Original articleTriage and case presentations in a chiropractic pediatric clinic
Introduction
Triage can be defined in a number of different ways, depending upon the setting in which the word is used. Merriam-Webster's Dictionary defines the word as1 “A system of dealing with cases (as patients) according to priority guidelines intended to maximize success.” Taber's Cyclopedic Medical Dictionary has a similar definition but suggests more advanced thinking2: “Common triage categories used in the field would include P-1 or red, P-2 or yellow, P-3 or green.” One can classify their “crisis” patients in one of the 3 categories: P1/red/emergency (needs immediate referral); P2/yellow/cautionary (warrants additional attention and follow-up), or P3/green (limited concern).2
In the 2005 Job Analysis of Chiropractic,3 pediatric chiropractic care increased from 9.7% of patients in 1991 to more than 18% in 2003. No information is provided on the number of pregnant patients. An increase in the number of pediatric cases that are being seen by the chiropractic profession suggests that there will be a growing number of conditions that present to chiropractor's offices that will require some level of triage.
The use of triage in chiropractic practices is to determine whether or not a case that has presented to an office, whether new or returning, is in need of a referral or if the presenting problem is of less concern. Hence, in the case of chiropractic care, using the concept of triage can aid in the clinician's differential diagnostic abilities.4, 5
It is essential that the examining chiropractor be familiar with common and less frequent pediatric and pregnancy challenges that may go unnoticed.5, 6, 7 A discerning clinician must always have his eyes and ears open, searching for clues that may suggest one diagnosis over another. Using the above triage categories, an appropriate assessment can occur by placing patients into P1 to P3 subsets.
The chiropractor with a pediatric emphasis can use triage during 2 separate and distinct junctures. The initial consultation is the first time the child or pregnant patient must be critically diagnosed. The second and more frequent use of our diagnostic ability occurs during regular office visits, in which existing patients present with a new or exacerbating symptom. Because chiropractors are transitioning to primary health care providers, patients often visit their offices for advice before or rather than visiting an emergency department or urgent care facility.8, 9
This article is an attempt to illustrate the role that triage (as defined by the author) plays for the chiropractor who specializes in a family practice, where he or she regularly sees children and pregnant women. This is examined both in the new patient setting and during visit-to-visit protocol.
Section snippets
Method
A 2-part retrospective study was undertaken in the clinical setting of a chiropractor who holds an advanced degree in chiropractic pediatrics (Fellow of the International Chiropractic Pediatric Association).
An analysis of the records of 48 new children and pregnant women who presented during a 1-year period was performed. Their initial presentation complaints and subsequent triage level during this first visit were noted. All new patients were placed in one of the 3 triage categories:
New patient analysis—pediatric subset
The 40 new children who presented to the office from May 1, 2005, to May 1, 2006, had the following breakdown of chief complaints: 14 (35%) orthopedic/spinal-related problems, 18 (45%) organic problems, and 8 (20%) wellness patients with no specific complaints. Of these 40 children, 34 (85%) were at a P3 triage level and 6 (15%) were at the P2 triage level. The presenting problems of the P2 children were as follows: 1 orthopedic/spinal concern, 2 cases of asthma, 1 child with vomiting, 1 with
Discussion
Chiropractic triage of the new patient seems to differ substantially from chiropractic triage of existing patients. The average level of triage for a new patient, whether pediatric or pregnant, was a P3 level, with more than 85% of new patients falling into this category. Fifteen percent were at a P2 level, and none were at the P1 level. This indicates that in the new patient category, whether pediatric or pregnant, patients generally do not come to a chiropractic office in a potential crisis
Conclusion
There are a growing number of parents and pregnant woman who trust their doctor of chiropractic as being their primary care clinician.8, 9 This is evidenced not only in the chiropractic literature but medical journals as well.10, 11, 12, 13, 14, 15 Triage methods are a way to help place a patient in a category that can increase the likelihood that patients receive an optimal, safe, and effective level of care. Their use can strengthen the chiropractor's abilities to manage patients with a
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