TRIAGE DECISIONS

PEDIATRIC EMERGENCIES: PREPARING AT TRIAGE

USING HEIGHT AND WEIGHT
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.

5-year-old patient presents to ED triage slightly
short of breath. The patient's mother states that the
child 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 resuscitation. A length-based pediatric resuscitation tape is used,
but the child appears large for his weight, and the ED team
expresses 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, which
results in a diagnosis of shoulder strain. Ibuprofen is ordered
and administered based on the stated weight from the
patient's mother and, upon reassessment, the patient
continues to have signicant pain. A measured weight
reveals 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 weight 1; this statement
also recommends the use of a length-based pediatric

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/Unit
Based 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: andii42@yahoo.com.
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

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VOLUME 39 ISSUE 4

resuscitation system, when needed. Although use of such

a system standardizes some of the expectations around
pediatric weight, the disparity between weight and height is
not 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 the
ED encounter can enhance safety for pediatric patients.
One method of early height and weight identication is
described in this article.
Background

Accurate pediatric weight is one measurement used to

prevent medication errors. 1
Parents are more accurate than ED nurses at estimating
pediatric weights, but they still underestimate by 10% or
more. 2 Length-based systems have been reported as
inaccurate, leading to underdosing of medications. 3,4
Obesity was cited as the primary reason for inaccuracies
in measuring weight using a length-based system. Scales
measuring in kilograms are recommended for use in
emergency departments, even during trauma resuscitations, 5 to obtain accurate weights for pediatric patients. 1,3
Selection of appropriate resuscitation equipment is
not dependant on the weight of the child. Endotracheal
tube (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 estimations 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, needed
resources during an emergency situation. After identication
of 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

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TRIAGE DECISIONS/Berg et al

tertiary trauma center, the team developed a plan to improve

pediatric patient safety and increase staff comfort in
managing a pediatric emergency in a community emergency
department with approximately 20% pediatric volumes.

The Plan

ED triage nurses will weigh each nonemergency patient in

kilograms at rst contact. Length will be measured for
infants and height will be measured for children who are
able to stand. 7 A colored dot sticker corresponding to the
measurement from the color-coded, length-based tape will
be placed on the identication band of each pediatric
patient. On the paper-based medical record, another
colored dot sticker is placed near the patient label on the
top page of the record. Because the medical record will be
scanned into the electronic record in black and white, the
name 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 hookand-loop fasteners for ease of use. Another length-based
tape was encased in hard, clear plastic and mounted near the
standing scale so that heel to head length/height could be
measured 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 identication
bracelets were available and chose stickers for space and cost
containment 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, and
practice on a stuffed animal was included. Concerns related
to potential inaccuracies of using a length-based tape for
weight estimation and the speed of estimating equipment
sizes were shared with the entire ED care team. The trauma
team also championed the roll-out following training and
continues to be accountable for ongoing process improvement and training.

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The Benet

Benets include a double check in terms of weight and

size. Pediatrics patients constitute a small portion of the ED
population, and critically sick or injured children are an
even smaller percentage. The proposed process is a quick
way to determine appropriate medication doses and
equipment sizes. When transferring children to other
facilities, this process of measurement is easy to communicate, and care provided is consistent and accurate across
the continuum and between facilities. Another benet was
increased awareness at regional system facilities, resulting in
similar staff-led processes at 4 other local emergency
departments, improving the safety of children regionally.

Summary

Obtaining an actual weight is critical to accurate medication

dosing. Knowledge of length/height is critical to equipment
sizing. Rapid and accurate measurement of both upon
arrival at the emergency department increases patient safety
and staff comfort in the case of a decompensating child
requiring resuscitation. Having a process in place that works
with the layout, medical record, and budget of the
department increases safety for the patient and may improve
outcomes, and if the process is led by staff champions,
acceptance of the process may be faster. Regardless of the
actual method, patient safety and staff satisfaction can be
improved with a simple process that prepares for an
emergency 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 lengthbased resuscitation tape accurately place pediatric patients into appropriate 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.

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6. Daugherty R, Nadkarni V, Brenn B. Endotracheal tube size estimation

for children with pathological short stature. Pediatr Emerg Care.
2006;22(11):710-7.
7. Los Angeles County Emergency Medical Services Agency. Color coded
drug doses: LA County kids. http://ems.dhs.lacounty.gov/Program
Approvals/ParamedicstudyMaterials/studyguides/BroselowColorCode.
pdf. Accessed April 6, 2013.

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Submissions to this column are encouraged and may be sent to

Andi L. Foley, RN, MSN, CEN
andii42@yahoo.com
or
Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN
pkhoward@uky.edu

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