Mortality in children is very rare at the emergency department in Western countries
In reaction to the rapid response of Pillai et al (1) on our paper on
the validity of the Manchester Triage System (MTS) in paediatric emergency
care (2) we have some important comments.
To validate the MTS for children, we used a reference standard for
urgency as outcome measure, which is a proxy for morbidity. This standard
is not a triage system. It consists of items, which are gathered at
presentation and at the end of ED consultation, independent of the triage
urgency level. These items were based on literature and combined by an
expert panel. The reference standard aimed to determine “real “ urgency.
Secondly, the authors argue that mortality can be used as an outcome
measure and refer to the study on the ETAT guidelines performed in Malawi.
Secondly they refer to a study evaluating the SICK score. (3,4)
The hospital in Malawi at which the ETAT guidelines were studied has
an in patient mortality in the paediatric population of 10%. The mortality
of our study population at the emergency department was 0.07% (n=17,600).
The congress abstract describing the evaluation of the SICK score used the
mortality of admitted patients as outcome measure. This score was not
applied to all emergency care patients. Furthermore, the mortality was not
provided in the abstract. (3) If mortality is used as an outcome measure
to study triage decisions in children, it must preferably concern
mortality at the emergency department and not the total in hospital
mortality. The total in hospital mortality is influenced by many other
factors besides the triage decision. Mortality can be used as outcome
measure to study triage systems, in settings with a high mortality.
Mortality in children is very rare at emergency departments in West
European countries.
1. Pillai A, Manchanda S. The term "reference standard" is
misleading. Triage can be validated against mortality/morbidity. BMJ
2008;Rapid Response 4 December 2008.
2. van Veen M, Steyerberg EW, Ruige M, van Meurs AH, Roukema J, van
der Lei J, et al. Manchester triage system in paediatric emergency care:
prospective observational study. Bmj 2008;337:a1501.
3. Gupta M, Sahni M, Rangasami J, Chakrabarti A, Halstead R, Green D,
et al. International Collaboration validating Sick score: a non-invasive
severity of illness assessment, RCPCH abstract. Arch Dis Child 2008;93
supl; A10.
4. Robertson MA, Molyneux EM. Description of cause of serious illness
and outcome in patients identified using ETAT guidelines in urban Malawi.
Arch Dis Child 2001;85(3):214-7.
Competing interests:
None declared
Competing interests:
No competing interests
19 December 2008
Mirjam van Veen
PhD student
Henriette A. Moll
Erasmus Medical Center-Sophia Children's Hospital, 3000 CB, Rotterdam, The Netherlands
In reaction to the rapid response of Pillai et al (1) on our paper on
the validity of the Manchester Triage System (MTS) in paediatric emergency
care (2) we have some important comments.
To validate the MTS for children, we used a reference standard for
urgency as outcome measure, which is a proxy for morbidity. This standard
is not a triage system. It consists of items, which are gathered at
presentation and at the end of ED consultation, independent of the triage
urgency level. These items were based on literature and combined by an
expert panel. The reference standard aimed to determine “real “ urgency.
Secondly, the authors argue that mortality can be used as an outcome
measure and refer to the study on the ETAT guidelines performed in Malawi.
Secondly they refer to a study evaluating the SICK score. (3,4)
The hospital in Malawi at which the ETAT guidelines were studied has
an in patient mortality in the paediatric population of 10%. The mortality
of our study population at the emergency department was 0.07% (n=17,600).
The congress abstract describing the evaluation of the SICK score used the
mortality of admitted patients as outcome measure. This score was not
applied to all emergency care patients. Furthermore, the mortality was not
provided in the abstract. (3) If mortality is used as an outcome measure
to study triage decisions in children, it must preferably concern
mortality at the emergency department and not the total in hospital
mortality. The total in hospital mortality is influenced by many other
factors besides the triage decision. Mortality can be used as outcome
measure to study triage systems, in settings with a high mortality.
Mortality in children is very rare at emergency departments in West
European countries.
1. Pillai A, Manchanda S. The term "reference standard" is
misleading. Triage can be validated against mortality/morbidity. BMJ
2008;Rapid Response 4 December 2008.
2. van Veen M, Steyerberg EW, Ruige M, van Meurs AH, Roukema J, van
der Lei J, et al. Manchester triage system in paediatric emergency care:
prospective observational study. Bmj 2008;337:a1501.
3. Gupta M, Sahni M, Rangasami J, Chakrabarti A, Halstead R, Green D,
et al. International Collaboration validating Sick score: a non-invasive
severity of illness assessment, RCPCH abstract. Arch Dis Child 2008;93
supl; A10.
4. Robertson MA, Molyneux EM. Description of cause of serious illness
and outcome in patients identified using ETAT guidelines in urban Malawi.
Arch Dis Child 2001;85(3):214-7.
Competing interests:
None declared
Competing interests: No competing interests