title: 'Down-triage' for children with abnormal vital signs: evaluation of a new triage practice at a paediatric emergency department in Japan.
abstract: OBJECTIVE
  Assessment of abnormal vital signs in triage is a challenge in the paediatric emergency department (PED), since vital signs may reflect anxiety, fever or pain rather than the clinical deterioration of the child. We aimed to evaluate the efficacy of subjective 'down-triage' (change of the initially determined acuity levels) of Japanese Triage and Acuity Scale (JTAS).
  
  
  METHODS
  This is a retrospective cohort study of patients in PED up to 15 years of age at a tertiary paediatric medical centre in Japan during a 1-year period. At the end of every JTAS triage process, PED nurses were allowed to 'down-triage' acuity levels of well-appearing patients with abnormal HR or RR, which were presumably attributable to fever, crying or being upset. We compared predictive performance of the triage system before and after 'down-triage' using admission rate as the primary outcome.
  
  
  RESULTS
  Among 37 961 PED visits during the study period, we analysed 37 219 records. A total of 17 089 patients (45.9%) were 'down-triaged' after their initial triage allocation upon arrival. Admission rates after 'down-triage' (83%, 33%, 7%, 1% and 3% for levels 1-5, respectively), compared with those of unmodified initial level (16%, 11%, 6%, 2% and 6% for levels 1-5, respectively), had a better apparent relevance with the anticipated admission rates of Canadian Triage and Acuity Scale.
  
  
  CONCLUSIONS
  Modification of JTAS through 'down-triage' by experienced staff improves prediction of disposition in a PED. Further research is needed to determine an objective protocol for 'down-triage' to ensure safe practice in a PED.
authors.affiliation: Division of General Pediatrics, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan.
authors.forename: Takuto
authors.identifier: http://orcid.org/0000-0001-8296-6412
authors.initials: T
authors.lastname: Takahashi
authors.affiliation: Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Fuchu, Tokyo, Japan.
authors.forename: Nobuaki
authors.initials: N
authors.lastname: Inoue
authors.affiliation: Division of Pediatric Critical Care Medicine, Department of Pediatric Emergency and Critical Care Medicine, Fuchu, Tokyo, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Shimizu
authors.affiliation: Division of General Pediatrics, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan.
authors.forename: Toshiro
authors.initials: T
authors.lastname: Terakawa
authors.affiliation: Pediatric Research in Emergency Therapeutics Program (PRETx.org), Division of Emergency Medicine, Department of Pediatrics, University of British Columbia, Child and Family Research Institute, Vancouver, British Columbia, Canada.
authors.forename: Ran D
authors.initials: RD
authors.lastname: Goldman
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007564:Japan; D008297:Male; D012189:Retrospective Studies; D014218:Triage / Q000379:methods*; D055986:Vital Signs
keywords: clinical assessment; management, emergency department management; nursing, emergency departments; paediatrics, paediatric emergency medicine; triage