Pediatric Nursing Triage in Mass Gathering: Education and Training Issues

Deaths of children could occur during mass gathering due to various reasons. Many of these deaths could be prevented if very sick children were identified and appropriate treatment started immediately upon their arrival at the health facility. This study investigates standardized role of the pediatric nurse in Emergency Triage, and the real situation occurring in Makkah local governmental hospitals, where nurses can hardly participate in the assessment, or decision making, and how the guidelines are used in the process. Significance of the study: Researchers have recently found that nurses reported limited knowledge and awareness of the wider emergency and disaster preparedness plans. This clarifies the research gap for pediatric nurses. Aims of the study: (1) is to review all the available studies in order to come up with a clear standardized role of the pediatric nurse in Emergency Triage. (2) to describe the requirements needed by the newly graduated nurses in order to be categorized by Health Authorities as an Emergency Triage Pediatric Nurse. (3) to recommend the integration of Triage competencies in BSC nursing curriculum. Setting: The study was conducted at the Faculty of Nursing, Umm Al Qura University, Saudi Arabia. Methods: A review of the literature on mass gatherings and triage systems, was conducted. Four databases were utilized: (1) OVID (2) PubMed, (3) Cochrane Collection Plus, and (4) Lippincott. The search terms: Triage, Pre-hospital triage, Field triage, Triage nurse, Nursing curriculum, Pediatric nurse, Emergency room clinical competencies. Results: Differences in the application of pediatric triage across local and international hospitals in Mass-Gathering events, are discussed. The lack of standardized role of pediatric nurses in emergency triage is demonstrated both on national and international levels. Conclusion: Pediatric nurses should have a standardized role in emergency triage. Recommendations: Pediatric triage in emergency settings must be integrated in BSC nursing curriculum.


Introduction
Deaths of children in hospital often occur within the first 24 h of admission. Many of these deaths could be prevented if very sick children were identified and appropriate treatment started immediately upon their arrival at the health facility. This can be facilitated by rapid triage for all children presenting to hospital in order to determine whether any emergency or priority signs are present and providing appropriate emergency treatment. WHO therefore published guidelines and training materials for pediatric emergency triage, assessment and treatment (ETAT) [1]. WHO pediatric ETAT guidelines aim to identify children presenting with airway obstruction and other breathing problems, circulatory impairment or shock, severely altered CNS function (coma or convulsive seizures) or severe dehydration, because it is these children who require urgent appropriate care to prevent death [1].
In 2013, [2] WHO guideline development scoping group reviewed the pediatric ETAT guidelines and identified areas of care and specific recommendations that should be updated considering the new evidence and international consensus [2]. Three priorities for the care of sick infants and children were identified: detection of hypoxemia and use of oxygen therapy, fluid management of infants and children presenting with impaired circulation and management of seizures. This guideline is intended for use in low-resource settings to provide clinical guidance to these health workers on managing infants and children presenting with signs of severe illness [2]. In 2003, the USA adopted and designed the emergency severity index (ESI). All are 5 category scales. The triage categorization level procedures depend on the patients' complaints and the vital signs as well as the expertise of the triage person(nurse/physician/others). It requires education and training.

Methods
Articles were reviewed by two team members, and relevant articles were obtained and reviewed by the team. Articles were selected from peer-reviewed journals; focused on the role of the

Concept of Triage
''Triage'' is a useful tool used in emergency departments (EDs) to prioritize the care of patients. Through a methodical process of different sequential steps, the triage nurse assigns a color code which goes from red critical patient with immediate access to medical examination to a white code that represents no urgency.
Clinical studies have shown that the incorrect assessment at triage represents one of the major errors in EDs and the patients can be victims of errors during the process of care, especially in complex systems such as EDs [3].
The triage recommended in the guidelines defines the priority to receive treatment using four color codes in the form of: Red (very critical, highest priority); Yellow (average critical, medium priority); Green (low critical, low priority, treatment can be delayed); and White (non-critical, urgent intervention is not required) [3]. Triage is defined as prioritizing or sorting the patients for the care and treatment, it is the process of determining the priority of patients' treatments based on the severity of their condition. The term comes from the French verb trier, meaning to separate, sift or select. Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient. Triage may also be used for patients arriving at the emergency department or telephoning medical advice systems. the concept of triage as it occurs in medical emergencies, including the prehospital setting, disasters, and emergency room treatment [4]. The goals of Triage, as set forth by the Canadian Association Of Emergency Physicians (CAEP), the National Emergency Nurses Affiliation of Canada (NENA) are: (1) to rapidly identify patients with urgent, life threatening conditions (2) to determine the most appropriate treatment area for patients presenting to the ED (3) to decrease congestion in emergency treatment areas; to provide ongoing assessment of patients (4) to provide information to patients and families regarding services, expected care, and waiting times, and (5) to contribute information that helps to define departmental acuity [5].

What is a Triage Nurse?
Ebrahimi M et al. [6] concluded that Triage nursing as a relatively new role for nurses is a challenging role in a dynamic environment which needs significant development to be practiced. Prioritizing is defined as the pivotal role for triage nurse. Comprehensive

Am J Biomed Sci & Res
Copy@ Farrag S imperative to achieve best patient outcomes and reduce the risk of inaccurate triage assessments, and education of the parents is a role of the triage nurse that promotes comfort and security in the level of care being provided [22].

Role of Triage Nurse
According to Sinclair [10], the basic job description for triage nurse is the same for any registered nurse, plus at least 2 years of critical care experience in a large ICU setting. The role requires identification of nurses who possess the following qualities:

Pre-hospital and Field Triage During Mass-casualty Incidents and Disasters / Pre-hospital Care System and Emergency Medical Services (EMS)
Pre as promptly as possible. The former is based on "delay and treat" philosophy whereas the latter is a "load and go" [32]. Although both are considered successful EMS models, outcomes cannot be easily compared given the fundamental difference in their operational methods.
The primary aim of EMS is to prevent unnecessary mortality  According to the study of Timothy Horeczko et al. [36], who stressed that The Pediatric Assessment Triangle (PAT) is a rapid evaluation tool that establishes a child's clinical status and his or her category of illness to direct initial management priorities.
Recently the PAT has been incorporated widely into the pediatric resuscitation curriculum. Emergency nurses can rely on the PAT as an objective early warning of children in or at high risk for clinical deterioration. It is especially helpful in cases when history and physical examination are limited. Furthermore, the PAT serves as a common vocabulary between health-care providers [37]. The Pediatric Assessment Triangle (PAT) generates a rapid, global assessment using only visual and auditory clues; it requires no equipment and takes seconds to perform. The PAT was designed to enable the provider to articulate formally a general impression of the child, establish the severity of the presentation and category of pathophysiology, and determine the type and urgency of intervention. Using the PAT, the provider makes observations of 3 components: appearance, work of breathing, and circulation to the skin (Figure 1) [38].

Nurses' Involvement Decision Making
The decision-making process is commonly termed triage and has been described as the sorting of medical conditions into different categories to achieve a true priority of care [12]. There are several factors that support the involvement of nurses in CPR (UK) who, as part of the "National Health Service plan" to raise standards, recommends nurse defibrillation as a basic rather than an extended role. Nurses are key health care professionals for using

AEDs in hospitals and for teaching other first responders--inside
and outside hospitals--how to use AEDs. Although the use of AEDs by nursing staff has been suggested and implemented in many hospitals, studies assessing the results of this practice are limited with small sample size [40]. For nurses to initiate defibrillation there is clearly a need for a widespread change in philosophy as well as equipment. Simply introducing AEDs may not be enough to improve survival. First, nurses must accept defibrillation as a primary rather than extended role. The concept of nurse-initiated defibrillation is supported by many nurses. Combining AED training with annual BLS training may facilitate the acceptance of defibrillation as a nursing role and assist in its wider dissemination [41].
Researchers in the USA in the early 1980s found that triage was associated with a wide range of patient handling activities during disasters. If, however, triage was the prioritization of victims based upon assessment of need, the evidence suggested this rarely each provider on scene is using a different approach to triage without universal understanding [12].

Hajj Mass Gathering
Hajj is a unique gathering with Mecca and Kaaba being spiritually important to many faiths across the globe, especially Muslims. This is because of the proclamation of the prophet's father, Ibrahaam, when he called all mankind to perform Hajj. That is why all Muslims on Earth feel that they must visit Mecca and Kaaba on a specific date and time, and that is the reason this small location hosts one of the largest human gatherings in the world [15]. The World Health Organization (WHO) defines mass gatherings as "events attended by a sufficient number of people to strain the planning and response resources of a community, state or nation. Mass gatherings can have good and bad long-term effects on the health sectors of host countries. As the largest annual mass gathering in the world, the hajj or pilgrimage to Mecca overburdens Saudi Arabia's health system because 2 to 3 million Muslim pilgrims from more than 180 countries converge on the country's holiest sites [8].

Ministry of Health in Saudi Arabia
Infection was a frequent feature of the Hajj especially with computer-based information systems, laboratory testing, infection control; and provide proper treatment [26]. Saudi recommendation to all pilgrims to wear surgical facemask when in crowds, hands hygiene and to be vaccinated against seasonal influenza [27].

Triage During Mass Gatherings
Triage is a complex process and is one means for determining which patients most need access to limited resources. Triage has been studied extensively, particularly in relation to triage in overcrowded emergency departments. The need for an effective triage and acuity scoring system for use during mass gatherings is clear, as these events not only create multiple patient encounters, but also have the potential to become mass-casualty incidents. Furthermore, triage during a large-scale disaster or mass-casualty incident requires that multiple, local agencies work together, necessitating a common language for triage and acuity scoring [43]. and, occasionally, critically ill patients. Mass-gathering events are dangerous; a higher incidence of injury occurs than would be expected from general population statistics [43].

Telephone Triage
Practices have been encouraged to develop flexible models of access tailored to local needs. Telephone triage, in which a patient requesting a face-to-face appointment is, in the first instance,

2.
Pediatric Assessment Triangle (PAT) as evaluation tool has been incorporated widely into the pediatric resuscitation curriculum.

3.
Triage related interventions still need extensive development to be reliable enough to practice by triage nurses.

4.
A nurse without specific training in triage and inexperienced in critical care was identified as the ''root cause'' of the sentinel event. To make improvements we planned a triage training course (for newly employed nurses and a refresher course for existing staff) and created a team of dedicated triage nurses.

5.
Telephone triage, in which a patient requesting a faceto-face appointment is, in the first instance, offered a call back from a doctor or nurse, is increasingly being adopted to manage demand.

6.
Due to the annual Hajj pilgrimage, Emergency Medicine training in Saudi Arabia emphasizes mass gathering casualty care, disaster preparedness and ability to cope with multicultural people with no background medical knowledge.

Emergency Medicine training programs include a National
Hajj Preparation course and mandatory Hajj rotation during the residency program to prepare for this real-world challenge [18].

7.
Nurses have insufficient knowledge about disaster preparedness due to a lack of acceptance of core competencies and the absence of disaster preparedness in nursing curricula.

8.
The recommendation that education in disaster preparedness, response and management must be included and further developed in basic nursing programs as well as in all postgraduate nursing programs.

9.
The nursing education community has agreed that the existing curricula are too focused on content and do not teach the most vital nursing skills of critical thinking, clinical reasoning, and decision-making [48]. In fact, the National League for Nursing in the United States mandates that critical thinking skills must be included in nursing programs in order to gain accreditation. 10. language barriers are a major issue for triage nurses, especially in terms of comprehending the subtle nuances of critical messages. In effort to reduce such misunderstandings as well as to establish better clinician-patient communication for such hospitals, it would be wise to offer classes on basic foreign language skills for health professionals [49].

Inaccurate decisions and systemic inefficiency of triage
nurses, despite their degree of experience, can result in patients being under-triaged or over-triaged.
12. Specific to pediatric emergency departments, most of the patient data is gathered from the parents. For this reason, nurses in pediatric triage training should be taught specific skills and techniques in information gathering when dealing with the parents.
13. Emergency departments typically have structured triage guidelines for health care providers. Such guidelines aid in determining which patients must be evaluated promptly and which may wait safely, and aid in determining anticipated use of resources [50].