Delphi Panel Defines 50 Criteria for Pediatric Critical Illness

Refining Triage Precision in Pediatric Emergency Care

Effective emergency response depends on the rapid identification of patients who require immediate, high-level clinical intervention to prevent morbidity and mortality. While standardized definitions have successfully streamlined the management of adult conditions such as sepsis and septic shock, pediatric emergency care often faces unique challenges in objective risk stratification [1, 2]. Current clinical guidelines emphasize that early recognition and timely management are the foundations of improved outcomes for critically ill patients [3, 4]. However, the absence of a universally accepted gold standard for what constitutes a critical pediatric case complicates the development of predictive models and the benchmarking of prehospital performance [5]. A new study now addresses this gap by establishing a consensus-based framework to define critical illness and injury in children through a 22-member Delphi panel, providing a standardized metric for triage accuracy.

Multidisciplinary Consensus Through the Delphi Method

To establish a standardized measure for pediatric critical illness, the researchers convened a 22-member Delphi panel composed of experts across several clinical domains. This multidisciplinary group included subspecialists in pediatrics, pediatric emergency medicine, pediatric surgery, trauma, prehospital medicine, and emergency medical services. By integrating perspectives from both hospital-based specialists and those in the field, the panel aimed to create a definition that reflects the clinical realities of emergency medical services and acute hospital care. This collaborative structure was designed to bridge the gap between prehospital triage and the definitive interventions required upon hospital arrival, ensuring that the criteria are relevant to the entire continuum of care. The study utilized a modified Delphi process, which is a structured communication technique designed to reach a reliable consensus among experts through sequential rounds of voting and feedback. This iterative method allowed the panel to refine priorities based on collective expertise and objective data rather than individual bias. The researchers completed 4 rounds of voting to evaluate various diagnostic, intervention, and clinical outcome criteria. This rigorous approach ensured that the final measures were not merely the result of a single survey but were developed through a systematic, multi-stage evaluation of clinical priorities. Engagement remained high throughout the study, with participation rates in the voting rounds ranging between 95% and 100%. This consistent involvement from the 22 experts underscores the perceived importance of establishing these triage standards. In the final survey round, the panel achieved a consensus level of 82% on the operational criteria. This high degree of agreement among diverse specialists provides a robust foundation for the 50 identified measures, which include specific medical and trauma diagnoses, interventions, and medications intended to identify at-risk children more precisely in the prehospital setting.

A Fifty-Point Framework for Clinical Severity

The researchers established operational hospital-based outcome criteria for pediatric critical illness and/or injury by identifying a comprehensive set of clinical indicators. To ensure these measures were relevant to the actual clinical course of a patient, the panel specifically considered key diagnostic, intervention, and clinical outcome criteria for patients following their arrival at the hospital. This focus on post-arrival data allows for a more objective retrospective analysis of whether prehospital triage decisions matched the eventual clinical severity. Through the iterative Delphi process, the panel reached consensus on a total of 50 measures that define the state of being critically ill or injured in a pediatric population. Within this 50-point framework, the panel categorized the indicators to cover a broad spectrum of emergency presentations. The criteria include 8 medical diagnoses and 14 trauma diagnoses, providing a standardized list of conditions that necessitate high-level emergency care. In addition to specific diagnoses, the panel included 1 trauma mechanism as a standalone criterion for critical status. By standardizing these diagnostic categories, the study provides clinicians and emergency medical services systems with a clear, evidence-based benchmark for what constitutes a critical case, moving beyond subjective assessments of clinical severity. Beyond diagnostic labels, the framework incorporates active clinical management and patient trajectory. The 50 measures include 6 clinical assessments and 13 medical interventions, such as advanced airway management or circulatory support, which serve as proxies for physiological instability. The panel also reached consensus on 6 specific medications and 2 patient dispositions, such as admission to a pediatric intensive care unit or direct transfer to the operating suite, as definitive markers of critical illness. These criteria provide a multifaceted definition of severity that integrates the initial physical exam, the intensity of required treatment, and the ultimate clinical destination. This standardized approach enables more precise identification of at-risk children in the prehospital setting and facilitates future benchmarking of emergency medical services performance.

Implications for Prehospital Benchmarking and Triage

The primary objective of this study was to define a hospital-based measure of critical illness and/or injury to support the development of emergency medical services-based models. By establishing a standardized set of 50 criteria, the researchers provide a retrospective gold standard that can be used to evaluate the accuracy of field triage decisions. These established criteria enable future benchmarking of emergency medical services performance, allowing systems to objectively measure how often prehospital providers correctly identify children who ultimately require intensive hospital resources. This framework allows for more precise identification of at-risk children in the prehospital setting, which is essential for ensuring that high-acuity patients are transported directly to facilities capable of providing definitive pediatric subspecialty care. The researchers have identified several subsequent research steps to transition these consensus measures into active clinical tools. A key priority involves determining the prevalence of these criteria within varying hospital-based settings, ranging from community emergency departments to specialized pediatric trauma centers, to ensure the framework remains robust across different levels of care. Furthermore, future work involves developing prediction models to identify prehospital factors associated with these outcomes. By correlating specific field observations with the 50-point hospital-based criteria, clinicians can build validated algorithms to improve the sensitivity and specificity of pediatric triage during the initial emergency response, ultimately ensuring that the most vulnerable patients receive the appropriate level of care without delay.

References

1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016. doi:10.1001/jama.2016.0287

2. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine. 2021. doi:10.1097/ccm.0000000000005337

3. Dellinger RP, Levy MM, Carlet J, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Medicine. 2007. doi:10.1007/s00134-007-0934-2

4. Rhodes A, Evans L, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine. 2017. doi:10.1097/ccm.0000000000002255

5. Wynants L, Calster BV, Collins GS, et al. Prediction models for diagnosis and prognosis of covid-19: systematic review and critical appraisal. BMJ. 2020. doi:10.1136/bmj.m1328