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Michelson KA, Bachur RG, Grubenhoff JA, Cruz AT, Chaudhari PP, Reeves SD, Porter JJ, Monuteaux MC, Dart AH, Finkelstein JA. OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS. J Emerg Med 2023; 65:e9-e18. [PMID: 37355425 PMCID: PMC10527892 DOI: 10.1016/j.jemermed.2023.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/15/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Missed diagnosis can predispose to worse condition-specific outcomes. OBJECTIVE To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. RESULTS We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis. CONCLUSIONS Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Andrea T Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California; Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Scott D Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan A Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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Coulthard MG, Osborne JM, McCaffery K, McAuley SA, McEniery JA. Multi-incident analysis of reviews of serious adverse clinical events in children with serious bacterial infection and/or sepsis in Queensland, Australia between 2012 and 2017. J Paediatr Child Health 2022; 58:497-503. [PMID: 34553810 DOI: 10.1111/jpc.15759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
AIM To report on findings from a multi-incident analysis of reviews of serious paediatric adverse clinical events related to serious bacterial infection and/or sepsis (hereafter referred to as sepsis for brevity) in Queensland, Australia, between 2012 and 2017. METHODS The Queensland Paediatric Quality Council reviewed documentation from reviews of serious adverse events occurring in children (<18 years) with a diagnosis of sepsis at Queensland public hospitals between 2012 and 2017, including clinical details, coronial reports, autopsy reports and root cause analysis documents. A multi-incident tool was designed and used by an expert panel to identify patient and facility demographics, contributing factors, and human and system factors associated with paediatric serious adverse events. RESULTS There were 28 serious adverse clinical events reported related to paediatric sepsis, characterised by a high proportion of deaths (23) and a predominance of children aged under 4 years. Approximately half of all facilities were classified as rural and remote health services. Contributing factors included difficulty in recognising and responding to the deteriorating patient, inadequate management/treatment, diagnostic error (mainly diagnostic delay) and escalation delay/failure. Major system factors included communication issues, incorrect use of the early warning tool, inadequate coordination of care planning, policy/protocol/guideline failures and workforce problems. CONCLUSION Multi-incident analysis is a useful tool for identifying themes that recur in similar events and presents opportunities for system-wide improvement. Common themes and contributing factors were identified which may provide possibilities for earlier identification and intervention in childhood serious bacterial infection and/or sepsis.
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Affiliation(s)
- Mark G Coulthard
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Mayne Academy of Paediatrics, School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Jodie M Osborne
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia
| | - Kevin McCaffery
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Sharon A McAuley
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Mayne Academy of Paediatrics, School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Julie A McEniery
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Mayne Academy of Paediatrics, School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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Repeated Emergency Department Visits Among Children with Invasive Bacterial Infections. Pediatr Infect Dis J 2021; 40:e205-e207. [PMID: 33464016 DOI: 10.1097/inf.0000000000003062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We carried out a retrospective cohort study of 271 previously healthy children younger than 14 years old diagnosed with invasive bacterial infection in an emergency department. Of them, 72 (26.6%) had previous visits to the emergency department. Not identifying children with an invasive bacterial infection and not administering antibiotics on the first visit was associated with a severe outcome.
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Gray SJ, Wacogne ID, Roland D. Fifteen-minute consultation: Safety netting effectively. Arch Dis Child Educ Pract Ed 2019; 104:226-230. [PMID: 30429203 DOI: 10.1136/archdischild-2018-315991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/25/2018] [Accepted: 10/07/2018] [Indexed: 11/03/2022]
Affiliation(s)
| | - Ian D Wacogne
- Department of General Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - Damian Roland
- Department of Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
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Roland D, Snelson E. 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Arch Dis Child Educ Pract Ed 2019; 104:43-48. [PMID: 29496733 DOI: 10.1136/archdischild-2017-313199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 01/10/2018] [Accepted: 01/17/2018] [Indexed: 11/03/2022]
Abstract
Determining severity of illness and undertaking an adequate risk assessment is a fundamental part of acute paediatric practice. This review highlights physiology, communication, heuristics and external elements as factors which influence decision-making and discusses how incidence of disease and seniority of clinician impact might influence outcomes.
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Affiliation(s)
- Damian Roland
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
| | - Edward Snelson
- Sheffield Children's Hospital, Sheffield, UK.,Sheffield Hallam University, Sheffield, UK
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Characteristics of children with microbiologically confirmed invasive bacterial infections in the emergency department. Eur J Emerg Med 2018; 25:274-280. [PMID: 28118320 DOI: 10.1097/mej.0000000000000453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Determination of the characteristics of paediatric invasive bacterial infections (IBI) is essential for early identification of children requiring immediate antibiotic therapy. The main objective is to characterize the emergency presentation of the IBI among children aged younger than 14 years. PATIENTS AND METHODS A prospective registry-based cohort study including all patients aged younger than 14 years diagnosed with confirmed IBI (culture or genomic detection using the polymerase chain reaction) was carried out in a paediatric emergency department between 2008 and 2015. Severity criteria were as follows: death, sequelae or admission to the ICU. RESULTS Of the 223 IBIs reported, 187 (83.9%) corresponded to previously healthy patients (median age=19 months) and 165 (74%) were well appearing. The most common diagnoses were occult bacteraemia [60 (26.9%)] and sepsis [56 (25.1%)]. The most frequent pathogens were Streptococcus pneumoniae [68 (30.5%)] and Neisseria meningitidis [42 (18.8%)]. Four (1.8) patients died (S. pneumoniae, 2) and eight (3.5%) had sequelae (S. pneumoniae, 5). The diagnoses and clinical characteristics of the children varied significantly depending on the isolated pathogen. Duration of fever less than 24 h, symptoms other than fever and not being well-appearing upon arrival to the emergency department were independent risk factors for greater severity (area under the receiver operating characteristics curve=0.805; 95% confidence interval: 0.741-0.868). CONCLUSION IBIs are commonly diagnosed in previously healthy and well-appearing young children. S. pneumoniae was responsible for the majority of deaths or sequelae. Short duration of fever, symptoms other than fever and not being stable on arrival are associated with greater severity.
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Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss BS. Fever in Children: Pearls and Pitfalls. CHILDREN (BASEL, SWITZERLAND) 2017; 4:E81. [PMID: 28862659 PMCID: PMC5615271 DOI: 10.3390/children4090081] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023]
Abstract
Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children. We review the epidemiology and measurement of fever, the meaning of fever and associated clinical signs in children of different ages and under special conditions, including fever in children with cognitive impairment, recurrent fevers, and fever of unknown origin. While the majority of febrile children have mild, self-resolving viral illness, a minority may be at risk of life-threatening infections. Clinical assessment differs markedly from adult patients. Hands-off evaluation is paramount for a correct evaluation of breathing, circulation and level of interaction. Laboratory markers and clinical prediction rules provide limited help in identifying children at risk for serious infections; however, clinical examination, prudent utilization of laboratory tests, and post-discharge guidance ("safety netting") remain the cornerstone of safe management of febrile children.
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Affiliation(s)
- Egidio Barbi
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34137 Trieste, Italy.
| | - Pierluigi Marzuillo
- Department of Woman and Child and General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Elena Neri
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34137 Trieste, Italy.
| | - Samuele Naviglio
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34137 Trieste, Italy.
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34137 Trieste, Italy.
| | - Baruch S Krauss
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston 02115, MA, USA.
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The Spectrum of Pediatric Sepsis: "Septicemia" Misses Severe Cases. Ann Emerg Med 2016; 66:685-6. [PMID: 26590745 DOI: 10.1016/j.annemergmed.2015.07.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Indexed: 11/24/2022]
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