Characteristics of revisits of children at risk for serious infections in pediatric emergency care

Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever

Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.

What is important to the GP in recognizing acute appendicitis in children: a delphi study

BACKGROUND

For diagnostic research on appendicitis in registration data, insight is needed in the way GPs generate medical records. We aimed to reach a consensus on the features that GPs consider important in the consultation and medical records when evaluating a child with suspected appendicitis.

METHODS

We performed a three-round Delphi study among Dutch GPs selected by purposive sampling. An initial feature list was created based on a literature search and features in the relevant Dutch guideline. Finally, using a vignette describing a child who needed later reassessment, we asked participants to complete an online questionnaire about which consultation features should be addressed and recorded.

RESULTS

A literature review and Dutch guideline yielded 95 consultation features. All three rounds were completed by 22 GPs, with the final consensus list containing 26 symptoms, 29 physical assessments and signs, 2 additional tests, and 8 further actions (including safety-netting, i.e., informing the patient about when to contact the GP again). Of these, participants reached consensus that 37 should be actively addressed and that 20 need to be recorded if findings are negative.

CONCLUSIONS

GPs agreed that negative findings do not need to be recorded for most features and that records should include the prognostic and safety-netting advice given. The results have implications in three main domains: for research, that negative findings are likely to be missing; for medicolegal purposes, that documentation cannot be expected to be complete; and for clinical practice, that safety-netting advice should be given and documented.

Pediatric emergency revisits of children with COVID-19

OBJECTIVE

This study was conducted to reveal the characteristics of pediatric emergency revisits of children with COVID-19 and the factors associated with clinical worsening and hospitalization at the revisit.

MATERIALS AND METHODS

In pediatric emergency visits of children between July 2020 and March 2021 with COVID-19, the patients who had a revisit within 7 days were included in the study. Demographic and clinical characteristics, test results, and the relationship of these variables with clinical worsening and hospitalization at the revisit were investigated.

RESULTS

In 6779 children with COVID-19, 284 (4.1%) patients included in the study. 51.8% of the patients were male, the median age was 11.1 years, and median time to revisit time was 2.0 days. The rates of clinical worsening and hospitalization were 9.1% and 14.7%, respectively. Children younger than 24 months and those with chronic diseases were more commonly hospitalized at the revisit. Though the frequency of laboratory and radiologic testing at the revisit was significantly increased compared to the first presentation, tests did not play an important role in the decision-making processes. More than 85% of patients were clinically mild at the first presentation and revisit.

CONCLUSIONS

Children with a diagnosis of COVID-19 can revisit the emergency without evident clinical worsening. Since revisits cause increase in frequency of laboratory and radiological testing, preventing unnecessary revisits of children with COVID-19 can reduce the workload and cost of health care services. We may consider changing our perspective on revisit patients to make decisions based on clinical findings instead of obtaining for more laboratory tests.

Early reattenders to the paediatric emergency department: A prospective cohort study and multivariate analysis

AIMS

The rate of unplanned reattendances is used as an indicator of the quality of care delivered in a paediatric emergency department (PED). With early reattendance in the UK well above the national target of 1-5%, we aimed to identify the factors which predict unplanned early reattendance to the PED.

METHODS

This is a prospective, single-centre cohort study undertaken over 12 months. Data were collected on all patients who reattended the PED within 7 days of their initial visit as well as for a comparative cohort of patients with no visit in the preceding or subsequent 7 days. Multiple patient and departmental variables were recorded and analysed using a multivariate regression model.

RESULTS

There were a total of 19 420 index visits to the PED, of which 1461 patients had an unscheduled reattendance within 7 days - a rate of 7.5%. Factors associated with unplanned but related reattendance include young age and diagnosis with a respiratory or other medical illness. Interestingly, the grade of clinician appeared to be relevant with patients seen by junior members of the medical team less likely to reattend. Acuity of illness was not a significant factor. A substantial number of unplanned early reattenders (36.3%) would have been missed had a time period of 72 h been used rather than 7 days.

CONCLUSIONS

This study identifies the typical patient who will have an unplanned, related early reattendance to a PED. This study also supports the use of a 7-day time period when using early reattendance as a performance indicator.

Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care

BACKGROUND

Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.

OBJECTIVE

To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.

METHODS

Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.

RESULTS

95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.

CONCLUSIONS

We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

Factors Associated with Unscheduled Emergency Department Revisits in Children with Acute Lower Respiratory Tract Diseases

Purpose

To identify factors associated with unscheduled emergency department (ED) revisits within 72 hours in children with acute dyspnea from lower respiratory tract diseases.

Patients and Methods

This retrospective cohort study included pediatric patients (age group: one month to 15 years old) who visited the ED with acute lower respiratory tract diseases between January 1st, 2017 and February 28th, 2019. The medical records were reviewed and discharged patients were dichotomized into revisit and non-revisit groups, based on whether the patients needed a revisit or not. Baseline characteristics, vital signs, diagnosis, treatment, pediatrician consultation, ED length of stay, and primary doctor of both groups were compared. Univariate and multivariate analyses by logistic regression were used to determine the significant factors associated with the revisits.

Results

Medical records of 918 eligible pediatric patients (1417 visits) were reviewed. Factors significantly associated with the revisits were history of asthma or current controller use (odds ratio [OR]: 3.08: 95% confidence interval [CI]: 1.86-5.1). Not prescribing systemic corticosteroids (P < 0.001), or prescribing them upon discharge without first dose in the ED (P = 0.022) were significantly associated with revisits.

Conclusion

No prescription of systemic corticosteroids or prescription upon discharge, without an immediate dose at the ED, in children with history of asthma or current controller use were associated with revisits.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities

OBJECTIVES

In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language.

METHODS

A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test.

RESULTS

Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers.

CONCLUSIONS

Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

Background

To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.

Methods and findings

A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit (‘index’ visit), in 2012–2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65–0.74) and summary calibration slope of 0.83 (95% CI 0.67–0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87–5.01) and specificity 0.96 (95% CI 0.95–0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25–0.35), sensitivity 0.88 (95% CI 0.86–0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68–0.75) and summary calibration slope of 0.84 (95% CI 0.71–0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.

Conclusion

We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Characteristics and outcomes of patients with an unscheduled return visit within 72 hours to the Paediatric Emergency Centre at a Private Tertiary Referral Hospital in Kenya

Introduction

Patients’ unscheduled return visits (URVs) to the paediatric emergency Centre (PEC) contribute to overcrowding and affect health service delivery and overall quality of care. This study assessed the characteristics and outcomes of paediatric patients with URVs (within 72 hours) to the PEC at a private tertiary hospital in Kenya.

Methods

We conducted a retrospective chart review of all URVs within 72 hours among paediatric patients aged ≤15 years between 1 July and 31 December 2018 at the tertiary hospital in Nairobi, Kenya.

Results

During the study period, 1.6% (n=172) of patients who visited the PEC returned within 72 hours, with 4.7% revisiting the PEC more than once. Patients’ median age was 36 months (interquartile range: 42 months); over half were male (51.7%), 55.8% were ambulatory and 84.3% were insured. In addition, 21% (n=36) had chronic diseases and 7% (n=12) had drug allergies. Respiratory (59.5%) and gastrointestinal (21.5%) tract infections were the most common diagnoses. Compared with the first visit, more patients with URVs were classified as urgent (1.7% vs. 5.2%) and were non-ambulatory (44.2% vs. 49.5%, p=<0.001); 18% of these patients were admitted. Of these 58% were male, 83.9% were aged 0–5 years, 12.9% were classified as urgent, 64.5% had respiratory tract infections and 16.1% had gastrointestinal tract infections. Being admitted was associated with patient acuity (p=0.004), laboratory tests (p=<0.001) and ambulatory status (p=0.041).

Conclusion

The URV rate is low in our setting. Patients who returned to the PEC within 72 hours tended to be male, under 5 years old and insured. Many were non-urgent cases with diagnoses of respiratory and gastrointestinal tract infections. The findings suggest that some URVs were necessary and may have contributed to better care and improved outcomes while others highlight a need for effective patient education and comprehensive initial assessment.

Performance of axillary and rectal temperature measurement in private pediatric practice

To better understand the role and reliability of axillary temperature measurements in clinical real life, axillary and rectal measurements in infants presenting in a private pediatric practice because of fever were compared. Prospectively, 169 infants (81 girls), median 9 (interquartile range 6-13) months of age, were examined at room temperature (20-24 °C). Two left and two right axillary, as well as two rectal measurements were taken with a digital thermometer and subsequently averaged. The median and interquartile range for axillary and rectal measurements were 36.9 (36.3-37.6) °C and 38.2 (37.4-38.9) °C, respectively (p < 0.0001). The limits of agreement in the Bland-Altman plots were 0.32 to 1.98 °C, with a mean bias of 1.15 °C. Axillary thermometers showed a good sensitivity for detecting rectal temperature > 38 °C (95%) but limited specificity (75%), with an area-under-the-curve of 0.95.Conclusions: Axillary readings are always lower than rectal ones, the limits of agreement are quite wide. Axillary readings can be used for screening but critical measurements should be confirmed by more reliable methods. What is Known • In infants and toddlers, temperature has been traditionally taken rectally. • Axillary measurements are better accepted and are recommended in current guidelines. What is New • Axillary temperature was always lower than rectal temperature. • The limits of agreement of axillary thermometers are wide. • Axillary thermometers have a good sensitivity but limited specificity and are therefore adequate for fever screening.

Outcomes in children evaluated but not transported by ambulance personnel: retrospective cohort study

BACKGROUND

Not all children with an out-of-hospital emergency medical contact are transported by ambulance to the emergency department (ED). Non-transport means that after on-scene evaluation and possible treatment, ambulance personnel may advise the patient to monitor the situation at home or may refer the patient to seek medical attention by other means of transport. As selecting the right patients for ambulance transport is critical for optimising patient safety and resource use, we studied outcomes in non-transported children to identify possible risk groups that could benefit from ambulance transport.

METHODS

In a population-based retrospective cohort study of all children aged 0-15 years encountered but not transported by ambulance in Helsinki, Finland, between 1 January 2014 and 31 December 2016, we evaluated (1) 12-month mortality, (2) intensive care admissions, (3) unscheduled ED contacts within the following 96 hours after the non-transport decision and (4) the clinical status of the child on presentation to ED in the case of a secondary ED visit.

RESULTS

Of all children encountered by out-of-hospital emergency medical services, 3579/7765 (46%) were not transported to ED by ambulance. There was no mortality or intensive care admissions related to the non-transport. The risk factors for an unscheduled secondary ED visit after a non-transport decision were young age (p=0.001), non-transport decision during the early morning hours (p<0.001) and certain dispatch codes, including 'dyspnoea' (p<0.001), 'vomiting/diarrhoea' (p=0.030) and 'mental illness' (p=0.019). We did not detect deterioration in patients' clinical presentation at ED traceable to non-transport decisions.

CONCLUSIONS

Not transporting all children by ambulance after an out-of-hospital emergency medical contact was not associated with deaths, intensive care admissions or significant deterioration in general condition in our study population and healthcare system. Special attention and a formal non-transport protocol are warranted in certain subgroups, including infants.