1
|
Ramgopal S, Martin-Gill C, Michelson KA. Pediatric Vital Signs Documentation in a Nationally Representative US Emergency Department Sample. Hosp Pediatr 2024; 14:e2023007645. [PMID: 38910528 DOI: 10.1542/hpeds.2023-007645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/15/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Vital sign measurement and interpretation are essential components of assessment in the emergency department. We sought to assess the completeness of vital signs documentation (defined as a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation) in a nationally representative sample of children presenting to the emergency department, characterize abnormal vital signs using pediatric advanced life support (PALS) criteria, and evaluate their association with hospitalization or transfer. METHODS We conducted a retrospective, cross-sectional study using the 2016-2021 National Hospital Ambulatory Medical Care Survey. We evaluated the proportion of children (aged ≤15 years) with complete vital signs and identified characteristics associated with complete vital signs documentation. We assessed the proportion of children having abnormal vital signs when using PALS criteria. RESULTS We included 162.7 million survey-weighted pediatric encounters. Complete vital signs documentation was present in 50.8% of encounters. Older age and patient acuity were associated with vital signs documentation. Abnormal vital signs were documented in 73.0% of encounters with complete vital signs and were associated with younger age and hospitalization or transfer. Abnormal vital signs were associated with increased odds of hospitalization or transfer (odds ratio 1.51, 95% confidence interval 1.11-2.04). Elevated heart rate and respiratory rate were associated with hospitalization or transfer. CONCLUSIONS A low proportion of children have documentation of complete vital signs, highlighting areas in need of improvement to better align with pediatric readiness quality initiatives. A high proportion of children had abnormal vital signs using PALS criteria. Few abnormalities were associated with hospitalization or transfer.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenneth A Michelson
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
2
|
Freire G, Kuppermann N, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Atenafu EG, Stephens D, Steele DW, Fernandes RM, Florin TA, Kharbanda A, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. Predicting Escalated Care in Infants With Bronchiolitis. Pediatrics 2018; 142:peds.2017-4253. [PMID: 30126934 DOI: 10.1542/peds.2017-4253] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.
Collapse
Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Australia.,University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Departments of Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - David Schnadower
- Department of Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles G Macias
- Department of Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, and .,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | |
Collapse
|
3
|
Sullivan DJ, Primhak RA, Bevan C, Breakwell LM, Humphreys N. Complications in pediatric scoliosis surgery. Paediatr Anaesth 2014; 24:406-11. [PMID: 24372904 DOI: 10.1111/pan.12338] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Scoliosis surgery in childhood is associated with a range of postoperative complications that may require admission to the pediatric intensive care unit (PICU) or high-dependency unit (HDU). AIM The aim of this study was to identify preoperative factors associated with PICU and HDU admissions after corrective surgery and devise a scoring system that could be used by clinicians to predict the level of dependency required postoperatively. METHODS A retrospective case note review was carried out in 90 patients who underwent corrective scoliosis surgery at Sheffield Children's Hospital (SCH) between January 2008 and October 2010. Predictors of PICU and HDU requirement postoperatively were identified and a simple scoring system created using multiple logistic regression and receiver operator characteristic (ROC). RESULTS There was a statistically significant difference in the preoperative parameters (pulmonary function, Cobb angle, and number of vertebrae fused) of those patients who required PICU or HDU care compared with those who did not. The area under the receiver operator characteristic curve for the final scoring system was 0.95 for PICU admission and 0.87 for HDU admission at the optimal cut-off point, demonstrating good diagnostic accuracy. CONCLUSIONS The authors have identified a significant relationship between preoperative variables and the levels of dependency required postoperatively and have proposed a scoring system which can be used to aid decision-making involving bed planning for patients after corrective scoliosis surgery. However, this work is based on the clinical course of a single set of patients who had surgery in a single tertiary center and has not been tested on patients from other centers.
Collapse
Affiliation(s)
- Daniel J Sullivan
- Paediatric Intensive Care Unit, Sheffield Children's Hospital, Sheffield, UK
| | | | | | | | | |
Collapse
|
4
|
Evans J, Marlais M, Abrahamson E. Clinical predictors of nasal continuous positive airway pressure requirement in acute bronchiolitis. Pediatr Pulmonol 2012; 47:381-5. [PMID: 21901857 DOI: 10.1002/ppul.21549] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 07/23/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION There is growing use of nasal continuous positive airway pressure ventilation (nCPAP) for infants with bronchiolitis, based on clinical assessment of severity. Despite this there have been no studies which identify clinical predictors for the requirement of nCPAP. OBJECTIVE To identify clinical factors in infants with acute bronchiolitis in the emergency department (ED), which might predict a requirement for nCPAP following admission. MATERIALS AND METHODS Retrospective review of pediatric ED case notes was conducted on bronchiolitis admissions to one dedicated Paediatric ED over a 12-month period. Potential predictors were identified through literature review. Data extraction of predictors was carried out and recorded for each case. Logistic regression was conducted for each variable to identify statistically significant predictors of nCPAP requirement. RESULTS Twenty-eight (17%) of the 163 admitted infants received nCPAP. The strongest predictors of nCPAP requirement in were as follows: oxygen requirement within the ED (P < 0.001), lower oxygen saturation (P < 0.001), younger age at presentation (P = 0.002), higher respiratory rate (P = 0.002), higher heart rate (P = 0.003), lower Glasgow Coma Scale score (0.006), and younger gestational age (P = 0.024). CONCLUSION We have identified clinical variables that were predictive of nCPAP requirement in infants admitted to our unit with bronchiolitis, oxygen requirement in the ED being the strongest single predictor. This is the first such study in the UK, and we hope it may be a starting point for further work that may provide an evidence base to aid clinicians in predicting the use of nCPAP in infants with bronchiolitis.
Collapse
Affiliation(s)
- Jordan Evans
- Department of Paediatric Emergency Medicine, Chelsea and Westminster Hospital, London, UK
| | | | | |
Collapse
|
5
|
Gorelick MH, Alessandrini EA, Cronan K, Shults J. Revised Pediatric Emergency Assessment Tool (RePEAT): a severity index for pediatric emergency care. Acad Emerg Med 2007; 14:316-23. [PMID: 17312335 DOI: 10.1197/j.aem.2006.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To develop and validate a multivariable model, using information available at the time of patient triage, to predict the level of care provided to pediatric emergency patients for use as a severity of illness measure. METHODS This was a retrospective cohort study of 5,521 children 18 years of age or younger treated at four emergency departments (EDs) over a 12-month period. Data were obtained from abstraction of patient records. Logistic regression was used to develop (75% of sample) and validate (25% of sample) models to predict any nonroutine diagnostic or therapeutic intervention in the ED and admission to the hospital. Data on ED length of stay and hospital costs were also obtained. RESULTS Eight predictor variables were included in the final models: presenting complaint, age, triage acuity category, arrival by emergency medical services, current use of prescription medications, and three triage vital signs (heart rate, respiratory rate, and temperature). The resulting models had adequate goodness of fit in both derivation and validation samples. The area under the receiver operating characteristic curve was 0.73 for the ED intervention model and 0.85 for the admission model. The Revised Pediatric Emergency Assessment Tool (RePEAT) score was then calculated as the sum of the predicted probability of receiving intervention and twice the predicted probability of admission. The RePEAT score had a significant univariate association with ED costs (r = 0.44) and with ED length of stay (r = 0.27) and contributed significantly to the fit of multivariable models comparing these outcomes across sites. CONCLUSIONS The RePEAT score accurately predicts level of care provided for pediatric emergency patients and may provide a useful means of risk adjustment when benchmarking outcomes
Collapse
Affiliation(s)
- Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | | | | |
Collapse
|
6
|
O'Donohoe PB, Kessler R, Beattie TF. Exploring the clinical utility of blood ketone levels in the emergency department assessment of paediatric patients. Emerg Med J 2007; 23:783-7. [PMID: 16988307 PMCID: PMC2579600 DOI: 10.1136/emj.2006.035758] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Ketonuria (on standard urine testing) is a frequent finding in children presenting to emergency departments. With the advent of hand-held ketone meters, blood ketone levels can now be rapidly quantified. HYPOTHESIS Point of care testing (POCT) of blood ketone levels could provide clinically useful information on severity of illness in children and risk of hospital admission. METHODS A prospective study using POCT of blood ketone levels in a convenience sample of children <13 years old, with a typical case mix of medical problems. FINDINGS 186 children were studied. The range of ketone levels varied widely among this study population depending on the presenting complaint. Higher levels were noted in those presenting with anorexia or vomiting and fever. The median ketone level of the total study population was 0.2 (range 0-6.0, interquartile range 0.1-0.9) mmol/l. Ketone levels correlated poorly with discharge destination and duration of admission. However, receiver-operator characteristics for ketones as a predictor of admission were comparable to Pediatric Risk of Admission scores (area under the curve 0.64 and 0.72, respectively) and may represent an independent risk factor for admission. A ketone level >1.2 mmol/l has a positive predictive value of 66.7% for admission. Ketone levels correlated well with decreased oral intake (R2 = 0.25; p<0.001). CONCLUSIONS A strong association was found between ketone levels, decreased oral intake and fever. Although ketone levels do not correlate well with more traditional markers of illness severity, they can help to predict the requirement for admission to hospital when interpreted in the context of the presenting illness. They may have applications in both the emergency department and primary care settings. Further prospective testing is required to validate these findings.
Collapse
Affiliation(s)
- P B O'Donohoe
- College of Medicine, University of Edinburgh, Edinburgh, UK.
| | | | | |
Collapse
|
7
|
Walsh P, Rothenberg SJ, O'Doherty S, Hoey H, Healy R. A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. Eur J Emerg Med 2005; 11:265-72. [PMID: 15359199 DOI: 10.1097/00063110-200410000-00005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To develop and validate a logistic regression model to predict need for admission and length of hospital stay in children presenting to the Emergency Department with bronchiolitis. SETTING Two children's hospitals in Dublin, Ireland. METHODS We reviewed 118 episodes of bronchiolitis in 99 children admitted from the Emergency Department. Those discharged within 24 h by a consultant/attending paediatrician were retrospectively categorized as suitable for discharge. We then validated the model using a cohort of 182 affected infants from another paediatric Emergency Department in a bronchiolitis season 2 years later. In the validation phase actual admission, failed discharge, and age less than 2 months defined the need for admission. RESULTS The model predicted admission with 91% sensitivity and 83% specificity in the validation cohort. Age [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.76-0.97], dehydration (OR 2.54, 95% CI 1.34-4.82), increased work of breathing (OR 3.39, 95% CI 1.29-8.92) and initial heart rate above the 97th centile (OR 3.78, 95% CI 1.05-13.57) predicted the need for admission and a longer hospital stay. CONCLUSION We derived and validated a severity of illness model for bronchiolitis. This can be used for outcome prediction in decision support tools or severity of illness stratification in research/audit.
Collapse
Affiliation(s)
- Paul Walsh
- Department of Emergency Medicine, Kern Medical Centre, Bakersfield, CA, USA.
| | | | | | | | | |
Collapse
|