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PEDIATRIC EMERGENCIES: PREPARING AT TRIAGE
USING HEIGHT AND W EIGHT
Authors: Brandy Berg, BSN, RN, CEN, CPN, Chantel Arnone,
BSN, RN, Janine Cannon-Davis, BSN, RN,and Andi Foley, MSN, RN, CEN,
Federal Way, WA
Section Editors: Andi L. Foley, RN, MSN, CEN, and Patricia Kunz
Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN
Earn Up to 8.0 CE Hours. See page 414.
A 5-year-old patient presents to ED triage
slightly short of breath. The patient's mother states that
thechild has a history of asthma and home medications
have not provided relief. The child is moved rapidly to
a treatment area where care is begun, and within 10
minutes,
the child's condition declines, requiring aggressive
resusci-tation. A length-based pediatric resuscitation tape is
used,but the child appears large for his weight, and the ED
teamexpresses concern regarding appropriate medication doses.
A 4-year-old presents to ED triage with an
isolated,painful shoulder injury after a fall from a dining room
chair.The child is taken directly to fast track to begin care,
whichresults in a diagnosis of shoulder strain. Ibuprofen is
orderedand administered based on the stated weight from
thepatient's mother and, upon reassessment, the patientcontinues to
have signicant pain. A measured weightreveals that the initial
medication was underdosed.
These scenarios with differing levels of urgency illustrate
concerns about obtaining accurate weight of children. ENA has
published a position statement regarding utilization of
kilograms for pediatric weight1; this statementalso recommends the
use of a length-based pediatric
resuscitation system, when needed. Although use of sucha system
standardizes some of the expectations aroundpediatric weight, the
disparity between weight and height isnot addressed.
Quick identication of a patient as sick versus not
sick
is imperative for a skilled ED nurse in order to triage
safely. As the aforementioned scenarios illustrate, being
prepared with a height or length and weight as early as
possible in theED encounter can enhance safety for pediatric
patients.One method of early height and weight identication
isdescribed in this article.
Background
Accurate pediatric weight is one measurement used
toprevent medication errors.1
Parents are more accurate than ED nurses at
estimating pediatr ic weights, but they still
underestimate by 10% or
more.2
Length-based systems have been reported asinaccurate,
leading to underdosing of medications.3,4
Obesity was cited as the primary reason for inaccuraciesin
measuring weight using a length-based system. Scalesmeasuring in
kilograms are recommended for use inemerg ency departments,
even during trauma resuscita-tions,5 to obtain accurate weights for
pediatric patients.1,3
Selection of appropriate resuscitation equipment isnot dependant
on the weight of the child. Endotrachealtube (ETT) sizing can be
performed using a variety of methods, including weight, age,
length, or various nger dimensions.6 Length-based
systems have been shown to
be as accurate at ETT size selection as age-based estima-tions
or anesthesiologist selection using unknown
criteria regardless of weight or stature.6
For safety of pediatric patients, knowledge of an
accurate weight and length may improve speed of available,
neededresources during an emergency situation. After identicationof
this gap and to address the need of both height/length and
weight as early in the ED visit as possible, the ED
trauma team, consisting primarily of ED nurses, began
seeking possible solutions. After attending a local pediatric
disaster conference and hearing about a system in place at the
local
T R I A G E D E C I S I O N S
Brandy Berg is Emergency Department Nurse, FHS St. Francis
Hospital,
Federal Way, WA.
Chantel Arnone is Emergency Department Nurse, FHS St. Francis
Hospital,
Federal Way, WA.
Janine Cannon-Davis is Trauma Program Manager, FHS St.
Francis Hospital,
Federal Way, WA. Andi Foley, Member, Washington ENA,
is Clinical Nurse Specialist/UnitBased Educator, Emergency
Department, FHS St. Francis Hospital, Federal
Way, WA.
For correspondence, write: Andi Foley, MSN, RN, CEN,
Emergency
Department, FHS St. Francis; E-mail:
[email protected].
J Emerg Nurs 2013;39:409-11.
Available online 6 May 2013.
0099-1767/$36.00
Copyright © 2013 Emergency Nurses Association. Published by
Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.03.017
July 2013 VOLUME 39 • ISSUE 4
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tertiary trauma center, the team developed a plan to
improvepediatric patient safety and increase staff comfort
inmanaging a pediatric emergency in a community
emergency department with approximately 20% pediatric
volumes.
The Plan
ED triage nurses will weigh each nonemergency patient
inkilograms at rst contact. Length will be measured
for infants and height will be measured for children who
areable to stand.7 A colored dot sticker corresponding to
themeasurement from the color-coded, length-based tape willbe
placed on the identication band of each pediatricpatient. On the
paper-based medical record, another colored dot sticker is
placed near the patient label on thetop page of the record. Because
the medical record will bescanned into the electronic record in
black and white, thename of the color will be written on the
sticker for clarication during chart reviews and retrospective
audits of the new process.
The Equipment
Scales were already in use during triage in the
emergency department. The infant scale was located on a
counter with
a laminated length-based tape mounted nearby using hook-and-loop
fasteners for ease of use. Another length-basedtape was encased in
hard, clear plastic and mounted near thestanding scale so that heel
to head length/height could bemeasured while obtaining the weight.
A dispenser for colored dot sticker rolls was also mounted
near the standing scale. The team was aware that color-coded
identicationbracelets were available and chose stickers for space
and costcontainment reasons.
The Training
During an ED staff meeting, the nursing-led ED trauma team
presented the process. Use of the stickers, a refresher on the
use of the color-coded length-based tape, andpractice on a stuffed
animal was included. Concerns relatedto potential inaccuracies of
using a length-based tape for
weight estimation and the speed of estimating
equipmentsizes were shared with the entire ED care team. The
trauma team also championed the roll-out following training
andcontinues to be accountable for ongoing process improve-ment and
training.
The Benet
Benets include a “double check ” in
terms of weight andsize. Pediatrics patients constitute a small
portion of the EDpopulation, and critically sick or injured
children are aneven smaller percentage. The proposed process is a
quick
way to determine appropriate medication doses andequipment
sizes. When transferring children to other facilities, this
process of measurement is easy to commu-nicate, and care provided
is consistent and accurate acrossthe continuum and between
facilities. Another benet wasincreased awareness at regional system
facilities, resulting insimilar staff-led processes at 4 other
local emergency departments, improving the safety of children
regionally.
Summary
Obtaining an actual weight is critical to accurate
medicationdosing. Knowledge of length/height is critical to
equipmentsizing. Rapid and accurate measurement of both uponarrival
at the emergency department increases patient safety and staff
comfort in the case of a decompensating childrequiring
resuscitation. Having a process in place that works
with the layout, medical record, and budget of
thedepartment increases safety for the patient and may
improveoutcomes, and if the process is led by staff champions,
acceptance of the process may be faster. Regardless of theactual
method, patient safety and staff satisfaction can beimproved with a
simple process that prepares for anemergency in pediatric care.
REFERENCES
1. Nurses Association Emergency. Position statement: weighing
pediatric
patients in kilograms.
http://www.ena.org/SiteCollectionDocuments/
Position%20Statements/WeighingPedsPtsinKG.pdf . Accessed
April 6,
2013.
2. Partridge R, Abramo T, Givens T. Analysis of parental and
nurse weight
estimates of children in the pediatric emergency department.
Pediatr
Emerg Care. 2009;25(12):816-8.
3. Knight J, Nazim M, Wilson A. Is the Broselow tape a reliable
indicator
for use in all pediatric trauma patients? A look at a rural
trauma center
Pediatr Emerg Care. 2011;27(6):479-82.
4. Hashikawa A, Juhn Y, Homme J, Gardner B, Moore B. Does
length-
based resuscitation tape accurately place pediatric patients
into appro-
priate color-coded zones? Pediatr Emerg Care.
2007;23(12):856-61.
5. Sinha M, Lezine M, Frechette A, Foster K. Weighing the
pediatric patient
during trauma resuscitation and its concordance with estimated
weight
using Broselow Luten Emergency Tape. Pediatr Emerg
Care.
2012;28(6):544-7.
TRIAGE DECISIONS/Berg et al
410 JOURNAL OF EMERGENCY NURSING VOLUME 39
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