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Masta R, Kukupe E, Marcus R, Duke T. The identification of WHO emergency signs in children by nurses at triage in an emergency department. Paediatr Int Child Health 2024; 44:8-12. [PMID: 38482930 DOI: 10.1080/20469047.2024.2328903] [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: 12/06/2023] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND The World Health Organization recommends the use of a three-tier triage system to recognise a sick child in low- and middle-income countries. The three tiers are based on standardised emergency and priority signs. No studies have evaluated the prevalence or reliable detection of these emergency signs. AIMS To determine the prevalence of WHO emergency signs and the underlying causes, and to determine whether nurses could reliably detect these signs in children presenting to the emergency department at Port Moresby General Hospital in Papua New Guinea. METHODS A prospective study measured inter-rater agreement between nurses at triage and a blinded second assessor trained in paediatrics. RESULTS The prevalence of emergency signs was 16.7%: 32 of 192 children had these signs at presentation; 18 (9.4%) had severe respiratory distress; 10 (5.2%) had severe dehydration; and 3 (1.6%) had convulsions. There was an acceptable inter-rater agreement between nurses and doctors (Cohen's Kappa score >0.4) for some signs: subcostal recession, intercostal recession, nasal flaring, lethargy, weak volume pulses, convulsions, sunken eyes and a poor conscious state. Obstructed breathing, cyanosis, tracheal tug and cold hands and feet were less commonly detected and had poor inter-rater agreement (Kappa score <0.4). CONCLUSIONS Effective screening at triage can enable prompt emergency treatment by nurses and can help focus doctors' attention on children who require it most. There is a need for additional training in the identification of some emergency signs. ABBREVIATIONS CED: children's emergency department; ETAT: emergency triage assessment and treatment; HCC: Hospital Care for Children; PMGH: Port Moresby General Hospital; PNG: Papua New Guinea; WHO: World Health Organization.
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Affiliation(s)
- Rachel Masta
- Children's Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Everlyn Kukupe
- Children's Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Rupert Marcus
- Children's Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Trevor Duke
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
- Department of Paediatrics, University of Melbourne, Parkville, Australia
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Sheikh Z, Potter E, Li Y, Cohen RA, Dos Santos G, Bont L, Nair H. Validity of Clinical Severity Scores for Respiratory Syncytial Virus: A Systematic Review. J Infect Dis 2024; 229:S8-S17. [PMID: 37797314 DOI: 10.1093/infdis/jiad436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is a widespread respiratory pathogen, and RSV-related acute lower respiratory tract infections are the most common cause of respiratory hospitalization in children <2 years of age. Over the last 2 decades, a number of severity scores have been proposed to quantify disease severity for RSV in children, yet there remains no overall consensus on the most clinically useful score. METHODS We conducted a systematic review of English-language publications in peer-reviewed journals published since January 2000 assessing the validity of severity scores for children (≤24 months of age) with RSV and/or bronchiolitis, and identified the most promising scores. For included articles, (1) validity data were extracted, (2) quality of reporting was assessed using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis checklist (TRIPOD), and (3) quality was assessed using the Prediction Model Risk Of Bias Assessment Tool (PROBAST). To guide the assessment of the validity data, standardized cutoffs were employed, and an explicit definition of what we required to determine a score was sufficiently validated. RESULTS Our searches identified 8541 results, of which 1779 were excluded as duplicates. After title and abstract screening, 6670 references were excluded. Following full-text screening and snowballing, 32 articles, including 31 scores, were included. The most frequently assessed scores were the modified Tal score and the Wang Bronchiolitis Severity Score; none of the scores were found to be sufficiently validated according to our definition. The reporting and/or design of all the included studies was poor. The best validated score was the Bronchiolitis Score of Sant Joan de Déu, and a number of other promising scores were identified. CONCLUSIONS No scores were found to be sufficiently validated. Further work is warranted to validate the existing scores, ideally in much larger datasets.
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Affiliation(s)
- Zakariya Sheikh
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, United Kingdom
| | - Ellie Potter
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, United Kingdom
| | - You Li
- School of Public Health, Nanjing Medical University, China
| | - Rachel A Cohen
- Epidemiology Viral Non-respiratory VaccinesValue Evidence and Outcomes, GSK, Wavre, Belgium
| | - Gaël Dos Santos
- Epidemiology Bacterial Vaccines, Value Evidence and Outcomes, GSK, Wavre, Belgium
| | - Louis Bont
- Department of Pediatrics, University Medical Center Utrecht, The Netherlands
| | - Harish Nair
- School of Public Health, Nanjing Medical University, China
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sheikh Z, Potter E, Li Y, Drysdale SB, Wildenbeest JG, Robinson H, McGinley J, Lin GL, Öner D, Aerssens J, Justicia-Grande AJ, Martinón-Torres F, Pollard AJ, Bont L, Nair H. External Validation of the Discriminative Validity of the ReSVinet Score and Development of Simplified ReSVinet Scores in Secondary Care. J Infect Dis 2024; 229:S18-S24. [PMID: 37712125 DOI: 10.1093/infdis/jiad388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND There is no consensus on how to best quantify disease severity in infants with respiratory syncytial virus (RSV) and/or bronchiolitis; this lack of a sufficiently validated score complicates the provision of clinical care and, the evaluation of trials of therapeutics and vaccines. The ReSVinet score appears to be one of the most promising; however, it is too time consuming to be incorporated into routine clinical care. We aimed to develop and externally validate simplified versions of this score. METHODS Data from a multinational (the Netherlands, Spain, and United Kingdom) multicenter case-control study of infants with RSV were used to develop simplified versions of the ReSVinet score by conducting a grid search to determine the best combination of equally weighted parameters to maximize for the discriminative ability (measured by area under the receiver operating characteristic curve [AUROC]) across a range of outcomes (hospitalization, intensive care unit admission, ventilation requirement). Subsequently discriminative validity of the score for a range of secondary care outcomes was externally validated by secondary analysis of datasets from Rwanda and Colombia. RESULTS Three candidate simplified scores were identified using the development dataset; they were excellent (AUROC >0.9) at discriminating for a range of outcomes, and their performance was not significantly different from the original ReSVinet score despite having fewer parameters. In the external validation datasets, the simplified scores were moderate to excellent (AUROC, 0.7-1) across a range of outcomes. In all outcomes, except in a single dataset for predicting admission to the high-dependency unit, they performed at least as well as the original ReSVinet score. CONCLUSIONS The candidate simplified scores developed require further external validation in larger datasets, ideally from resource-limited settings before any recommendation regarding their use.
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Affiliation(s)
- Zakariya Sheikh
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Ellie Potter
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - You Li
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Simon B Drysdale
- Centre for Neonatal & Paediatric Infection, St George's, University of London, London, United Kingdom
| | - Joanne G Wildenbeest
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hannah Robinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Joseph McGinley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Gu-Lung Lin
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Deniz Öner
- Infectious Diseases Translational Biomarkers, Janssen Pharmaceutica, Beerse, Belgium
| | - Jeroen Aerssens
- Infectious Diseases Translational Biomarkers, Janssen Pharmaceutica, Beerse, Belgium
| | - Antonio José Justicia-Grande
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago, University of Santiago, Santiago de Compostela, Spain
| | - Federico Martinón-Torres
- Department of Pediatrics, Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Louis Bont
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harish Nair
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
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Dangor Z, Lala S, Verwey C, Reubenson G, White D, Moore D, Jeena P, Masekela R, Zar H. Bronchiolitis versus bronchopneumonia: navigating antibiotic use within the LRTI spectrum. S Afr Med J 2023; 113:20-23. [PMID: 37278266 DOI: 10.7196/samj.2023.v113i6.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 06/07/2023] Open
Abstract
Bronchiolitis, a common reason for infant hospitalisation in South Africa (SA), is caused by viral pathogens. Bronchiolitis is typically an illness of mild to moderate severity that occurs in well-nourished children. Hospitalised SA infants frequently have severe disease and/or coexisting medical conditions, and these cases of bronchiolitis may have bacterial co-infection that requires antibiotic therapy. However, the existence of widespread antimicrobial resistance in SA warrants the judicious use of antibiotics. This commentary describes: (i) common clinical pitfalls leading to an incorrect diagnosis of bronchopneumonia; and (ii) considerations for antibiotic therapy in hospitalised infants with bronchiolitis. If antibiotics are prescribed, the indication for their use should be clearly stated, and antibiotic therapy must be stopped promptly if investigations indicate that bacterial co-infection is unlikely. Until more robust data emerge, we recommend a pragmatic management strategy to inform antibiotic use in hospitalised SA infants with bronchiolitis in whom bacterial co-infection is suspected.
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Demir A, Özdemir Karadas N, Karadas U. Clinical Utility of Respiratory Scores at Admission for Estimating the Definitive Microbiological Diagnosis in Lower Respiratory Tract Infections in Infants. Glob Pediatr Health 2022; 9:2333794X221098830. [PMID: 35784807 PMCID: PMC9244933 DOI: 10.1177/2333794x221098830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022] Open
Abstract
We aimed at determining the clinical utility of respiratory scores and the durations of wheezing or respiratory distress during hospitalization in infants with lower respiratory tract infections (LRTI) at admission for estimating the definitive microbiological diagnosis. We obtained data from a study population of 201 patients, 79 girls and 122 boys. There was a significant divide in the causative agents of LRTI among patients younger and older than 6 months of age (P = .002), and significantly different respiratory score findings were determined in infants with viral LRTI: a low respiratory score in a younger-than-6 month infant suggests Adenovirus as the causative agent and a high respiratory score suggests Parainfluenza 1 or 2; as for infants of 6 months of age or older, a low respiratory score indicates Influenza A or B or a mixed infection, whereas a high respiratory score is likely an indication of Parainfluenza 3 or RSV.
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Affiliation(s)
- And Demir
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Hakizimana B, Kalimba E, Ndatinya A, Saint G, van Miert C, Cartledge PT. Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda - a validation and inter-rater reliability study. PLoS One 2021; 16:e0258882. [PMID: 34735488 PMCID: PMC8568200 DOI: 10.1371/journal.pone.0258882] [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: 07/13/2020] [Accepted: 10/07/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap. OBJECTIVES to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1-12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used. METHODS A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant. RESULTS 100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98-0.99) and 0.980 (0.97-0.99). The convergent validity (Pearson's correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92-0.99, p<0.001) and 0.880 (CI: 0.80-0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively. CONCLUSION LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.
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Affiliation(s)
- Boniface Hakizimana
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Edgar Kalimba
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- King Faisal Hospital, Kigali, Rwanda
| | | | - Gemma Saint
- Institute of Child Health, University of Liverpool, Liverpool, United Kingdom
- Department of Respiratory Pediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Clare van Miert
- School of Nursing and Allied Health Liverpool John Moores University, Liverpool, United Kingdom
| | - Peter Thomas Cartledge
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, United States of America
- Rwanda Human Resources for Health (HRH) Program, Ministry of Health, Kigali, Rwanda
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