Variation in pediatric emergency department care of sickle cell disease and fever

Children with sickle cell disease and fever but no respiratory symptoms: Is a chest x-ray needed?

BACKGROUND

The National Heart, Lung, and Blood Institute (NHLBI) defines acute chest syndrome (ACS) as a new infiltrate on chest x-ray (CXR) and at least 1 of the following: fever (≥38.50C), hypoxia, or respiratory symptoms. NHLBI expert consensus recommends a CXR in patients with sickle cell disease (SCD) who have fever and respiratory symptoms. Past work has shown that physicians fail to recognize ACS in children with SCD who present with fever, leading to varied CXR obtainment criteria.

PURPOSE

To determine the prevalence of ACS in patients with SCD presenting to our ED with fever with or without respiratory symptoms.

METHODS

A retrospective analysis of ED visits by patients with SCD (ages 0 to 20 years) who presented with fever (>/= 38.5o C) within the past 24 h between January 2019 to December 2022 was done. The presence or absence of NHLBI-defined respiratory symptoms and CXR results were extracted. The prevalence of ACS, demonstrated on CXR, for febrile children with and without respiratory symptoms was estimated.

RESULTS

There were 137 children (288 unique ED visits) with fever. We found 0 % of visits with fever and no respiratory symptoms had ACS whereas 22.6 % with at least 1 respiratory symptom (p < 0.001).

CONCLUSIONS

Our findings provide strong evidence that a CXR is not necessary in a child with SCD presenting to the ED with fever and no NHLBI-defined respiratory symptoms. This evidence could improve quality of care and decrease unnecessary CXR use in the SCD population.

Variation in hospital admission of sickle cell patients from the emergency department using the Pediatric Health Information System

BACKGROUND

Universal newborn screening and improved treatment options have led to increased survival in sickle cell disease (SCD). However, patients with SCD still rely heavily on acute care services.

OBJECTIVE

To determine the variation seen in hospitalizations for the top complaints for ED visits for children with SCD nationally.

METHODS

We performed a retrospective review of the Pediatric Health Information Systems (PHIS) Database between October 2011 and September 2015. Emergency department (ED) encounters were selected by using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes for SCD with and without crisis, fever, and pain. Univariate analyses were performed, as well as index of dispersion (ID) to assess variation by day of the week and region. ANOVA and t-test were used to determine statistical significance.

RESULTS

A total of 68 661 ED encounters at 36 hospitals met the criteria for inclusion. Of those encounters, 50.1% were admitted to the hospital. Pain and fever were the most common primary diagnoses among this population. Although variation in hospitalization was seen overall, as well as for a primary diagnosis of pain or fever, this variation was not explained by weekday/weekend designation.

CONCLUSION

The results of our study confirm pain and fever as the most common primary diagnoses for children with SCD who seek acute care, as well as demonstrate that while significant variation in hospitalization exists, it is not associated with day of the week. Further studies to elucidate patient- and hospital-level factors that influence admission variation are necessary.

A Quality Initiative to Decrease Time to Antibiotics in Children with Sickle Cell Disease and Fever

Children with sickle cell disease (SCD) are at increased risk for sepsis secondary to functional asplenia. Timely administration of antibiotics, within 60 minutes of triage, is a national indicator of quality SCD care in the United States. However, there are no reports demonstrating the feasibility of doing so in the outpatient hematology-oncology clinic setting.

Local Problem

At baseline, in our pediatric hematology-oncology outpatient center, just 10% of children with SCD and fever received timely antibiotics.

Methods

We implemented a process improvement initiative for children with SCD and fever with the aim of ≥90% receiving timely antibiotics. We enacted interventions focused on general clinic processes from check-in to antibiotics and population-specific interventions, including an intravenous access protocol, notification/communication among staff members, and design of an electronic order set.

Results

The percentage of children receiving timely antibiotics improved from 10% to 77% with successful maintenance following the interventions. Residual delays are due to nonexpeditious order placement and difficult intravenous access.

Conclusion

Improving the timely administration of antibiotics in the outpatient hematology-oncology clinic setting for children with SCD and fever is possible. Achieving at least 90% timely antibiotics for children with SCD and fever in the outpatient clinic setting will require ongoing efforts at expeditious order placement and intravenous access.

Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever

OBJECTIVES

Urgent medical evaluation is recommended for patients with sickle cell disease (SCD) and fever. Clear recommendations exist regarding certain aspects of treatment, but other areas lack evidence. We determined practice variation for children with SCD presenting with fever to the emergency department (ED).

METHODS

Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED with fever greater than or equal to 38.5°C in the ED or preceding 24 hours. Visits from 3 sickle cell centers were included. Outcomes included blood culture, complete blood count, antibiotic treatment, chest x-ray, urinalysis, electrolytes, and hospital disposition. Differences greater than 10% were considered clinically meaningful.

RESULTS

The population included 14,454 visits, of which 4143 (29%) were febrile and met all inclusion criteria. A complete blood count and blood culture were obtained at 94% of visits, and antibiotics were given at 91%, with no differences among sites. Meaningful differences existed for disposition, with 52%, 43%, and 99% of patients admitted to the inpatient units at hospitals A, B, and C, respectively. Differences were seen in obtaining a urinalysis (33%, 17%, and 21%), electrolytes (2%, 50%, and 12%), and chest x-rays for patients 2 years and older (78%, 77%, 64%) for hospitals A, B, and C, respectively.

CONCLUSIONS

Significant variation exists in the proportion of children who receive a urinalysis, electrolytes, chest x-ray, and, most importantly, admission to the hospital. These examples of practice variation represent potential opportunities to define best care practices for children with SCD presenting to the ED for fever.

A Standardized Clinical Pathway to Decrease Hospital Admissions Among Febrile Children With Sickle Cell Disease

BACKGROUND AND OBJECTIVE

Recurrent hospital admissions for patients with sickle cell disease (SCD) are costly and contribute to a low quality of life for patients. We implemented a clinical pathway to safely discharge SCD patients with fever who are evaluated in the emergency department (ED) of a large tertiary care center.

METHODS

An interdisciplinary team of ED and hematology physicians, nurses, and an improvement advisor developed a clinical pathway that identified febrile SCD patients at low risk of serious bacterial infection based on historical, clinical, and laboratory criteria who could be discharged from the ED. Phone follow-up was planned through the use of an automated electronic notification that was sent to an established hematology follow-up pool at the time of ED discharge. We conducted two "fake front end" trials in the ED to receive feedback on our process before full implementation. A postpathway implementation quality improvement team monitored discharge rates, phone follow-up rates and adverse events.

RESULTS

In the first 9 weeks postpathway implementation, 100 SCD patients were evaluated for fever; 84 (24%) met low-risk criteria and were discharged home. This reduction in admission rate has been maintained throughout the 3 years postimplementation. Successful phone follow-up was achieved in all discharged patients within 24 hours and no adverse events were identified.

CONCLUSIONS

Low-risk febrile patients with SCD can be safely discharged from the ED. An automated notification system within the electronic medical record system can facilitate patient follow-up after ED discharge. Future quality improvement efforts aimed to further reduce admissions in this population should target patients with modifiable risk factors for serious bacterial infection.

Which Febrile Children With Sickle Cell Disease Need a Chest X-Ray?

OBJECTIVE

Controversy exists regarding which febrile children with sickle cell disease (SCD) should receive a chest x-ray (CXR). Our goal is to provide data informing the decision of which febrile children with SCD presenting to the emergency department (ED) require a CXR to evaluate for acute chest syndrome (ACS).

METHODS

Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED at one of two academic children's hospitals with fever ≥38.5°C between January 1, 2010, and December 31, 2012. Demographic characteristics, respiratory symptoms, and laboratory results were abstracted. The primary outcome was the presence of ACS. Binary recursive partitioning was performed to determine predictive factors for a diagnosis of ACS.

RESULTS

A total of 185 (10%) of 1,837 febrile ED visits met ACS criteria. The current National Heart, Lung, and Blood Institute (NHLBI) consensus criteria for obtaining a CXR (shortness of breath, tachypnea, cough, or rales) identified 158 (85%) of ACS cases, while avoiding 825 CXRs. Obtaining a CXR in children with NHLBI criteria or chest pain and in children without those symptoms but with a white blood cell (WBC) count ≥18.75 × 10⁹ /L or a history of ACS identified 181 (98%), while avoiding 430 CXRs.

CONCLUSION

Children with SCD presenting to the ED with fever and shortness of breath, tachypnea, cough, rales, or chest pain should receive a CXR due to high ACS rates. A higher WBC count or history of ACS in a child without one of those symptoms may suggest the need for a CXR. Prospective validation of these criteria is needed.