Practice variations in the treatment of febrile infants among pediatric emergency physicians

Non-pharmacological Management of Fever in Otherwise Healthy Children

BACKGROUND

Fever is a common childhood problem faced in both hospital and community settings. In many cases the fever is associated with mild to moderate self-limiting illnesses. There has been a rapid increase in antipyretic use as the means of managing or treating this adaptive physiological response to infection. The use of alternative means of caring for a febrile child could minimise the amount of antipyretics administered to children and thereby reduce the potential risks.

OBJECTIVE

The objective of this systematic review was to establish what non-pharmacological practices are effective in managing fever in children, three months to 12 years of age, who are otherwise healthy.

INCLUSION CRITERIA

Interventions for inclusion were physiological e.g. maintenance of hydration and rest, and external cooling, either direct e.g. sponging, clothing, or environmental e.g. fans, ambient temperature. Outcomes of interest were effect on fever, increase in comfort, decrease in parental anxiety and reduction in unnecessary use of health services.

SEARCH STRATEGY

The search sought English, Spanish, Portuguese, Mandarin and Italian language studies, published 2001-2011 in 12 major databases.

CRITICAL APPRAISAL, DATA EXTRACTION AND DATA SYNTHESIS

Critical appraisal of and data extraction from eligible studies were undertaken using standardised tools developed by the Joanna Briggs Institute. As statistical pooling of data was precluded, the findings are presented in narrative form.

RESULTS

Twelve randomised controlled trials were included, involving 986 children in total. Only one intervention identified in the review protocol - direct external cooling measures - was addressed by the studies. Eleven studies included sponging as an intervention while one also included clothing (unwrapping). No studies investigated physiological interventions, (e.g. hydration or rest), or environmental cooling measures, (e.g. fans or ambient temperature) as separate interventions. Three of these interventions (encouragement of fluid intake, rest and fans) were reported as part of the standard care provided to participants in several studies or were controlled in the study (ambient temperature). Only two of the four outcomes identified in the review protocol were examined (effect on fever (all 12 studies) and patient comfort). Although tepid sponging alone resulted in an immediate decrease in temperature, this response was of short duration, with antipyretics or antipyretics plus sponging having a more lasting effect. In addition, the observed levels of discomfort of the sponged children were higher than the other groups. For both measures, this effect was not statistically significant in every case.

CONCLUSION

The care of a febrile child needs to be individualised, based on current knowledge of the effectiveness and risks of interventions. The administration of antipyretics should be minimised, used selectively and with caution, even in otherwise healthy children. The results of this systematic review support previous findings that routine tepid sponging does not have an overall beneficial effect. However measures such as encouraging fluid intake and unwrapping the child should be encouraged.

IMPLICATIONS FOR PRACTICE

The two foci of care should be the child and the parents/primary caregiver. For the child, care should aim to support the body's physiological responses i.e. maintain hydration, minimise use of antipyretics. Support the parents to reduce anxiety e.g. by involving them in care and providing appropriate education, particularly in respect to correct dosages of antipyretics.

IMPLICATIONS FOR RESEARCH

Given the now well demonstrated discomfort engendered by tepid sponging, its use in treating febrile children is no longer advocated and does not warrant further research. However aspects of other non-pharmacological interventions have not been so well researched e.g. parental response to advice on fluid intake and appropriate clothing.

The association of emergency department crowding and time to antibiotics in febrile neonates

OBJECTIVES

The objective was to assess the relationship between emergency department (ED) crowding and timeliness of antibiotic administration to neonates presenting with fever in a pediatric ED.

METHODS

This was a retrospective cohort study of febrile neonates (aged 0-30 days) evaluated for serious bacterial infections (SBIs) in a pediatric ED from January 2006 to January 2008. General linear models were used to evaluate the association of five measures of ED crowding with timeliness of antibiotic administration, controlling for patient characteristics. A secondary analysis was conducted to determine which part of the ED visit for this population was most affected by crowding.

RESULTS

A total of 190 patients met inclusion criteria. Mean time to first antibiotic was 181.7 minutes (range = 18-397 minutes). At the time of case presentation, the number of patients waiting in the waiting area, total number of hours spent in the ED by current ED patients, number of ED patients awaiting admission, and hourly boarding time were all positively associated with longer times to antibiotic. The time from patient arrival to room placement exhibited the strongest association with measures of crowding.

CONCLUSIONS

Emergency department crowding is associated with delays in antibiotic administration to the febrile neonate despite rapid recognition of this patient population as a high-risk group. Each component of ED crowding, in terms of input, throughput, and output factors, was associated with delays. Further work is required to develop processes that foster a more rapid treatment protocol for these high-risk patients, regardless of ED crowding pressures.

Human parechoviruses in infants with systemic infection

Human parechoviruses (HPeVs) are RNA viruses related to neonatal sepsis, meningoencephalitis and other infections in young children. Little clinical and epidemiological information is available on these viruses. HPeVs were sought in cerebrospinal fluid from 397 infants aged less than 12 months from whom a sample was obtained to exclude meningitis or encephalitis from 2006 to 2009. HPeV infections were also tested in stool samples from 271 children aged less than 3 years old with gastroenteritis from November 2008 to March 2009. HPeV detection was by real-time polymerase chain reaction assay (region 5'UTR), followed by genotyping (region VP3/VP1). HPeVs were detected in the cerebrospinal fluid of nine infants (2.3%), one aged 6 months and eight aged 14-55 days old. All were admitted to hospital for febrile syndrome with abrupt clinical deterioration and suspected systemic infection without clear laboratory signs of meningeal inflammation. The same virus was detected in all the available nasopharyngeal aspirates, stool, and/or serum samples from each patient. At least eight of the nine cases were caused by HPeV3. HPeVs were detected in stool samples from 17 children (6.3%), the most prevalent types being types 1 and 3. In conclusion, HPeV infection is common in the Basque Country (Spain) and HPeV3 is a significant cause of hospital admission due to systemic infection in the first few months of life. In these patients, HPeVs should be investigated as part of routine tests for enterovirus.

[High exposure to antibiotics in the population and differences by sex and age]

PURPOSE

To determine antibiotic use and its distribution by age and gender, as well as the most prescribed therapeutic group.

DESIGN

Observational descriptive with retrospective data.

SETTINGS AND PARTICIPANTS

Population from the Lleida (Spain) Health Region receiving antibiotic prescriptions from 2002 to 2007.

MEASUREMENTS

Daily Dose Per Inhabitant (DID) was calculated, as well as the number of patients under treatment. The study variables were: age, gender, number of patients under antibiotic treatment and pharmacological group.

RESULTS

Mean prevalence of patients receiving antibiotics was 36.93% (33.51% in men and 40.42% in women). The DID in Lleida during 2007 is 23.52. The majority (56%) had received antibiotics once a year. The antibiotic consumption prevalence has a "V" shape with higher values among children and old people. There is an annual exposure to antibiotics in 58.8% of the 0 to 4 years-old age group. The most prescribed antibiotic is amoxicillin/clavulanic.

CONCLUSIONS

We observe a high antibiotic prescription rate among children and older people, the high consumption in childhood being of note. There is also a higher use of antibiotics among women and changing of prescription towards broad spectrum antibiotics.

Physician practice variation in the pediatric emergency department and its impact on resource use and quality of care

OBJECTIVE

To evaluate variation in case-mix adjusted resource use among pediatric emergency department (ED) physicians and its correlation with ED length of stay (LOS) and return rates.

METHODS

Resource use patterns at 2 EDs for 36 academic physicians (163,669 patients at ED1) and 45 private physicians (289,199 patients at ED2) from 2003 to 2006 were abstracted for common laboratory tests, imaging studies, intravenous therapy (fluids/antibiotics), LOS and 72-hour return rate for discharged patients, and hospital admissions for all patients. Case-mix adjustment was based on triage acuity, diagnostic category, demographics, and temporal measures.

OUTCOME MEASURES

(1) adjusted overall resource use for ED1 and ED2 physicians and (2) observed-to-expected ratios for ED1 physicians.

RESULTS

Case-mix adjusted hospital admission rates among physicians varied nearly 3-fold (6.3%-18%) for ED1 and 8-fold (2.5%-19.4%) for ED2. Intravenous therapy use varied 2-fold (4.9%-10.4%) at ED1 and 3-fold (3.6%-11.4%) at ED2. Emergency department 2 physicians had an almost 2-fold (10.9%-20.6%) variation in imaging use. Variation in head computed tomography use was 2-fold (1.1%-2.5%) at ED1 and 5-fold (0.9%-4.8%) at ED2. Physicians had longer than expected LOS if they had higher than expected use of laboratory tests (r, 0.41; 95% confidence interval [CI], 0.09-0.65; P < 0.05) and imaging (r, 0.48; 95% CI, 0.17-0.69; P < 0.01). Return rate was not significantly correlated with resource use in any category. Physicians with higher than expected use of laboratory tests had higher than expected use of imaging (r, 0.62; 95% CI, 0.36-0.78; P < 0.001), head computed tomography (r, 0.49; 95% CI, 0.19-0.70; P < 0.01), and intravenous therapy (r, 0.51; 95% CI, 0.20-0.71; P < 0.01).

CONCLUSIONS

Significant variation exists in physician use of common ED resources. Higher resource use was associated with increased LOS but did not reduce return to ED. Practice variation such as this may represent an opportunity to improve health care quality and decrease costs.

Quality initiatives in the emergency department

PURPOSE OF REVIEW

To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) RECENT FINDINGS: Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED--such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate.

SUMMARY

There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.

Fever

PURPOSE OF REVIEW

The present review presents novel infections and better evidence on current practices related to fever in children.

RECENT FINDINGS

Studies using more accurate diagnostic methods have provided evidence for prevalence of certain diseases, their clinical presentation and anticipated complications. Answers to certain clinical dilemmas related to febrile children in a pediatric office practice have been addressed recently. Some studies have explored current issues like immunization of pregnant women with influenza vaccine and the outbreak investigation of the swine H1N1 influenza.

SUMMARY

Fever still remains the most common reason for visits to the pediatrician or emergency room. Better diagnostic methods; appropriate therapeutic or preventive strategies; and continued surveillance for novel infections have improved outcomes from both an individual and public health perspective.