372 - Optimizing Triage: Assessing Age-Adjusted Shock Index as an Adjunct to Improve Emergency Severity Index Mis-Triage

Saturday, April 29, 2023

3:30 PM – 6:00 PM ET

Poster Number: 372
Publication Number: 372.211

Eilan M. Levkowitz, Medical College of Georgia at Augusta University, Augusta, GA, United States; Desiree Seeyave, Medical College of Georgia at Augusta University, Augusta, GA, United States; Robert Gibson, Medical College of Georgia at Augusta University, North Augusta, SC, United States; Hongyan Xu, Medical College of Georgia at Augusta University, Augusta, GA, United States; Li Fang Zhang, Medical College of Georgia at Augusta University, Augusta, GA, United States; Brian R. Buck, Medical College of Georgia at Augusta University, Fayetteville, GA, United States; Michael R. Bruno, Medical College of Georgia at Augusta University, Evans, GA, United States

Presenting Author(s)

Eilan M. Levkowitz, DO (he/him/his)

Fellow
Medical College of Georgia at Augusta University
Augusta, Georgia, United States

Background: The shock index, pediatric age-adjusted (SIPA), is defined as maximum heart rate divided by minimum systolic blood pressure by age. It has been shown to be more specific than individual vital signs in predicting morbidity and mortality in trauma and non-traumatic ICU admissions. An optimized triage system is vital for patient safety and health outcomes. Subtle vital sign abnormalities are systematically under-appreciated by the Emergency Severity Index (ESI), the main triage system used in the United States, and were more likely to be associated with under-triage to lower acuity levels. Mis-triage leads to higher rates of critical outcomes and admissions.

Objective:

Our primary objective is to assess if SIPA can identify ESI level 3 patients that require up-triage. Secondary objectives include identifying the effects of fever on SIPA’s prediction ability, as well as assess the association of participant variables on outcomes.

Design/Methods: Retrospective chart review identified children ages 1-15 years triaged as level 3 in the Emergency Department from January 2018 to December 2021. We used previously published SIPA thresholds by age grouping, 1–6 years ( >1.2), 7–12 years ( >1.0), 13–17 years ( >0.9), along with the number of life-saving interventions received to determine if there is a significant difference of triage identification between the ESI and the ESI plus SIPA.

Results: Among 192 patients, an elevated SIPA demonstrated improved discrimination relative to non-elevated SIPA: average interventions: 1.14 vs 0.74, p< 0.016; average interventions using SIPA with heart rate corrected for each degree of fever >=38C: 1.14 vs 0.77, P< 0.006; average interventions controlling for race and gender: 1.15 vs 0.71, P< 0.001 ; ventilatory support: 16.44% vs 3.36%, P< 0.002; fluid bolus: 28.77% vs 14.29%, P< 0.015; IV medications including antibiotics, antiepileptics, immune globulin, albumin: 45.21% vs 30.25%, P< 0.036. There was no difference between other interventions, hospital or ICU LOS between the two groups.

Conclusion(s): SIPA can aid in identifying Level 3 ESI patients more likely to require a life-saving intervention, especially ventilatory support, intravenous fluids, and certain IV medications. Fever as well as race and gender did not affect SIPA prediction ability, proving that SIPA is objective in its prediction ability. This supports the inclusion of SIPA to the ESI Danger zone vitals used to determine up-triage to ESI level 2.