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Keuning MW, Klarenbeek NN, Bout HJ, Broer A, Draaijer M, Hol J, Hollander N, Merelle M, Nassar-Sheikh Rashid A, Nusman C, Oostenbroek E, Ridderikhof ML, Roelofs M, van Rossem E, van der Schoor SRD, Schouten SM, Taselaar P, Vasse K, van Wermeskerken AM, van der Zande JMJ, Zuurbier R, Bijlsma MW, Pajkrt D, Plötz FB. Prospective multicenter evaluation of adherence to the Dutch guideline for children aged 0-16 years with fever without a source-febrile illness in children (FINCH) study. Eur J Pediatr 2024; 183:2921-2933. [PMID: 38619569 PMCID: PMC11192673 DOI: 10.1007/s00431-024-05553-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 04/16/2024]
Abstract
Evaluation of guidelines in actual practice is a crucial step in guideline improvement. A retrospective evaluation of the Dutch guideline for children with fever without an apparent source (FWS) showed 50% adherence in young infants. We prospectively evaluated adherence to the Dutch guideline and its impact on management in current practice. Prospective observational multicenter cross-sectional study, including children 3 days to 16 years old presented for FWS at one of seven emergency departments in participating secondary and tertiary care hospitals in the Netherlands. Adherence to the Dutch FWS guideline, adapted from the National Institute for Health and Care Excellence (NICE) guideline, was evaluated, and patterns in non-adherence and the impact of non-adherence on clinical outcomes and resource use were explored. Adherence to the guideline was 192/370 (52%). Adherence was lowest in patients categorized as high risk for severe infection (72/187, 39%), compared to the low-risk group (64/73, 88%). Differences in adherence were significant between risk categories (P < 0.001) but not between age categories. In case of non-adherence, less urinalysis, fewer bacterial cultures (blood, urine, and cerebral spinal fluid), and less empirical antibiotic treatment were performed (P < 0.050). Clinical outcomes were not significantly different between the non-adherence and the adherence group, particularly regarding missed severe infections. CONCLUSIONS We found a high non-adherence rate of 48%, which did not lead to unfavorable clinical outcomes. This substantiates the need for a critical reevaluation of the FWS guideline and its indications for bacterial cultures, viral testing, and antibiotic treatment. WHAT IS KNOWN • Despite the development of national guidelines, variation in practice is still substantial in the assessment of febrile children to distinguish severe infection from mild self-limiting disease. • Previous retrospective research suggests low adherence to national guidelines for febrile children in practice. WHAT IS NEW • In case of non-adherence to the Dutch national guideline, similar to the National Institute for Health and Care Excellence (NICE) guideline from the United Kingdom, physicians have used fewer resources than the guideline recommended without increasing missed severe infections.
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Affiliation(s)
- Maya W Keuning
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | | | - Hidde J Bout
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Amber Broer
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Melvin Draaijer
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Jeroen Hol
- Department of Pediatrics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Nina Hollander
- Department of Pediatrics, Flevoziekenhuis, Almere, The Netherlands
| | - Marieke Merelle
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | | | - Charlotte Nusman
- Department of Pediatrics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Emma Oostenbroek
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Milan L Ridderikhof
- Department of Emergency Medicine, Amsterdam, UMC , University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Manouck Roelofs
- Department of Pediatrics, Zaans Medical Center, Zaandam, The Netherlands
| | - Ellen van Rossem
- Department of Pediatrics, Flevoziekenhuis, Almere, The Netherlands
| | | | - Sarah M Schouten
- Department of Pediatrics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Taselaar
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Koen Vasse
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | - Roy Zuurbier
- Department of Pediatrics, Tergooi MC, Blaricum, The Netherlands
| | - Merijn W Bijlsma
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Dasja Pajkrt
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frans B Plötz
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Pediatrics, Tergooi MC, Blaricum, The Netherlands
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Katoh M, Kanazawa T, Abe Y, Sun G, Matsui T. Development of a non-contact 15-second paediatric respiratory rate monitor using microwave radar and its clinical application. Acta Paediatr 2023; 112:493-495. [PMID: 36301152 DOI: 10.1111/apa.16585] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Miyu Katoh
- Graduate School of Systems Design, Tokyo Metropolitan University, Tokyo, Japan
| | - Takeru Kanazawa
- Children's Medical Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yoshifusa Abe
- Children's Medical Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Guanghao Sun
- Graduate School of Informatics and Engineering, The University of Electro-Communications, Chofu, Japan
| | - Takemi Matsui
- Graduate School of Systems Design, Tokyo Metropolitan University, Tokyo, Japan
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Wertheim D, Seddon P. Measuring respiratory rate in children. Acta Paediatr 2023; 112:342-343. [PMID: 36605003 DOI: 10.1111/apa.16645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Affiliation(s)
- David Wertheim
- Faculty of Engineering, Computing and the Environment, Kingston University, Surrey, UK
| | - Paul Seddon
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Pociute A, Kottilingal Farook MF, Dagys A, Kevalas R, Laucaityte G, Jankauskaite L. Platelet-Derived Biomarkers: Potential Role in Early Pediatric Serious Bacterial Infection and Sepsis Diagnostics. J Clin Med 2022; 11:jcm11216475. [PMID: 36362702 PMCID: PMC9658833 DOI: 10.3390/jcm11216475] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Fever is the most common complaint of children who are attending a pediatric emergency department (PED). Most of the fever cases are of viral origin; however, the most common markers, such as leucocyte, neutrophil count, or C-reactive protein, are not sensitive or specific enough to distinguish the etiology of fever, especially if children present at the early phase of infection. Currently, platelets have been attributed a role as important sentinels in viral and bacterial infection pathogenesis. Thus, our aim was to analyze different platelet indices, such as PNLR (platelet-to-neutrophil/lymphocyte ratio), PNR (platelet-to-neutrophil ratio) as well as specific secreted proteins, such as sP-selectin, CXCL4, CXCL7, and serotonin. We included 68 children who were referred to PED with the early onset of fever (<12 h). All children with comorbidities, older than five years, and psychiatric diseases, who refused to participate were excluded. All the participants were divided into viral, bacterial, or serious bacterial infection (SBI) groups. All the children underwent blood sampling, and an additional sample was collected for protein analysis. Our analysis revealed statistically significant differences between leucocyte, neutrophil, and CRP levels between SBI and other groups. However, leucocyte and neutrophil counts were within the age norms. A higher PNLR value was observed in a bacterial group, PNR-in viral. As we tested CXCL7 and sP-selectin, alone and together those markers were statistically significant to discriminate SBI and sepsis from other causes of infection. Together with tachypnoe and SpO2 < 94%, it improved the prediction value of sepsis as well as SBI. CXCL4 and serotonin did not differ between the groups. Concluding, CXCL7 and sP-selectin showed promising results in early SBI and sepsis diagnosis.
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Affiliation(s)
- Aiste Pociute
- Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | | | - Algirdas Dagys
- Department of Pediatrics, Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Rimantas Kevalas
- Department of Pediatrics, Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Goda Laucaityte
- Department of Pediatrics, Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Lina Jankauskaite
- Department of Pediatrics, Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
- Correspondence:
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Hagedoorn NN, Zachariasse JM, Borensztajn D, Adriaansens E, von Both U, Carrol ED, Eleftheriou I, Emonts M, van der Flier M, de Groot R, Herberg JA, Kohlmaier B, Lim E, Maconochie I, Martinón-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Tsolia M, Zavadska D, Zenz W, Levin M, Vermont C, Moll HA. Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study. Arch Dis Child 2022; 107:116-122. [PMID: 34158280 PMCID: PMC8784994 DOI: 10.1136/archdischild-2020-320992] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 06/06/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE (1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children. DESIGN/SETTING Observational study in 11 European EDs (2017-2018). PATIENTS Febrile children with measured blood pressure. MAIN OUTCOME MEASURES Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs). RESULTS Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8. CONCLUSIONS High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED.
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Affiliation(s)
| | - Joany M Zachariasse
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dorine Borensztajn
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elise Adriaansens
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr von Haunersches Children's Hospital, Children's Clinic and Children's Polyclinic of the Ludwig Maximilian University of Munich, Munchen, Germany,Partner Site Munich, German Centre for Infection Research, Braunschweig, Germany
| | - Enitan D Carrol
- Institute of Infection, Veterinary and Ecological Sciences, Global Health Liverpool, University of Liverpool, Liverpool, UK,Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Irini Eleftheriou
- Second Department of Paediatrics, P and A Kyriakou Children’s Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases and Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands,Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud University, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Ronald de Groot
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands,Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud University, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jethro Adam Herberg
- Division of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Emma Lim
- Paediatric Immunology, Infectious Diseases and Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Federico Martinón-Torres
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud Gerard Nijman
- Division of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases, Ljubljana University Clinical Center, Ljubljana, Slovenia
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Maria Tsolia
- Second Department of Paediatrics, P and A Kyriakou Children’s Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dace Zavadska
- Department of Pediatrics, Rigas Stradinas University, Riga, Latvia
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Division of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Clementien Vermont
- Department of Paediatric Infectious Diseases and Immunology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriette A Moll
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Leeb F, Sharma U, Yeghiazaryan L, Moll HA, Greber-Platzer S. Improving the safety of the Manchester triage system for children with congenital heart disease. Eur J Pediatr 2022; 181:3831-3838. [PMID: 36029332 PMCID: PMC9546792 DOI: 10.1007/s00431-022-04594-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 08/15/2022] [Indexed: 11/07/2022]
Abstract
UNLABELLED This study is a prospective evaluation of the validity of a Manchester triage system (MTS) modification for detecting under-triaged pediatric patients with congenital heart disease (CHD). Children with CHD visiting the emergency unit of the Department of Pediatrics and Adolescent Medicine, University Hospital Vienna in 2014 were included. The MTS modification updated the prioritization of patients with complex syndromic diseases, specific symptoms related to chronic diseases, decreased general condition (DGC), profound language impairment, unknown medical history, or special needs. A four-level outcome severity index based on diagnostic and therapeutic interventions, admission to hospital, and follow-up strategies was defined as a reference standard for the correct clinical classification of the MTS urgency level. Of the 19,264 included children, 940 had CHD. Of this group, 266 fulfilled the inclusion criteria for the modified triage method. The MTS modification was significantly more often applied in under-triaged (65.9%) than correctly or over-triaged (25%) children with CHD (p-value χ2 test < 0.0001, OR 5.848, 95% CI: 3.636-9.6). CONCLUSION The MTS urgency level upgrade modification could reduce under-triage in children with CHD. Applying a safety strategy concept to the MTS could mitigate under-triage in such a high-risk patient group. WHAT IS KNOWN • The Manchester triage system is considered to be valid and reliable but tends to over-triage. • A study by Seiger et al. showed poor performance in children with chronic illnesses, especially in children with cardiovascular diseases. WHAT IS NEW • The MTS modification with one urgency level upgrade could decrease under-triage in children with congenital heart disease. • As reference standard a four level outcome severity index (OSI) was established to include diagnostic investigations, medical interventions, hospital admission or follow up visits in the assessment.
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Affiliation(s)
- Franziska Leeb
- grid.22937.3d0000 0000 9259 8492Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Ursula Sharma
- grid.22937.3d0000 0000 9259 8492Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lusine Yeghiazaryan
- grid.22937.3d0000 0000 9259 8492Center for Medical Statistics, Informatics and Intelligent Systems, Institute of Medical Statistics, Medical University Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Henriëtte A. Moll
- grid.416135.40000 0004 0649 0805Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Susanne Greber-Platzer
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study. Eur J Pediatr 2022; 181:4199-4209. [PMID: 36178539 PMCID: PMC9649464 DOI: 10.1007/s00431-022-04606-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. There is practice variation in management due to differences in guidelines and their usage and adherence. We aimed to assess whether management in febrile children below 3 months attending European Emergency Departments (EDs) was according to the guidelines for fever. This study is part of the MOFICHE study, which is an observational multicenter study including routine data of febrile children (0-18 years) attending twelve EDs in eight European countries. In febrile children below 3 months (excluding bronchiolitis), we analyzed actual management compared to the guidelines for fever. Ten EDs applied the (adapted) NICE guideline, and two EDs applied local guidelines. Management included diagnostic tests, antibiotic treatment, and admission. We included 913 children with a median age of 1.7 months (IQR 1.0-2.3). Management per ED varied as follows: use of diagnostic tests 14-83%, antibiotic treatment 23-54%, admission 34-86%. Adherence to the guideline was 43% (374/868) for blood cultures, 29% (144/491) for lumbar punctures, 55% (270/492) for antibiotic prescriptions, and 67% (573/859) for admission. Full adherence to these four management components occurred in 15% (132/868, range 0-38%), partial adherence occurred in 56% (484/868, range 35-77%). CONCLUSION There is large practice variation in management. The guideline adherence was limited, but highest for admission which implies a cautious approach. Future studies should focus on guideline revision including new biomarkers in order to optimize management in young febrile children. WHAT IS KNOWN • Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. • There is practice variation in management of young febrile children due to differences in guidelines and their usage and adherence. WHAT IS NEW • Full guideline adherence is limited, whereas partial guideline adherence is moderate in febrile children below 3 months across Europe. • Guideline revision including new biomarkers is needed to improve management in young febrile children.
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Zanetto L, van de Maat J, Nieboer D, Moll H, Gervaix A, Da Dalt L, Mintegi S, Bressan S, Oostenbrink R. Diagnostic variation for febrile children in European emergency departments. Eur J Pediatr 2022; 181:2481-2490. [PMID: 35314869 PMCID: PMC9110537 DOI: 10.1007/s00431-022-04417-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/21/2021] [Accepted: 02/10/2022] [Indexed: 02/02/2023]
Abstract
UNLABELLED The study aimed to explore the use of diagnostics for febrile children presenting to European emergency departments (EDs), the determinants of inter-hospital variation, and the association between test use and hospitalization. We performed a secondary analysis of a cross-sectional observational study involving 28 paediatric EDs from 11 countries. A total of 4560 children < 16 years were included, with fever as reason for consultation. We excluded neonates and children with relevant comorbidities. Our primary outcome was the proportion of children receiving testing after primary evaluation, by country and by focus of infection. Variability between hospitals and effects of blood testing on patient disposition were explored by multilevel regression analyses, adjusting for patient characteristics (age group, triage level, appearance, fever duration, focus of infection) and hospital type (academic, teaching, other). The use of routine diagnostics varied widely, mostly in the use of blood tests, ranging from 3 to 75% overall across hospitals. Age < 3 months, high-acuity triage level, ill appearance, and suspicion of urinary tract infection displayed the strongest association with blood testing (odds ratios (OR) of 8.71 (95% CI 5.23-14.53), 19.46 (3.66-103.60), 3.13 (2.29-4.26), 10.84 (6.35-18.50), respectively). Blood testing remained highly variable across hospitals (median OR of the final model 2.36, 1.98-3.54). A positive association was observed between blood testing and hospitalization (OR 13.62, 9.00-20.61). CONCLUSION the use of diagnostics for febrile children was highly variable across European EDs, yet patient and hospital characteristics could only partly explain inter-hospital variability. Focus groups of participating sites should help define reasons for unexpected variation. WHAT IS KNOWN • Although previous research has shown variation in the emergency department (ED) management of febrile children, there is limited information on the use of diagnostics in European EDs. • A deeper knowledge of variability and its determinants can steer optimization of care. WHAT IS NEW • The use of diagnostics for febrile children was highly variable across European EDs, yet patient and hospital characteristics could only partly explain inter-hospital variability. • Data on between-centre comparison offer opportunities to further explore factors influencing unwarranted variation.
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Affiliation(s)
- Lorenzo Zanetto
- Department of Women’s and Children’s Health, University of Padova, Padua, 35128 Italy
| | - Josephine van de Maat
- Department of General Pediatrics, Erasmus Medical Center Sophia Children’s Hospital, Rotterdam, 3015 CN Netherlands
| | - Daan Nieboer
- Department of General Pediatrics, Erasmus Medical Center Sophia Children’s Hospital, Rotterdam, 3015 CN Netherlands
| | - Henriette Moll
- Department of General Pediatrics, Erasmus Medical Center Sophia Children’s Hospital, Rotterdam, 3015 CN Netherlands
| | - Alain Gervaix
- Department of Pediatrics, Gynaecology and Obstetrics, University Hospital of Geneva, Geneva, 1205 Switzerland
| | - Liviana Da Dalt
- Department of Women’s and Children’s Health, University of Padova, Padua, 35128 Italy
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padua, 35128, Italy.
| | - Rianne Oostenbrink
- Department of General Pediatrics, Erasmus Medical Center Sophia Children’s Hospital, Rotterdam, 3015 CN Netherlands
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Zhang C, Zhang L, Qiong L, Zeng L, Wu D, Qin F. Systematic review of methodology and reporting quality of global guidelines on fever in children. Medicine (Baltimore) 2021; 100:e28021. [PMID: 35049213 PMCID: PMC9191381 DOI: 10.1097/md.0000000000028021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/11/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the global clinical practice guidelines on fever in children. We also aimed to select a guideline with good methodology and reporting quality to provide scientific reference for diagnosis and treatment of fever in children. METHODS The Chinese and English databases Embase, PubMed, Cochrane library, China National Knowledge Infrastructure, Wanfang database, clinical guides, and the website of the Department of Public Health Administration were retrieved up to January 2020. The clinical practice guidelines on fever in children were included. The AGREE II instrument and Reporting Items for Practice Guidelines in Healthcare statement were used to evaluate the methodology and reporting quality of the guidelines. RESULTS Eight clinical guidelines for fever in children were included. Methodological quality assessment showed that the recommendation level of ISP, South Africa, National Institute for Health and Care Excellence, China, and American College of Emergency Physicians were grade B (recommended with modification), while that of American Academy of Pediatrics, New South Wales, and South Australia was grade C recommendation (not recommended). No grade A recommendation guideline was found. The reporting quality from higher to lower was National Institute for Health and Care Excellence, the Chinese guideline, American College of Emergency Physicians, ISP, South Africa, New South Wales, South Australia, and American Academy of Pediatrics. The guideline recommendations were similar in various countries, but they were slightly different in various aspects, including body temperature measurement and the timing of drug administration. CONCLUSION There are limitations in the methodology and reporting quality of all eight global guidelines on fever in children. For future development of these guidelines, attention should be paid to improving applicability of the guidelines in terms of methodology. Additionally, the principles and explanations for formation of recommendations should be described, as well as the limitations of the reporting guideline in detail in terms of the reporting quality. Treatments of fever in children are similar in different countries, but there are still differences that require further research.
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Affiliation(s)
- Chuan Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Liao Qiong
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Di Wu
- West China school of pharmacy, Sichuan University, Chengdu, China
| | - Fang Qin
- West China school of pharmacy, Sichuan University, Chengdu, China
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Borensztajn D, Zachariasse JM, Greber-Platzer S, Alves CF, Freitas P, Smit FJ, van der Lei J, Steyerberg EW, Maconochie I, Moll HA. Shortness of breath in children at the emergency department: Variability in management in Europe. PLoS One 2021; 16:e0251046. [PMID: 33951099 PMCID: PMC8099081 DOI: 10.1371/journal.pone.0251046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 04/20/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability. DESIGN The TrIAGE project, a prospective observational study based on electronic health record data. PATIENTS AND SETTING Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014). MAIN OUTCOME MEASURES We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables. RESULTS In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings. CONCLUSION European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.
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Affiliation(s)
- Dorine Borensztajn
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- * E-mail:
| | - Joany M. Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Susanne Greber-Platzer
- Department of Paediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Claudio F. Alves
- Department of Paediatrics, Hospital Prof. Dr. Fernando da Fonseca, Lisbon, Portugal
| | - Paulo Freitas
- Intensive Care Unit, Hospital Prof. Dr. Fernando da Fonseca, Lisbon, Portugal
| | - Frank J. Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ian Maconochie
- Department of Paediatric Accident and Emergency, Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Henriëtte A. Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Improving the prioritization of children at the emergency department: Updating the Manchester Triage System using vital signs. PLoS One 2021; 16:e0246324. [PMID: 33561116 PMCID: PMC7872278 DOI: 10.1371/journal.pone.0246324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/18/2021] [Indexed: 02/05/2023] Open
Abstract
Background Vital signs are used in emergency care settings in the first assessment of children to identify those that need immediate attention. We aimed to develop and validate vital sign based Manchester Triage System (MTS) discriminators to improve triage of children at the emergency department. Methods and findings The TrIAGE project is a prospective observational study based on electronic health record data from five European EDs (Netherlands (n = 2), United Kingdom, Austria, and Portugal). In the current study, we included 117,438 consecutive children <16 years presenting to the ED during the study period (2012–2015). We derived new discriminators based on heart rate, respiratory rate, and/or capillary refill time for specific subgroups of MTS flowcharts. Moreover, we determined the optimal cut-off value for each vital sign. The main outcome measure was a previously developed 3-category reference standard (high, intermediate, low urgency) for the required urgency of care, based on mortality at the ED, immediate lifesaving interventions, disposition and resource use. We determined six new discriminators for children <1 year and ≥1 year: “Very abnormal respiratory rate”, “Abnormal heart rate”, and “Abnormal respiratory rate”, with optimal cut-offs, and specific subgroups of flowcharts. Application of the modified MTS reclassified 744 patients (2.5%). Sensitivity increased from 0.66 (95%CI 0.60–0.72) to 0.71 (0.66–0.75) for high urgency patients and from 0.67 (0.54–0.76) to 0.70 (0.58–0.80) for high and intermediate urgency patients. Specificity decreased from 0.90 (0.86–0.93) to 0.89 (0.85–0.92) for high and 0.66 (0.52–0.78) to 0.63 (0.50–0.75) for high and intermediate urgency patients. These differences were statistically significant. Overall performance improved (R2 0.199 versus 0.204). Conclusions Six new discriminators based on vital signs lead to a small but relevant increase in performance and should be implemented in the MTS.
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Schinkelshoek G, Borensztajn DM, Zachariasse JM, Maconochie IK, Alves CF, Freitas P, Smit FJ, van der Lei J, Steyerberg EW, Greber-Platzer S, Moll HA. Management of children visiting the emergency department during out-of-office hours: an observational study. BMJ Paediatr Open 2020; 4:e000687. [PMID: 32984551 PMCID: PMC7493126 DOI: 10.1136/bmjpo-2020-000687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours. METHODS We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital. RESULTS Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining. CONCLUSIONS Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.
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Affiliation(s)
- Gina Schinkelshoek
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Dorine M Borensztajn
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Ian K Maconochie
- Department of Paediatric Accident and Emergency, Imperial College Healthcare NHS Trust, London, UK
| | - Claudio F Alves
- Department of Paediatrics, Professor Doutor Fernando Fonseca Hospital, Amadora, Lisboa, Portugal
| | - Paulo Freitas
- Intensive Care Unit, Professor Doutor Fernando Fonseca Hospital, Amadora, Lisboa, Portugal
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Susanne Greber-Platzer
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
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Zachariasse JM, Nieboer D, Maconochie IK, Smit FJ, Alves CF, Greber-Platzer S, Tsolia MN, Steyerberg EW, Avillach P, van der Lei J, Moll HA. Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:583-591. [PMID: 32710839 DOI: 10.1016/s2352-4642(20)30139-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS. METHODS The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece). FINDINGS Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82-0·90) for high-urgency patients and 0·67 (0·61-0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87-0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81-0·85). INTERPRETATION The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs. FUNDING Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.
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Affiliation(s)
- Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ian K Maconochie
- Department of Paediatric Emergency Medicine, Imperial College NHS Healthcare Trust, London, UK
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, Netherlands
| | - Claudio F Alves
- Department of Paediatrics, Emergency Unit, Hospital Professor Doutor Fernando da Fonseca, Lisbon, Portugal
| | - Susanne Greber-Platzer
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Maria N Tsolia
- National and Kapodistrian University of Athens, Second Department of Paediatrics, P and A Kyriakou Children's Hospital, Athens, Greece
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Paul Avillach
- Department of Medical Informatics, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands; Harvard Medical School, Department of Biomedical Informatics, Boston, MA, USA
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands.
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