.
abstract: 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.
authors.affiliation: Department of Pediatrics, Room Sp 1540, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, PO Box 2060, 3000 CB Rotterdam, Netherlands. h.a.moll@erasmusmc.nl.
authors.forename: Nienke
authors.initials: N
authors.lastname: Seiger
authors.forename: Mirjam
authors.initials: M
authors.lastname: van Veen
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: Johan
authors.initials: J
authors.lastname: van der Lei
authors.forename: Henriëtte A
authors.initials: HA
authors.lastname: Moll
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D003967:Diarrhea / Q000209:etiology* / Q000628:therapy; D004417:Dyspnea / Q000209:etiology* / Q000628:therapy; D004636:Emergency Service, Hospital; D005260:Female; D005334:Fever / Q000209:etiology* / Q000628:therapy; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007239:Infections / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014218:Triage / Q000379:methods*
keywords: child; chronic disease; emergency medical services; triage; validity