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Association of out of hospital paediatric early warning score with need for hospital admission in a Scottish emergency ambulance population. Eur J Emerg Med 2021; 27:454-460. [PMID: 32804696 DOI: 10.1097/mej.0000000000000725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Physiological derangement, as measured by paediatric early warning score (PEWS) is used to identify children with critical illness at an early point to identify and intervene in children at risk. PEWS has shown some utility as a track and trigger system in hospital and also as a predictor of adverse outcome both in and out of hospital. This study examines the relationship between prehospital observations, aggregated into an eight-point PEWS (Scotland), and hospital admission. METHODS A retrospective analysis of all patients aged less than 16 transported to hospital by the Scottish Ambulance Service between 2011 and 2015. Data were matched to outcome data regarding hospital admission or discharge and length of stay. RESULTS Full data were available for 21 202 paediatric patients, of whom 6340 (29.9%) were admitted to hospital. Prehospital PEWS Scotland was associated with an odds ratio for admission of 1.189 [95% confidence interval (CI): 1.176-1.202; P < 0.001]. The area under receiver operating curve of 0.617 (95% CI: 0.608-0.625; P < 0.001) suggests poorly predictive ability for hospital admission. There was no association between prehospital PEWS Scotland and length of hospital stay. CONCLUSION These data show that a single prehospital PEWS Scotland was a poor predictor of hospital admission for unselected patients in a prehospital population. The decision to admit a child to hospital is not solely based on the physiological derangement of vital signs, and hence physiological-based scoring systems such as PEWS Scotland cannot be used as the sole criteria for hospital admission, from an undifferentiated prehospital population.
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Calicchio M, Valitutti F, Della Vecchia A, De Anseris AGE, Nazzaro L, Bertrando S, Bruzzese D, Vajro P. Use and Misuse of Emergency Room for Children: Features of Walk-In Consultations and Parental Motivations in a Hospital in Southern Italy. Front Pediatr 2021; 9:674111. [PMID: 34169048 PMCID: PMC8217610 DOI: 10.3389/fped.2021.674111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/26/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: Inappropriate use of the emergency department (ED) represents a major worldwide issue both in pediatric and adult age. Herein, we aim to describe features of pediatric visits to the ED of Salerno University Hospital and to evaluate parental reasons behind the decision to walk in. Materials and Methods: We performed a retrospective observational study evaluating ED encounters for children from January 2014 to December 2019. The appropriateness of visits was measured with a national tool assessing every ED encounter, namely, "the Mattoni method," which consists of the combination of the triage code assigned, the diagnostic resources adopted, and the consultation outcomes. Moreover, 64 questionnaires were collected from a sample of parents in the waiting rooms in January 2020. Results: A total number of 42,507 visits were recorded during the study period (19,126 females; mean age ± SD: 4.3 ± 3.8 years), the majority of whom were inappropriate (75.8% over the considered period; 73.6% in 2014; 74.6% in 2015; 76.3% in 2016; 76.7% in 2017; 77.9% in 2018; 75.5% in 2019). Most of the inappropriate consultations arrived at the ED by their own vehicle (94.4%), following an independent decision of the parents (97.2%), especially in the evening and at night on Saturdays/Sundays/holidays (69.7%). A multivariate analysis revealed the following: patients of younger age (OR: 1.11, 95% C.I. 1.06-1.16; p < 0.0019), night visits (OR 1.39; 95% C.I.: 1.32-1.47; p < 0.001), patients living in the municipality of Salerno (OR 1.28; 95% C.I.: 1.22-1.34; p < 0.001), weekend day visits (OR 1.48; 95% C.I.: 1.41-1.56; p < 0.001), and independent parental decision without previous contact with primary care pediatrician (OR 3.01; 95% C.I.: 2.64-3.44; p < 0.001) were all significant independent predictors of inappropriate consultation. The most frequent trigger of ED encounters was fever (51.4%). Hospital admission made up 17.6% of all consultations. The questionnaire showed that most parents were aware of the lack of urgency (20.3%) or minor urgency (53.1%) of the visit. The reasons for walking in were the impossibility to receive a home consultation (70%), the difficulty of contacting their family pediatrician during weekends and holidays (54.4%), as well as the search for a quick, effective, diagnosis and therapy (48.4%). Conclusions: The study suggests a highly inappropriate use of ED for children in our region. This issue deserves considerable attention by health care system leaders in order to optimally integrate hospitals and primary care.
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Affiliation(s)
- Maria Calicchio
- Clinical Pediatrics and Pediatrics, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Francesco Valitutti
- Clinical Pediatrics and Pediatrics, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Antonio Della Vecchia
- Medical Administration, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | | | - Lucia Nazzaro
- Clinical Pediatrics and Pediatrics, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Sara Bertrando
- Clinical Pediatrics and Pediatrics, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Dario Bruzzese
- Department of Preventive Medical Sciences, Federico II University, Naples, Italy
| | - Pietro Vajro
- Clinical Pediatrics and Pediatrics, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy.,Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
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Hodgson HS, Webb N, Diskin L. Consultant-led triage of paediatric hospital referrals: a service evaluation. BMJ Paediatr Open 2021; 5:e000892. [PMID: 33693065 PMCID: PMC7903069 DOI: 10.1136/bmjpo-2020-000892] [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: 09/28/2020] [Revised: 12/09/2020] [Accepted: 01/09/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE We established a paediatric demand management (PDM) service in our paediatric department in 2017. The aim of this consultant-delivered service is to manage referrals more efficiently by providing active triage of all referrals, daily rapid access clinics and easily accessible advice for primary healthcare professionals. This study presents an evaluation of this service. DESIGN Mixed-methods service evaluation with analysis of data for every contact with the PDM service over a 2-year period. For each patient, the method of contact, reason for contact, presenting complaint and triage outcome were recorded. Feedback from general practitioners (GPs) and patients was gathered. RESULTS Data were analysed for 7162 patients. More than a quarter (2034; 28%) of all referrals were managed with advice only. Of the 4703 outpatient clinic referrals, 1285 (27%) were managed without a clinic appointment. More than half (54%) of the requests for paediatric assessment unit (PAU) admission were managed alternatively, typically with advice only or a rapid access clinic appointment. This has reversed the increasing trend of PAU admissions from primary care of preceding years. Financial analysis suggested the avoidance of these clinic appointments, and PAU admissions provided a substantial cost saving. CONCLUSIONS Our results indicate that the PDM service has succeeded in reducing unnecessary hospital attendances by managing patients more effectively and strengthening partnerships with primary care. The service has received overwhelmingly positive feedback from GPs. This service could be replicated in other Trusts and developed in the future to facilitate further management of paediatric cases in a primary care setting.
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Affiliation(s)
| | - Nicholas Webb
- Paediatrics, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Lynn Diskin
- Paediatrics, Royal United Hospitals Bath NHS Trust, Bath, UK
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Gjengstø Hunderi JO, Lødrup Carlsen KC, Rolfsjord LB, Carlsen K, Mowinckel P, Skjerven HO. Parental severity assessment predicts supportive care in infant bronchiolitis. Acta Paediatr 2019; 108:131-137. [PMID: 29889987 DOI: 10.1111/apa.14443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/14/2018] [Accepted: 06/07/2018] [Indexed: 11/25/2022]
Abstract
AIM In infants with acute bronchiolitis, the precision of parental disease severity assessment is unclear. We aimed to determine if parental assessment at the time of hospitalisation predicted the use of supportive care, and subsequently determine the likelihood that the infant with acute bronchiolitis would receive supportive care. METHODS From the Bronchiolitis ALL south-east Norway study, we included all 267, 0-12 month old, infants with acute bronchiolitis whose parents at the time of hospitalisation completed a three-item visual analogue scale (VAS) concerning Activity, Feeding and Illness. Respiratory rate, oxygen saturation (SpO2 ) and use of supportive care were recorded daily. By multivariate logistic regression analyses we included significant predictors available at hospital admission to predict the use of supportive care. RESULTS The parental Activity, Feeding and Illness VAS scores significantly predicted supportive care with odds ratios of 1.23, 1.26 and 1.36, respectively. The prediction algorithm included parental Feeding and Illness scores, SpO2 , gender and age, with an area under the curve of 0.76 (95% CI 0.69, 0.81). A positive likelihood ratio of 2.1 gave the highest combined sensitivity of 81% and specificity of 61%. CONCLUSION Parental assessment at hospital admission moderately predicted supportive care treatment in infants with acute bronchiolitis.
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Affiliation(s)
- Jon Olav Gjengstø Hunderi
- Department of Pediatrics and Adolescent Medicine Østfold Hospital Trust Sarpsborg Norway
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Karin C. Lødrup Carlsen
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Innlandet Hospital Trust Elverum Norway
| | - Kai‐Håkon Carlsen
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Petter Mowinckel
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Håvard Ove Skjerven
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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Habib MI, Khan KMA. Profile and outcomes of critically ill children in a lower middle-income country. Emerg Med J 2017; 35:52-55. [PMID: 28720723 DOI: 10.1136/emermed-2016-205720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 06/05/2017] [Accepted: 06/08/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the clinical profile and outcome of critically ill children presenting to a paediatric ED in a lower middle-income country. METHODS We performed a retrospective analysis of children (<14 years) presenting to the ED of the National Institute of Child Health, Karachi, between January and December 2014 who were assigned to acuity 1 (requiring immediate life-saving interventions) according to the Emergency Severity Index. Data included demographic variables, presenting complaints, interventions and outcomes in the ED. RESULTS There were 172 162 visits during the year. Of these, 13 551 (8%) were level 1. 64% of level 1 patients were transported to the ED without ambulance service. Neonates (0-28 days) constituted 48% of level 1 children; their most frequent presenting complaints were respiratory symptoms, followed by fever and reluctance to feed. Above the neonatal age group, the most common presenting complaints were gastrointestinal symptoms (with signs of hypoperfusion), followed by seizures, reluctance to feed and respiratory symptoms. 64% of children of >28 days presenting were malnourished. Interventions included cardiopulmonary resuscitation, application of bubble continuous positive airway pressure and endotracheal intubation. Overall mortality was 13%; 63% of all deaths were in the neonatal age group. CONCLUSION Children with the highest triage acuity represent 8% of all visits to a paediatric ED. In this group, neonates account for nearly half of all the children, and more than half of all the deaths among critically ill children came in ED. A large proportion of high-acuity children are malnourished.
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Bowen L, Shaw A, Lyttle MD, Purdy S. The transition to clinical expert: enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions. Emerg Med J 2016; 34:76-81. [PMID: 27496899 PMCID: PMC5384604 DOI: 10.1136/emermed-2015-205211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 06/30/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Rates of unplanned paediatric admissions are persistently high. Many admissions are short-stay events, lasting less than 48 hours. OBJECTIVE This qualitative research explores factors that influence clinical decision making in the paediatric ED (PED) for children under 5 attending with acute respiratory conditions, focusing on how management decisions adapt with increasing experience. METHOD Semi-structured interviews were conducted with 15 PED clinicians (doctors, emergency nurse practitioners and registered nurses) with varying levels of experience in paediatric emergency medicine (PEM), emergency medicine or paediatrics. Audio-recorded interviews were transcribed and analysed thematically. RESULTS There were clear differences in decision-making approaches between experienced clinicians and junior staff. The latter were more risk adverse, relying heavily on guidelines, set admission criteria, clinical theory and second opinions. This was particularly true for doctors. 'Informal' learning was apparent in accounts from less-experienced doctors and nurses, whereby tacit knowledge and risk management played an increasing role in the development of clinical intuition that permitted rapid assessment and treatment of young patients. CONCLUSIONS The emergence of intuition entwined with approaches to risk management and the role of these skills in clinical decision making, carry implications for the development of training programmes for clinicians working in PEM. Enhanced training for such groups to permit development of the supplementary skills described in this study could have the ability to improve care delivery and even reduce paediatric admissions.
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Affiliation(s)
- Leah Bowen
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Alison Shaw
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Paciotti B, Roberts KE, Tibbetts KM, Paine CW, Keren R, Barg FK, Holmes JH, Bonafide CP. Physician attitudes toward family-activated medical emergency teams for hospitalized children. Jt Comm J Qual Patient Saf 2014; 40:187-92. [PMID: 24864527 DOI: 10.1016/s1553-7250(14)40024-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Shahnaz A, Parker RA, Wills S, Ross Russell RI. Assessing efficient patient care: should length of stay be calculated independently of local admission rates? Arch Dis Child 2013; 98:951-4. [PMID: 24043552 DOI: 10.1136/archdischild-2013-303863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the length of hospitalisation for infants with bronchiolitis across the Eastern region and to assess the impact of the varying admission rates in each hospital. DESIGN Data collection through the Hospital Episode Statistics (HES) using the ICD clinical coding for bronchiolitis across all hospitals in east of England for three winter seasons (October to March for the years 2009/10, 2010/11 and 2011/12). MAIN OUTCOME MEASURE Length of hospital stay, corrected to adjust for local population. RESULTS Seventeen hospitals across the east of England were included in this study. Overall admission rate (as a percentage of the population) for the region was 3.3% and consistent with national data, but rates within individual hospitals varied between 1.5% and 5.7% over the 3-year period. Bed days per 1000 population ('standardised bed days') per year varied almost fourfold, from 34.5 to 122.3 in different hospitals. Corrected length of stay showed high discordance when compared to average length of stay. CONCLUSIONS The average length of stay is substantially affected by admission rates, with hospitals who admit a greater proportion of infants appearing to have a shorter uncorrected length of stay. We propose that a single corrected measure for length of stay should be used when assessing the efficiency of care because it is unaffected by variations in local admission rates and is adjusted for local population size.
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Affiliation(s)
- A Shahnaz
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, , Cambridge, UK
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9
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Paranjothy S, Dunstan F, Watkins WJ, Hyatt M, Demmler JC, Lyons RA, Fone D. Gestational age, birth weight, and risk of respiratory hospital admission in childhood. Pediatrics 2013; 132:e1562-9. [PMID: 24249824 DOI: 10.1542/peds.2013-1737] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate the risk of emergency respiratory hospital admission during childhood associated with gestational age at birth and growth restriction in utero. METHODS The study included a total population electronic birth cohort with anonymized record-linkage of multiple health and administrative data sets. Participants were 318,613 children born in Wales, United Kingdom, between May 1, 1998, and December 31, 2008. The main outcome measure was emergency respiratory hospital admissions. RESULTS The rate of admission in the first year of life ranged from 41.5 per 100 child-years for infants born before 33 weeks' gestation to 9.8 per 100 child-years for infants born at 40 to 42 weeks' gestation. The risk of any emergency respiratory admission up to age 5 years increased as gestational age decreased to <40 weeks. Even at 39 weeks' gestation, there was an increased risk of emergency hospital admissions for respiratory conditions compared with infants born at 40 to 42 weeks (adjusted hazard ratio 1.10; 95% confidence interval 1.08-1.13). Small for gestational age (<10th centile for gestation and gender-specific birth weight) was independently associated with an increased risk of any emergency respiratory admission to hospital (adjusted hazard ratio 1.07; 95% confidence interval 1.04-1.10). CONCLUSIONS The risk of emergency respiratory admission up to age 5 years decreased with each successive week in gestation up to 40 to 42 weeks. Although the magnitude of increased risk associated with moderate and late preterm births is small, the number of infants affected is large and therefore presents a significant impact on health care services.
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Affiliation(s)
- Shantini Paranjothy
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, United Kingdom.
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Maharaj V, Hsu R, Beadman A. Preventing paediatric admissions for respiratory disease: a qualitative analysis of the views of health care professionals. J Eval Clin Pract 2006; 12:515-22. [PMID: 16987113 DOI: 10.1111/j.1365-2753.2006.00652.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
RATIONALE The number of emergency paediatric admissions is increasing each year. The reasons for this are unclear but may include increasing demand from parents, changes in GP working patterns, and an increase in unnecessary admissions. Respiratory disease is the commonest diagnostic category for emergency admission in childhood. AIMS To generate hypotheses for reduction in unnecessary admissions for respiratory disease by qualitative analysis of the views of health care professionals, to determine the proportion of preventable admissions as perceived by clinicians, and to assess the modified Paediatric Appropriateness Evaluation Protocol against clinicians judgements of appropriateness of admission. DESIGN Eight health care professionals analysed clinical data from primary and secondary care for 94 cases that were admitted to an emergency assessment unit and received a hospital discharge diagnosis of respiratory disease. They assessed whether each admission was appropriate, whether it was preventable, and how it might have been prevented. RESULTS A total of 31% of cases admitted to the assessment unit (29/94) were classified as preventable by the majority of professionals assessing the case. Provision of additional support, monitoring, and observation in the community was cited as a means of prevention in 33/94 cases. There was poor agreement between the modified PAEP and clinicians' assessments of appropriateness of admission (kappa 0.1). CONCLUSIONS If the agreed views of these experienced doctors and nurses are correct, provision of additional services in the community could be an important means of preventing emergency admissions for respiratory disease. This hypothesis should be tested by further research including the views of families. The study provides further evidence that the modified PAEP may not be valid for use in UK practice. If inappropriate admission rates are to be used to measure effectiveness of services we need to develop an objective measure of appropriateness valid for use in the UK.
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Small F, Alderdice F, McCusker C, Stevenson M, Stewart M. A prospective cohort study comparing hospital admission for gastro-enteritis with home management. Child Care Health Dev 2005; 31:555-62. [PMID: 16101651 DOI: 10.1111/j.1365-2214.2005.00550.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare physical and psychological outcomes in children presenting at Accident and Emergency Departments (A&E), diagnosed with gastro-enteritis and admitted to hospital with those of a similar age, sex and severity of illness discharged home. The physical and psychological well-being of children in these two groups, in the month after the episode, were compared as was further use of health care services. DESIGN A prospective cohort study. METHODS A comparison of 116 children aged 1-6 years with gastro-enteritis, presenting at A&E over a 6 months period. Admitted children were compared with children discharged, of a similar age, sex and illness severity (triage score) with follow-up at 1 week and 1 month. Clinical history, psychosocial factors, investigations and outcomes were recorded at presentation and physical, psychological and family outcomes at 1 week and 1 month. RESULTS Of 116 children, 112 (97%) completed the study (56 in each group). No differences were detected in psychosocial factors, socio-economic status, family factors, time of arrival at A&E or waiting times. Parental perception of illness was greater in the admitted group (P < 0.005), but was recorded after the decision on admission was made. At 1 week follow-up admitted children had increased separation anxiety compared with children who were discharged (P < 0.05), but this difference disappeared at 1 month. Clinical outcomes were the same for both groups, although admitted children had more investigations (91% vs. 39%). Parents were equally satisfied with their child's treatment, but one-third of children in both groups sought further consultation with a health professional in the following week. CONCLUSIONS There is no statistically significant difference in socio-demographic data, time of arrival at A&E, waiting times, clinical and psychosocial outcomes in children with acute gastro-enteritis admitted to hospital compared with a group of children of similar age, gender and severity of illness managed at home. However, parents seek reassurance and follow-up of acutely ill children, even if the child is admitted to hospital, which has service and resource implications.
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Affiliation(s)
- F Small
- Department of Child Health, The Queen's University of Belfast, UK
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Shepperd S, Perera R, Bates S, Jenkinson C, Hood K, Harnden A, Mant D. A children's acute respiratory illness scale (CARIFS) predicted functional severity and family burden. J Clin Epidemiol 2004; 57:809-14. [PMID: 15485733 DOI: 10.1016/j.jclinepi.2003.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2003] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The Canadian Acute Respiratory Illness and Flu Scale (CARIFS) was developed to measure illness severity in children with acute respiratory infection. The objective of this study was to evaluate its performance in a European primary care setting. STUDY DESIGN AND SETTING 178 children (median age 3 years) with cough and fever were recruited in UK general practice. Perceived severity of illness at recruitment was recorded by parents, doctors, and nurses. Parents also completed an illness diary, including the CARIF scale, until their child had recovered. In-depth interviews were conducted with 24 parents. RESULTS Parents found CARIFS relatively easy and quick to complete (78% of parents returned a fully completed diary covering the duration of the illness), internal consistency was high (minimum item correlation with total score 0.22; overall Cronbach's alpha statistic 0.85), and responsiveness to improvement in health was good (observed effect size of 0.45 at 8 h). At presentation, however, neither the overall CARIFS score nor the clinical element of the score correlated with physician assessment of clinical severity. CONCLUSION Of the three recognized domains of illness severity, CARIFS appears to be a good and valid measure of functional severity and burden of illness to the parent but it may not be a good measure of physiological severity.
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Affiliation(s)
- S Shepperd
- Department of Primary Health Care, University of Oxford, IHS Building, Old Road, Oxford OX3 7LF, UK
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14
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Abstract
BACKGROUND Children with special needs present a challenge to those involved in their care. AIMS To determine the role of the acute assessment unit for these children. METHODS Case notes and other records were reviewed for information on referrals, admissions, readmission within 7 and 28 days, length of stay, and management of 86 children registered for special needs. The study covered five years between January 1997 and December 2001. RESULTS Of the 86 children, 48 (58%) were boys; 62 children had cerebral palsy and 52 learning disability. There were 914 episodes, with 44% of these being self referrals and 35% from general practitioners; 35.5% of the episodes were managed in the assessment unit. The average length of stay in hospital was 5 days, ranging from <24 hours to 63 days; 37.5% of those admitted to the ward stayed for less than 24 hours. Respiratory tract infections and seizures were the main reasons for referral and admission. CONCLUSION Children with special needs tend to have a predictable pattern of conditions requiring inpatient care. One third of the inpatients episodes did not need a prolonged stay in hospital. This latter group of children could be managed at home with support of community nurses. Integrated care pathways need to be developed to minimise disruption to their lives. Appropriate resources should be made available to achieve these goals.
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Affiliation(s)
- M Mahon
- Department of Paediatrics, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK.
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15
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Davies C, Dale J. Paediatric home care for acute illness: I. GPs’ and hospital‐at‐home staff views. Int J Health Care Qual Assur 2003. [DOI: 10.1108/09526860310500023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Profile of children attending in a Pediatric Emergency Unit of an urban teaching hospital over a period of one year was analyzed. The total number of patients seen between September 1999 to August 2000 was 9205; there was a prepondence of boys (73%). The maximum number of patients were seen in the monsoon month of July and August. About half (52.5%) of the patients were infants. Fever (29.5%), breathing difficulty (17.4%) and diarrhea (14.5%) were the most common presenting symptoms. Respiratory and gastrointestinal illnesses were the two commonest pediatric emergencies. About 2% (n-198) patients died within 24 hours of hospitalization; 42.3% deaths were in the age group of 0-28 days. Sepsis was the most common diagnosis in patients who died. This information may help in planning and development of a Pediatric Emergency unit and prioritizing residents, training.
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Affiliation(s)
- Manju Salaria
- Department of Pediatrics, Post Graduate Institution of Medical Education and Research, Chandigarh, India
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Sartain SA, Maxwell MJ, Todd PJ, Jones KH, Bagust A, Haycox A, Bundred P. Randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care. Arch Dis Child 2002; 87:371-5. [PMID: 12390903 PMCID: PMC1763073 DOI: 10.1136/adc.87.5.371] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To assess the clinical effectiveness of a paediatric hospital at home service compared to conventional hospital care. METHODS A total of 399 children suffering from breathing difficulty (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72) were randomised to Hospital at Home or in-patient paediatric care. Main outcome measures were: comparative clinical effectiveness as measured by readmission rate within three months (used as a proxy for parental coping with illness); and length of stay/care and comparative satisfaction of both patients and carers. RESULTS Clinical effectiveness of both services was not significantly different. Length of care was one day longer in the Hospital at Home group; however, most parents and children preferred home care. CONCLUSIONS Hospital at Home is a clinically acceptable form of care for these groups of acute paediatric illness. Readmission rates within three months failed to show any advantage in terms of parental coping. Parents and patients expressed a strong preference for hospital at home.
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Eccleston P, Werneke U, Armon K, Stephenson T, MacFaul R. Accounting for overlap? An application of Mezzich's kappa statistic to test interrater reliability of interview data on parental accident and emergency attendance. J Adv Nurs 2001; 33:784-90. [PMID: 11298216 DOI: 10.1046/j.1365-2648.2001.01718.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
STUDY RATIONALE The number of interview studies with service users is rising because of growth in health services research. The level of agreement between multiple interview data coders requires statistical calculation to support results. Basic kappa statistics are often used but this depends on having mutually exclusive data. Researchers should be aware that this is not valid when an interview word or paragraph can be coded into more than one category. The 'proportional overlap' kappa extension by Mezzich et al. (1981, Journal of Psychiatric Research 16, 29-39) has been investigated as an original solution. OBJECTIVES To assess the level of agreement beyond chance between several raters of interview data by applying the 'proportional overlap' kappa statistic by Mezzich et al. to verbal interview data. The clinical area investigated was child attendance at an Accident and Emergency Department, where parental attendance experiences have been under-explored. METHODS Two researchers using a coding schedule coded a random sample of interview transcripts. These data were applied to Mezzich's procedure; coder 1 notes that a paragraph refers to category A and B but coder 2 notes A, B and C. The total agreement overlap in this case was 0.66 because two actual agreements out of three possible agreements were made. This was repeated for each paragraph and divided by the number of coding pairs. All agreement values were summed then subsequently divided by the total number of paragraphs to get Po (total number of observed agreements) and by the total number of coding pairs to get Pe (total number of agreements by chance alone). Po and Pe were used in the basic kappa formula to assess interview coding reliability. RESULTS The overall mean Po was 0.61, the mean Pe was 0.32, with a kappa score of 0.43; a moderate level of agreement which was statistically significant (t=4.8, P < 0.001, d.f.=23). CONCLUSION Mezzich's procedure may be applied to interview data to calculate agreement levels between several coders.
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Affiliation(s)
- P Eccleston
- Academic Division of Child Health, School of Human Development, University of Nottingham, Nottingham, UK.
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19
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Abstract
Comparative audits can be used as important tools for shaping service provision. Short stay facilities offer a more flexible and efficient approach to managing acute paediatric referrals. Users and providers views of the service are important. Children can be safely observed and discharged with parents empowered to continue care. Appropriate support systems should be in place in order to provide an ambulatory service.
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Affiliation(s)
- D Scott
- Child Health, Burnley Health Care NHS Trust, Lancashire, United Kingdom
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20
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Chevallier B. [Bronchiolitis in infants. Clinical criteria of severity for hospital admission]. Arch Pediatr 2001; 8 Suppl 1:39S-45S. [PMID: 11232441 DOI: 10.1016/s0929-693x(01)80154-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- B Chevallier
- Hôpital Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
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21
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Abstract
OBJECTIVE We evaluated the usefulness of a short stay or 23-hour ward in a pediatric unit of a large teaching hospital, Westmead Hospital, and an academic Children's hospital, The New Children's Hospital, to determine if they are a useful addition to the emergency service. METHODS This is a descriptive comparison of prospectively collected data on all children admitted to the short stay ward at Westmead Hospital (WH) during 1994 and the short stay ward at the New Children's Hospital (NCH) during 1997-98. These hospitals service an identical demographic area with the latter (NCH) a tertiary referral center. The following outcome measures were used: length of stay, appropriateness of stay, rate of admission to an in-hospital bed, and rate of unscheduled visits within 72 hours of discharge. Adverse events were reported and patient follow-up was attempted at 48 hours after discharge in all cases. RESULTS The short stay ward accounted for 10.3% (Westmead Hospital) and 14.7% (New Children's Hospital) of admissions, with 56% medical in nature, 30% surgical, and the remainder procedural or psychological. Admission patterns were similar, with asthma, gastroenteritis, convulsion, pneumonia, and simple surgical conditions accounting for most short stay ward admissions. The short stay ward increased hospital efficiency with an average length of stay of 17.5 hours (Westmead Hospital) compared to 20.5 hours (New Children's Hospital). The users of the short stay ward were children of young age less than 2 years, with stay greater than 23 hours reported in only 1% of all admissions to the short stay ward. The rate of patient admission to an in-hospital bed was low, (4% [Westmead Hospital] compared to 6% [New Children's Hospital]), with the number of unscheduled visits within 72 hours of short stay ward discharge less than 1%. There were no adverse events reported at either short stay ward, with parental satisfaction high. The short stay ward was developed through reallocation of resources from within the hospital to the short stay ward. This resulted in estimated savings of $1/2 million (Westmead Hospital) to $2.3 million (New Children's Hospital) to the hospital, due to more efficient bed usage. CONCLUSION This data demonstrates the robust nature of the short stay ward. At these two very different institutions we have shown improved bed efficient and patient care in a cost-effective way. We have also reported on greater parental satisfaction and early return of the child with their family to the community.
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Affiliation(s)
- G J Browne
- The New Children's Hospital, Royal Alexandra Hospital for Children, Westmead NSW, Australia.
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22
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Abstract
AIMS To estimate the nature and quantity of clinical experience available for trainees in paediatrics or general practice in acute general hospitals of differing sizes in the UK. To discuss implications for training and service configuration taking account of current Royal College recommendations (a minimum of 1,800 acute contacts each year and ideally covering a population of 450,000 to 500,000 people). METHODS Observed frequencies of diagnoses in Pinderfields Hospital, Wakefield were compared with those in five other hospitals in Yorkshire and four in the South of England, and with expected frequencies from a review of selected marker conditions using national routine and epidemiological data. Based on the Pinderfields data, we modelled expected frequencies of a wider range of diagnoses for different sized hospitals. RESULTS Small units (1,800 or less acute referrals a year) provide adequate exposure to common conditions such as gastroenteritis (157 per annum) and asthma (171 per annum) but encounter serious or unusual disease rarely. When modelled for units serving larger populations, numbers of such disorders remain small. For example, about 0.5% of admissions require intensive care to the level of ventilatory support. Medium size units offer a wide range of experience but differ little from those serving the population of 500,000 proposed as being optimal for training. This standard is not justified by the evidence in this review. Closing or amalgamating units on the scale necessary to achieve this ideal would be impractical as only five hospitals in England have a paediatric workload equivalent to this population; it would also raise issues of access and equity.
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Affiliation(s)
- R MacFaul
- Paediatric Department, Pinderfields Hospital, Pinderfields and Pontefract NHS Trust, Wakefield WF14 DG, UK.
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