SICK Score Study Research

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23/11/17 Nursing Reference this

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Sarah Mohammad Iqbal Chagani

This project is pilot study of the clinical student’s preceptor ERC approval research named as “SICK score study”

Introduction to the problem and topic

Triaging pediatric patients is a difficult and challenging task as under-triaging could lead to sentinel events and medical errors. Since pediatric patients are more susceptible and less expressive than adult; they deteriorate quickly and many of their signs and symptoms could go either unnoticed or non-prioritized. The increased influx of pediatric patients in ED and changing trends of trained staffing could result in patients being under-triaged or missed resulting in misallocation of limited resources of ED.

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Numerous scores have been initiated to calculate the severity of illness in children, but all scores have either been introduced in ICU or critical care units. Since Emergency Department serves as the first door to the hospital, it should also have a scoring system so that patients could be sorted accordingly and care is not compromised. WHO has introduced ETAT guidelines for pediatric triage in emergency department but it could only be implemented after proper training and education of staff.

A sign of Inflammation in sick children (SICK) score, created by Thompson, has been implemented in ED and is calculated using baseline vital signs and 4 important assessment questions. Since easy to calculate it can be implemented in ED without any specific training as vital signs are taken at the triage and the remaining parameters are verbally assessed but not documented. With this project, if significant sick score could be introduced, children triage could be made efficient and effective.

Assessment phase

Measurement of vital signs is a routine practice in all triage scales utilized in different hospitals for children visiting emergency department. On previous occasions, it has been seen that a lot of under triaging and over triaging has occurred resulting in missed priority levels of children and patients either being missed or not diagnosed appropriately. On two occasions, oncology pediatric patients were under-triaged resulting in sentinel events of mortality of those children in ED. It is not only important to monitor vital signs at triage but triage staff should be able to calculate severity score so that appropriate allocation of patients could take place. Currently, this hospital utilizes ESI priority system to allocate patients in ED, however, it would be interesting to observe the relationship of SICK score with the outcome of patients and compare it to the Priority levels.

Vital signs play a very important role in triaging and disposition decision making of pediatric patients. Respiratory rate, color, nasal flaring all are indicators of pediatric clinical condition, however, pulse oximetry is a non- invasive technique of ruling out the severity of illness in pediatric patients. In a study, pulse oximetry measures were taken to identify the change in treatment plan and decision making of physicians. For 305 patients with Sao2 values less than 95%, the clinicians ordered 81 additional diagnostic tests for 62 patients (20%) and 39 additional treatments for 33 children (11%), and changed or added diagnoses for 25 children (8.2%) (Mower, Sachs, Niscklin, & Baraff, 1997). Of this same group, clinicians admitted 50 (68%) children after rechecking the oxygen saturation, whereas 23 children were discharged without having their pulse oximetry rechecked (Mower, Sachs, Niscklin, & Baraff, 1997).

Furthermore, mortality levels could also be predicted with the vital signs and conscious levels of pediatric patients. Among 1133 patients, abnormality in heart rate and respiratory rates had no effect on the mortality of patients but mortality increased as the age of pediatric patients decreased with Odds ratio being 5.2, 15.4, 42.6, 57.0 and 98.3 (Kumar, Thomas, Singhal, Puliyel & Sreenivas, 2003).Unlike heart rate and respiratory rate, abnormal blood pressure, oxygen saturation and conscious levels were found to have a significant (p-value < 0.001) relationship with mortality of pediatric patient (Kumar, Thomas, Singhal, Puliyel & Sreenivas, 2003). On calculation of scores, it was identified that a children with higher scores had a higher odds ratio of 724 time death in hospital as compared to children with low odds ratio (Kumar, Thomas, Singhal, Puliyel & Sreenivas, 2003).

Abnormal vital signs have also been found to have a significant relationship with serious and life threatening infections in pediatric patients. Children with serious infection as compared to minor infection had significantly higher temperature >39C (p,0.001), tachycardia (p,0.001), tachypnea (p = 0.002), oxygen saturations (94% (p<0.001) and CRT >2 seconds (p<0.001) (Thompson, Coad, Harnden, Mayon, Perera & Mant, 2009). Simultaneously, children with intermediate infection were significantly more likely to have a temperature >39uC (p = 0.004), tachycardia (p<0.001), oxygen saturations (94% (p = 0.007) and CRT >2 seconds (p = 0.001) when compared with minor infection (Thompson, Coad, Harnden, Mayon, Perera & Mant, 2009).

Planning Phase

Purpose

The aim of this project is to redesign the triage policy for paediatric patients and all those paediatric patients with higher score will be prioritize earlier for proper disposition and early management, so as to further improve the patient satisfaction and morbidity/mortality outcome.

Objectives

  • To predict the disease severity with SICK Score
  • To find association of each independent variable and SICK score with the outcome variable

Variables

Dependant Variable

  • Outcome of patient
    1. Admit
    2. Discharge

Independent Variable

  • SICK Score
  • Heart Rate
  • Respiratory Rate
  • Temperature
  • Oxygen saturation
  • Systolic BP
  • Capillary Refill
  • Conscious Level
  • Seizures Activity
  • Gender
  • Triage Category

Approval and Plan

Permissions were taken from ED Clinical Manager and ED Head Nurse to introduce the data collection forms (already approved by ERC AKUH) on the main counter to be attached in the file of all pediatric entries. The Unit Receptionists were informed by Manager and HN regarding the forms and reinforcement was provided by clinical student. E-mails were sent to the rotating PGME pediatric residents and pediatric ED faculty members regarding a brief of the study and requesting for filling of forms. A box was introduced in the pediatric area near the working desk of doctors for collection of data forms. Since the study was already funded by an international agency, therefore, the photocopies of the forms were done by the preceptor as per the need identified by the clinical student.

Implementation phase

The collected data was entered in SPSS software and codes were given to the categorical data. The sick scores were calculated using software provided by the preceptor. The total forms collected during the three week time was 185 forms but only 100 were included as the remaining had missing information (Diagram 1)

The descriptive statistics of the variables revealed mean SICK score of 1.89 and a standard deviation of 0.98with the range between 0.00 – 5.10. Other variable statistics are defined in Table 1.

Table 1

Descriptive Statistics

 

N

Minimum

Maximum

Mean

Std. Deviation

Temperature of patient

100

36.0

39.6

37.101

.7511

Heart Rate of patient

100

62

220

128.53

31.256

Age

100

.000

15.500

5.24924

4.594531

Respiratory Rate of patient

100

18

88

31.79

13.964

Systolic BP of patient

100

58

133

98.19

15.880

Oxygen Saturation of patient

100

23

160

97.87

10.484

SICK_Score

100

.00

5.10

1.8930

.98609

Valid N (listwise)

100

       
           

As displayed in Table 2, discharge patients accounted for 61% of the population and admission were 39%. It could also be noted that 38% patients lie in the age range 1-5 years and minimum percentage of 6% could be seen in the age range <1 month.

Table 2

Variable

Category

Frequency N

Percentage %

Outcome

Admit

39

39

Discharge

61

61

Age

< 1 month

6

6

1-<12 month

8

8

1-5 years

38

38

5-10 years

29

29

>10 years

19

19

Gender

Male

68

68

Female

31

31

Triage category

P1

9

9

P2

20

20

P3

54

54

P4

15

15

P5

2

2

Capillary Refill

Normal < 3 econds

89

89

Abnormal > 3 seconds

11

11

Conscious level

Alert

96

96

Verbal

1

1

Pain

1

1

Unconscious

2

2

Seizures Activity

Present

27

27

Absent

73

73

On calculating the odds ratio (Table 3), it was found that SICK score had higher odds of 2.123 of patients being admitted to the hospital. Along with this, capillary refill also has higher odds of 2.46 to predict the admission outcome of patient.

Table 3

Variable

Odds ratio

SICK score

2.123

Age category

0.145

Triage category

0.00

Heart rate

0.976

Temperature

0.50

Oxygen saturation

0.938

Systolic BP

0.956

Conscious level

0.000

Seizure activity

0.936

Capillary refill

2.672

Respiratory rate

0.977

Gender

0.823

Surprisingly, triage category and conscious levels were found to have no effect on the odds of outcome – indicating either discrepancies in the assessment tool of the study or the training of the triage staff. Consciousness plays a very important role in decision making of the patient but the results of this study are directing towards consciousness level having no effect on the odds of the outcome – which could be an error of the assessment tool. Though the model was 71.7% accurate in predicting the outcome of patient but the results are also implying towards comparing the assessment tool used in the Indian SICK score study and the tool used in this project.

Evaluation

This project has identified the importance of calculating SICK score in identifying the level of severity of illness in pediatric patients for appropriate triaging and allocation in emergency department. It also indicates that other than the baseline vital signs capillary refill should also be initiated at the triage as on an individual level it has higher odds of determining the outcome of patients. But the results also suggest few errors either in the tool formulated or the triage staff training which needs to corrected before the final study is initiated. Missing values was also a major problem as a lot of forms and patient data had to be removed as the forms were not being filled completely. Recommendation would include comparing the sick score with another simpler scoring system like TOPR and also identifying the relationship between SICK score and the mortality of pediatric patients.

References

Mower, W. R., Sachs, C., Nicklin, E. L., & Baraff, L. J. (1997). Pulse Oximetry as a fifth Pediatric vital sign. Pediatrics. 99(5). 681 – 686.

Thompson, M., Coad, N., Harnden, A., Mayon, R., Perera, R., & Mant, D. (2009). How well do vital signs identify children with serious infection in pediatric emergency care. Archives of disabled children. 94. 888 – 893.

Kumar, N., Thomas, N., Singhal, D., Puliyel, J. M., & Sreenivas, V. (2003). Triage score for severity of illness. Indian Pediatrics. 40. 204-210. Retrieved from http://indianpediatrics.net/mar2003/mar-204-210.htm

Gupta1 MA, Chakrabarty A, Halstead R, Sahni M, Rangasami J, Puliyel A. et. al. Validation of “Signs of Inflammation in Children that Kill” (SICK) score for immediate non-invasive assessment of severity of illness. Italian Journal of Pediatrics 2010, 36:35

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Bhal S, Tygai V, Kumar N, Sreenivas V, Puliyel JM: Signs of Inflammation in Children that can Kill (SICK score): Preliminary prospective validation of a new non-invasive measure of severity of illness. J Postgrad Med 2006,

52:102-5.

Data collection form

MR #

Age â-¡

Age bands

â-¡ <1 month

â-¡ 1- <12 months

â-¡ 12 – <60 months

â-¡ 60 to < 120 months

â-¡ >120 months

Gender â-¡ Maleâ-¡ Female

Triage Time —————–

Triage category (ESI)—————–

SICK SCORE

Heart rate â-¡

Respiratory rate â-¡

Temperature â-¡

Oxygen saturation â-¡

Systolic blood pressure â-¡

CRT â-¡ ≥3 seconds â-¡< 3 seconds

Conscious level â-¡ Aâ-¡ V â-¡ P â-¡ U

Seizures â-¡ Absentâ-¡ Present

Outcome â-¡ Admitâ-¡ Dischargeâ-¡ Died

Mode of admission â-¡ Wardâ-¡ PICUâ-¡ NICU

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