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June 2022

Traffic Light assessment tool is ‘unreliable’

The NICE traffic light system, widely used in general practice for the assessment of unwell children, cannot accurately detect or exclude serious illness in children presenting to UK general practice with an acute illness.

Researchers writing in the British Journal of General Practice reached the conclusion that it cannot be relied on by clinicians for the assessment of acutely unwell children and that it is unsuitable for use as a clinical decision tool.

Children with acute illnesses such as a fever or cough account for a quarter of all GP appointments and over 2 million emergency department attendances each year. To help GPs assess which children need referral to hospital, NICE created a tool for identifying seriously ill children by grouping symptoms into ‘green’, ‘amber’, or ‘red’; corresponding to a low, intermediate, or high risk of serious illness respectively.

According to the tool, children in the green category can be managed at home. Children in the amber category can either be referred to hospital for assessment or sent home with safety-net advice. Children in the red category should be referred urgently for assessment in hospital.

The study looked at the data from over 6,700 children who saw their GP with an acute illness to see whether their ‘traffic light’ category matched the severity of their illness.

Researchers found that the prevalence of serious illness in 6703 acutely unwell young children presenting to UK general practice was only 0.3% but that the NICE traffic light system categorised 31.6% of all children as red; 62.7% as amber; and 5.7% as green. Overall, 139 (2.1%) children were admitted within 7 days of their initial presentation.

If the clinicians had followed the NICE guidance, a third of children (in the red category) would have been urgently referred to hospital, but using the red category as a threshold for hospital referral would also have meant that around 40% of seriously ill children would have been missed. Combining the red and amber categories would improve the sensitivity of the tool – but substantially increase the numbers of children sent into hospital. Clinicians would only be able to confidently exclude serious illness in a minority of children (6%) in the green category.

The majority of previous studies validating the Traffic Light assessment tool have been conducted in secondary care settings, and to the authors’ knowledge, no studies have validated the tool in UK general practice, although there was one small study in general practice in the Netherlands.

Clark A, et al. Br J Gen Pract 16 May 2022;

Practice Nurse 2022;52(5):7