Validation of the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in low- and middle-income countries: A multicentre observational study

Early recognition of children at risk of serious illness is essential in preventing morbidity and mortality, particularly in low- and middle-income countries (LMICs). This study aimed to validate the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in acute care settings in LMICs. This observational study is based on previously collected clinical data from consecutive children attending four diverse settings in LMICs. Inclusion criteria and study periods (2010-2021) varied. We simulated the ED-PEWS, consisting of patient age, consciousness, work of breathing, respiratory rate, oxygen saturation, heart rate, and capillary refill time, based on the first available parameters. Discrimination was assessed by the area under the curve (AUC), sensitivity and specificity (previously defined cut-offs < 6 and ≥ 15). The outcome measure was for each setting a composite marker of high urgency. 41,917 visits from Gambia rural, 501 visits from Gambia urban, 2,608 visits from Suriname, and 1,682 visits from Tanzania were included. The proportion of high urgency was variable (range 4.6% to 24.9%). Performance ranged from AUC 0.80 (95%CI 0.70-0.89) in Gambia urban to 0.62 (95%CI 0.55-0.67) in Tanzania. The low-urgency cut-off showed a high sensitivity in all settings ranging from 0.83 (95%CI 0.81-0.84) to 1.00 (95%CI 0.97-1.00). The high-urgency cut-off showed a specificity ranging from 0.71 (95%CI 0.66-0.75) to 0.97 (95%CI 0.97-0.97). The ED-PEWS has a moderate to good performance for the recognition of high urgency children in these LMIC settings. The performance appears to have potential in improving the identification of high urgency children in LMICs.

Which low urgent triaged febrile children are suitable for a fast track? An observational European study

BACKGROUND

The number of paediatric patients visiting the ED with non-urgent problems is increasing, leading to poor patient flow and ED crowding. Fast track aims to improve the efficiency of evaluation and discharge of low acuity patients. We aimed to identify which febrile children are suitable for a fast track based on presenting symptoms and management.

METHODS

This study is part of the Management and Outcome of Fever in children in Europe study, which is an observational study including routine data of febrile children <18 years attending 12 European EDs. We included febrile, low urgent children (those assigned a triage acuity of either 'standard' or 'non-urgent' using the Manchester Triage System) and defined children as suitable for fast track when they have minimal resource use and are discharged home. Presenting symptoms consisted of neurological (n=237), respiratory (n=8476), gastrointestinal (n=1953) and others (n=3473, reference group). Multivariable logistic regression analyses regarding presenting symptoms and management (laboratory blood testing, imaging and admission) were performed with adjustment for covariates: patient characteristics, referral status, previous medical care, previous antibiotic use, visiting hours and ED setting.

RESULTS

We included 14 139 children with a median age of 2.7 years (IQR 1.3-5.2). The majority had respiratory symptoms (60%), viral infections (50%) and consisted of self-referrals (69%). The neurological group received imaging more often (adjusted OR (aOR) 1.8, 95% CI 1.1 to 2.9) and were admitted more frequently (aOR 1.9, 95% CI 1.4 to 2.7). The respiratory group had fewer laboratory blood tests performed (aOR 0.6, 95% CI 0.5 to 0.7), were less frequently admitted (aOR 0.6, 95% CI 0.5 to 0.7), but received imaging more often (aOR 1.8, 95% CI 1.6 to 2.0). Lastly, the gastrointestinal group had more laboratory blood tests performed (aOR 1.2. 95% CI 1.1 to 1.4) and were admitted more frequently (aOR 1.4, 95% CI 1.2 to 1.6).

CONCLUSION

We determined that febrile children triaged as low urgent with respiratory symptoms were most suitable for a fast track. This study provides evidence for which children could be triaged to a fast track, potentially improving overall patient flow at the ED.

Clinical phenotypes and outcomes in children with multisystem inflammatory syndrome across SARS-CoV-2 variant eras: a multinational study from the 4CE consortium

Background

Multisystem inflammatory syndrome in children (MIS-C) is a severe complication of SARS-CoV-2 infection. It remains unclear how MIS-C phenotypes vary across SARS-CoV-2 variants. We aimed to investigate clinical characteristics and outcomes of MIS-C across SARS-CoV-2 eras.

Methods

We performed a multicentre observational retrospective study including seven paediatric hospitals in four countries (France, Spain, U.K., and U.S.). All consecutive confirmed patients with MIS-C hospitalised between February 1st, 2020, and May 31st, 2022, were included. Electronic Health Records (EHR) data were used to calculate pooled risk differences (RD) and effect sizes (ES) at site level, using Alpha as reference. Meta-analysis was used to pool data across sites.

Findings

Of 598 patients with MIS-C (61% male, 39% female; mean age 9.7 years [SD 4.5]), 383 (64%) were admitted in the Alpha era, 111 (19%) in the Delta era, and 104 (17%) in the Omicron era. Compared with patients admitted in the Alpha era, those admitted in the Delta era were younger (ES -1.18 years [95% CI -2.05, -0.32]), had fewer respiratory symptoms (RD -0.15 [95% CI -0.33, -0.04]), less frequent non-cardiogenic shock or systemic inflammatory response syndrome (SIRS) (RD -0.35 [95% CI -0.64, -0.07]), lower lymphocyte count (ES -0.16 × 109/uL [95% CI -0.30, -0.01]), lower C-reactive protein (ES -28.5 mg/L [95% CI -46.3, -10.7]), and lower troponin (ES -0.14 ng/mL [95% CI -0.26, -0.03]). Patients admitted in the Omicron versus Alpha eras were younger (ES -1.6 years [95% CI -2.5, -0.8]), had less frequent SIRS (RD -0.18 [95% CI -0.30, -0.05]), lower lymphocyte count (ES -0.39 × 109/uL [95% CI -0.52, -0.25]), lower troponin (ES -0.16 ng/mL [95% CI -0.30, -0.01]) and less frequently received anticoagulation therapy (RD -0.19 [95% CI -0.37, -0.04]). Length of hospitalization was shorter in the Delta versus Alpha eras (-1.3 days [95% CI -2.3, -0.4]).

Interpretation

Our study suggested that MIS-C clinical phenotypes varied across SARS-CoV-2 eras, with patients in Delta and Omicron eras being younger and less sick. EHR data can be effectively leveraged to identify rare complications of pandemic diseases and their variation over time.

Funding

None.

Emergency medical services utilisation among febrile children attending emergency departments across Europe: an observational multicentre study

Children constitute 6-10% of all patients attending the emergency department (ED) by emergency medical services (EMS). However, discordant EMS use in children occurs in 37-61% with fever as an important risk factor. We aimed to describe EMS utilisation among febrile children attending European EDs. This study is part of an observational multicentre study assessing management and outcome in febrile children up to 18 years (MOFICHE) attending twelve EDs in eight European countries. Discordant EMS use was defined as the absence of markers of urgency including intermediate/high triage urgency, advanced diagnostics, treatment, and admission in children transferred by EMS. Multivariable logistic regression analyses were performed for the association between (1) EMS use and markers of urgency, and (2) patient characteristics and discordant EMS use after adjusting all analyses for the covariates age, gender, visiting hours, presenting symptoms, and ED setting. A total of 5464 (15%, range 0.1-42%) children attended the ED by EMS. Markers of urgency were more frequently present in the EMS group compared with the non-EMS group. Discordant EMS use occurred in 1601 children (29%, range 1-59%). Age and gender were not associated with discordant EMS use, whereas neurological symptoms were associated with less discordant EMS use (aOR 0.2, 95%CI 0.1-0.2), and attendance out of office hours was associated with more discordant EMS use (aOR 1.6, 95%CI 1.4-1.9). Settings with higher percentage of self-referrals to the ED had more discordant EMS use (p < 0.05).  Conclusion: There is large practice variation in EMS use in febrile children attending European EDs. Markers of urgency were more frequently present in children in the EMS group. However, discordant EMS use occurred in 29%. Further research is needed on non-medical factors influencing discordant EMS use in febrile children across Europe, so that pre-emptive strategies can be implemented. What is Known: •Children constitute around 6-10% of all patients attending the emergency department by emergency medical services. •Discordant EMS use occurs in 37-61% of all children, with fever as most common presenting symptom for discordant EMS use in children. What is New: •There is large practice variation in EMS use among febrile children across Europe with discordance EMS use occurring in 29% (range 1-59%), which was associated with attendance during out of office hours and with settings with higher percentage of self-referrals to the ED. •Future research is needed focusing on non-medical factors (socioeconomic status, parental preferences and past experience, healthcare systems, referral pathways, out of hours services provision) that influence discordant EMS use in febrile children across Europe.

Are children with prolonged fever at a higher risk for serious illness? A prospective observational study

OBJECTIVES

To describe the characteristics and clinical outcomes of children with fever ≥5 days presenting to emergency departments (EDs).

DESIGN

Prospective observational study.

SETTING

12 European EDs.

PATIENTS

Consecutive febrile children <18 years between January 2017 and April 2018.

INTERVENTIONS

Children with fever ≥5 days and their risks for serious bacterial infection (SBI) were compared with children with fever <5 days, including diagnostic accuracy of non-specific symptoms, warning signs and C-reactive protein (CRP; mg/L).

MAIN OUTCOME MEASURES

SBI and other non-infectious serious illness.

RESULTS

3778/35 705 (10.6%) of febrile children had fever ≥5 days. Incidence of SBI in children with fever ≥5 days was higher than in those with fever <5 days (8.4% vs 5.7%). Triage urgency, life-saving interventions and intensive care admissions were similar for fever ≥5 days and <5 days. Several warning signs had good rule in value for SBI with specificities >0.90, but were observed infrequently (range: 0.4%-17%). Absence of warning signs was not sufficiently reliable to rule out SBI (sensitivity 0.92 (95% CI 0.87-0.95), negative likelihood ratio (LR) 0.34 (0.22-0.54)). CRP <20 mg/L was useful for ruling out SBI (negative LR 0.16 (0.11-0.24)). There were 66 cases (1.7%) of non-infectious serious illnesses, including 21 cases of Kawasaki disease (0.6%), 28 inflammatory conditions (0.7%) and 4 malignancies.

CONCLUSION

Children with prolonged fever have a higher risk of SBI, warranting a careful clinical assessment and diagnostic workup. Warning signs of SBI occurred infrequently but, if present, increased the likelihood of SBI. Although rare, clinicians should consider important non-infectious causes of prolonged fever.

European study confirms the combination of fever and petechial rash as an important warning sign for childhood sepsis and meningitis

AIM

This study investigated febrile children with petechial rashes who presented to European emergency departments (EDs) and investigated the role that mechanical causes played in diagnoses.

METHODS

Consecutive patients with fever presenting to EDs in 11 European emergency departments in 2017-2018 were enrolled. The cause and focus of infection were identified and a detailed analysis was performed on children with petechial rashes. The results are presented as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

We found that 453/34010 (1.3%) febrile children had petechial rashes. The focus of the infection included sepsis (10/453, 2.2%) and meningitis (14/453, 3.1%). Children with a petechial rash were more likely than other febrile children to have sepsis or meningitis (OR 8.5, 95% CI 5.3-13.1) and bacterial infections (OR 1.4, 95% CI 1.0-1.8) as well as need for immediate life-saving interventions (OR 6.6, 95% CI 4.4-9.5) and intensive care unit admissions (OR 6.5, 95% CI 3.0-12.5).

CONCLUSION

The combination of fever and petechial rash is still an important warning sign for childhood sepsis and meningitis. Ruling out coughing and/or vomiting was insufficient to safely identify low-risk patients.

Sex differences in febrile children with respiratory symptoms attending European emergency departments: An observational multicenter study

Objective

To assess sex differences in presentation and management of febrile children with respiratory symptoms attending European Emergency Departments.

Design and setting

An observational study in twelve Emergency Departments in eight European countries.

Patients

Previously healthy children aged 0–<18 years with fever (≥ 38°C) at the Emergency Department or in the consecutive three days before Emergency Department visit and respiratory symptoms were included.

Main outcome measures

The main outcomes were patient characteristics and management defined as diagnostic tests, treatment and admission. Descriptive statistics were used for patient characteristics and management stratified by sex. Multivariable logistic regression analyses were performed for the association between sex and management with adjustment for age, disease severity and Emergency Department. Additionally, subgroup analyses were performed in children with upper and lower respiratory tract infections and in children below five years.

Results

We included 19,781 febrile children with respiratory symptoms. The majority were boys (54%), aged 1–5 years (58%) and triaged as low urgent (67%). Girls presented less frequently with tachypnea (15% vs 16%, p = 0.002) and increased work of breathing (8% vs 12%, p<0.001) compared with boys. Girls received less inhalation medication than boys (aOR 0.82, 95% CI 0.74–0.90), but received antibiotic treatment more frequently than boys (aOR 1.09, 95% CI 1.02–1.15), which is associated with a higher prevalence of urinary tract infections. Amongst children with a lower respiratory tract infection and children below five years girls received less inhalation medication than boys (aOR 0.77, 95% CI 0.66–0.89; aOR 0.80, 95% CI 0.72–0.90).

Conclusions

Sex differences concerning presentation and management are present in previously healthy febrile children with respiratory symptoms presenting to the Emergency Department. Future research should focus on whether these differences are related to clinicians’ attitudes, differences in clinical symptoms at the time of presentation and disease severity.

Improving triage for children with comorbidity using the ED-PEWS: an observational study

OBJECTIVE

To assess the value of the Emergency Department-Pediatric Early Warning Score (ED-PEWS) for triage of children with comorbidity.

DESIGN

Secondary analysis of a prospective cohort.

SETTING AND PATIENTS

53 829 consecutive ED visits of children <16 years in three European hospitals (Netherlands, UK and Austria) participating in the TrIAGE (Triage Improvements Across General Emergency departments) project in different periods (2012-2015).

INTERVENTION

ED-PEWS, a score consisting of age and six physiological parameters.

MAIN OUTCOME MEASURE

A three-category reference standard as proxy for true patient urgency. We assessed discrimination and calibration of the ED-PEWS for children with comorbidity (complex and non-complex) and without comorbidity. In addition, we evaluated the value of adding the ED-PEWS to the routinely used Manchester Triage System (MTS).

RESULTS

5053 (9%) children had underlying non-complex morbidity and 5537 (10%) had complex comorbidity. The c-statistic for identification of high-urgency patients was 0.86 (95% prediction interval 0.84-0.88) for children without comorbidity, 0.87 (0.82-0.92) for non-complex and 0.86 (0.84-0.88) for complex comorbidity. For high and intermediate urgency, the c-statistic was 0.63 (0.62-0.63), 0.63 (0.61-0.65) and 0.63 (0.55-0.73) respectively. Sensitivity was slightly higher for children with comorbidity (0.73-0.75 vs 0.70) at the cost of a lower specificity (0.86-0.87 vs 0.92). Calibration was largely similar. Adding the ED-PEWS to the MTS for children with comorbidity improved performance, except in the setting with few high-urgency patients.

CONCLUSIONS

The ED-PEWS has a similar performance in children with and without comorbidity. Adding the ED-PEWS to the MTS for children with comorbidity improves triage, except in the setting with few high-urgency patients.

Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study

OBJECTIVE

(1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children.

DESIGN/SETTING

Observational study in 11 European EDs (2017-2018).

PATIENTS

Febrile children with measured blood pressure.

MAIN OUTCOME MEASURES

Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs).

RESULTS

Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8.

CONCLUSIONS

High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED.

Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data

Background

Among pediatric emergency department (ED) visits, a subgroup of children repeatedly visits the ED, making them frequent visitors (FVs). The aim of this study is to get insight into the group of pediatric ED FVs and to determine risk factors associated with a revisit.

Methods and findings

Data of all children aged 0–18 years visiting the ED of a university hospital in the Netherlands between 2017 and 2020 were included in this observational study based on routine data extraction. Children with 4 or more ED visits within 365 days were classified as FVs. Descriptive analysis of the study cohort at patient- and visit-level were performed. Risk factors for a recurrent ED visit were determined using a Prentice Williams and Peterson gap time cox-based model. Our study population of 10,209 children with 16,397 ED visits contained 500 FVs (4.9%) accounting for 3,481 visits (21.2%). At patient-level, FVs were younger and more often suffered from chronic diseases (CDs). At visit-level, frequent visits were more often initiated by self-referral and were more often related to medical problems (compared to trauma’s). Overall, FVs presented at the ED more often because of an infection (41.3%) compared to non-FVs (27.4%), either associated or not with the body system affected by the CD. We identified the presence of a comorbidity (non-complex CD HR 1.66; 1.52–1.81 and complex CD HR 2.00; 1.84–2.16) as determinants with the highest hazard for a return visit.

Conclusion

Pediatric ED FVs are a small group of children but account for a large amount of the total ED visits. FVs are younger patients, suffering from (complex) comorbidities and present more often with infectious conditions compared to non-FVs. Healthcare pathways, including safety-netting strategies for acute manifestations from their comorbidity, or for infectious conditions in general may contribute to support parents and redirect some patients from the ED.

Febrile children with comorbidities at the emergency department - a multicentre observational study

We aimed to describe characteristics and management of children with comorbidities attending European emergency departments (EDs) with fever. MOFICHE (Management and Outcome of Fever in children in Europe) is a prospective multicentre study (12 European EDs, 8 countries). Febrile children with comorbidities were compared to those without in terms of patient characteristics, markers of disease severity, management, and diagnosis. Comorbidity was defined as a chronic underlying condition that is expected to last > 1 year. We performed multivariable logistic regression analysis, displaying adjusted odds ratios (aOR), adjusting for patient characteristics. We included 38,110 patients, of whom 5906 (16%) had comorbidities. Most common comorbidities were pulmonary, neurologic, or prematurity. Patients with comorbidities more often were ill appearing (20 versus 16%, p < 0.001), had an ED-Paediatric Early Warning Score of > 15 (22 versus 12%, p < 0.001), or a C-reactive protein > 60 mg/l (aOR 1.4 (95%CI 1.3-1.6)). They more often required life-saving interventions (aOR 2.7, 95% CI 2.2-3.3), were treated with intravenous antibiotics (aOR 2.3, 95%CI 2.1-2.5), and were admitted to the ward (aOR 2.2, 95%CI 2.1-2.4) or paediatric intensive care unit (PICU) (aOR 5.5, 95% CI 3.8-7.9). They were more often diagnosed with serious bacterial infections (aOR 1.8, 95%CI 1.7-2.0), including sepsis/meningitis (aOR 4.6, 95%CI 3.2-6.7). Children most at risk for sepsis/meningitis were children with malignancy/immunodeficiency (aOR 14.5, 8.5-24.8), while children with psychomotor delay/neurological disease were most at risk for life-saving interventions (aOR 5.3, 4.1-6.9) or PICU admission (aOR 9.7, 6.1-15.5).

CONCLUSIONS

Our data show how children with comorbidities are a population at risk, as they more often are diagnosed with bacterial infections and more often require PICU admission and life-saving interventions.

WHAT IS KNOWN

• While children with comorbidity constitute a large part of ED frequent flyers, they are often excluded from studies.

WHAT IS NEW

• Children with comorbidities in general are more ill upon presentation than children without comorbidities. • Children with comorbidities form a heterogeneous group; specific subgroups have an increased risk for invasive bacterial infections, while others have an increased risk of invasive interventions such as PICU admission, regardless of the cause of the fever.

Rapid Viral Testing and Antibiotic Prescription in Febrile Children With Respiratory Symptoms Visiting Emergency Departments in Europe

BACKGROUND

Inappropriate antibiotic prescribing often occurs in children with self-limiting respiratory tract infections, contributing to antimicrobial resistance. It has been suggested that rapid viral testing can reduce inappropriate antibiotic prescribing. We aimed to assess the association between rapid viral testing at the Emergency Department (ED) and antibiotic prescription in febrile children.

METHODS

This study is part of the MOFICHE study, which is an observational multicenter study including routine data of febrile children (0-18 years) attending 12 European EDs. In children with respiratory symptoms visiting 6 EDs equipped with rapid viral testing, we performed multivariable logistic regression analysis regarding rapid viral testing and antibiotic prescription adjusted for patient characteristics, disease severity, diagnostic tests, focus of infection, admission, and ED.

RESULTS

A rapid viral test was performed in 1061 children (8%) and not performed in 11,463 children. Rapid viral test usage was not associated with antibiotic prescription (aOR 0.9, 95% CI: 0.8-1.1). A positive rapid viral test was associated with less antibiotic prescription compared with children without test performed (aOR 0.6, 95% CI: 0.5-0.8), which remained significant after adjustment for CRP and chest radiograph result. Twenty percent of the positively tested children received antibiotics. A negative rapid viral test was not associated with antibiotic prescription (aOR 1.2, 95% CI: 1.0-1.4).

CONCLUSIONS

Rapid viral test usage did not reduce overall antibiotic prescription, whereas a positive rapid viral test did reduce antibiotic prescription at the ED. Implementation of rapid viral testing in routine emergency care and compliance to the rapid viral test outcome will reduce inappropriate antibiotic prescribing at the ED.

Multi-PheWAS intersection approach to identify sex differences across comorbidities in 59 140 pediatric patients with autism spectrum disorder

Objective

To identify differences related to sex and define autism spectrum disorder (ASD) comorbidities female-enriched through a comprehensive multi-PheWAS intersection approach on big, real-world data. Although sex difference is a consistent and recognized feature of ASD, additional clinical correlates could help to identify potential disease subgroups, based on sex and age.

Materials and Methods

We performed a systematic comorbidity analysis on 1860 groups of comorbidities exploring all spectrum of known disease, in 59 140 individuals (11 440 females) with ASD from 4 age groups. We explored ASD sex differences in 2 independent real-world datasets, across all potential comorbidities by comparing (1) females with ASD vs males with ASD and (2) females with ASD vs females without ASD.

Results

We identified 27 different comorbidities that appeared significantly more frequently in females with ASD. The comorbidities were mostly neurological (eg, epilepsy, odds ratio [OR] > 1.8, 3-18 years of age), congenital (eg, chromosomal anomalies, OR > 2, 3-18 years of age), and mental disorders (eg, intellectual disability, OR > 1.7, 6-18 years of age). Novel comorbidities included endocrine metabolic diseases (eg, failure to thrive, OR = 2.5, ages 0-2), digestive disorders (gastroesophageal reflux disease: OR = 1.7, 6-11 years of age; and constipation: OR > 1.6, 3-11 years of age), and sense organs (strabismus: OR > 1.8, 3-18 years of age).

Discussion

A multi-PheWAS intersection approach on real-world data as presented in this study uniquely contributes to the growing body of research regarding sex-based comorbidity analysis in ASD population.

Conclusions

Our findings provide insights into female-enriched ASD comorbidities that are potentially important in diagnosis, as well as the identification of distinct comorbidity patterns influencing anticipatory treatment or referrals. The code is publicly available (https://github.com/hms-dbmi/sexDifferenceInASD).

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

Background

To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.

Methods and findings

A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit (‘index’ visit), in 2012–2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65–0.74) and summary calibration slope of 0.83 (95% CI 0.67–0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87–5.01) and specificity 0.96 (95% CI 0.95–0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25–0.35), sensitivity 0.88 (95% CI 0.86–0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68–0.75) and summary calibration slope of 0.84 (95% CI 0.71–0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.

Conclusion

We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Shortness of breath in children at the emergency department: Variability in management in Europe

OBJECTIVE

Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability.

DESIGN

The TrIAGE project, a prospective observational study based on electronic health record data.

PATIENTS AND SETTING

Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014).

MAIN OUTCOME MEASURES

We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables.

RESULTS

In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings.

CONCLUSION

European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.

Sex-specific differences in children attending the emergency department: prospective observational study

OBJECTIVE

To assess the role of sex in the presentation and management of children attending the emergency department (ED).

DESIGN

The TrIAGE project (TRiage Improvements Across General Emergency departments), a prospective observational study based on curated electronic health record data.

SETTING

Five diverse European hospitals in four countries (Austria, The Netherlands, Portugal, UK).

PARTICIPANTS

All consecutive paediatric ED visits of children under the age of 16 during the study period (8-36 months between 2012 and 2015).

MAIN OUTCOME MEASURES

The association between sex (male of female) and diagnostic tests and disease management in general paediatric ED visits and in subgroups presenting with trauma or musculoskeletal, gastrointestinal and respiratory problems and fever. Results from the different hospitals were pooled in a random effects meta-analysis.

RESULTS

116 172 ED visits were included of which 63 042 (54%) by boys and 53 715 (46%) by girls. Boys accounted for the majority of ED visits in childhood, and girls in adolescence. After adjusting for age, triage urgency and clinical presentation, girls had more laboratory tests compared with boys (pooled OR 1.10, 95% CI 1.05 to 1.15). Additionally, girls had more laboratory tests in ED visits for respiratory problems (pooled OR 1.15, 95% CI 1.04 to 1.26) and more imaging in visits for trauma or musculoskeletal problems (pooled OR 1.10, 95% CI 1.01 to 1.20) and respiratory conditions (pooled OR 1.14, 95% CI 1.05 to 1.24). Girls with respiratory problems were less often treated with inhalation medication (pooled OR 0.76, 95% CI 0.70 to 0.83). There was no difference in hospital admission between the sexes (pooled OR 0.99, 95% CI 0.95 to 1.04).

CONCLUSION

In childhood, boys represent the majority of ED visits and they receive more inhalation medication. Unexpectedly, girls receive more diagnostic tests compared with boys. Further research is needed to investigate whether this is due to pathophysiological differences and differences in disease course, whether girls present signs and symptoms differently, or whether sociocultural factors are responsible.

Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre study

BACKGROUND

Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS.

METHODS

The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece).

FINDINGS

Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82-0·90) for high-urgency patients and 0·67 (0·61-0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87-0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81-0·85).

INTERPRETATION

The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs.

FUNDING

Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.

Association between hypotension and serious illness in the emergency department: an observational study

BACKGROUND

The value of routine blood pressure measurement in the emergency department (ED) is unclear.

OBJECTIVE

To determine the association between hypotension in addition to tachycardia and the Shock Index for serious illness.

DESIGN

Observational study.

SETTING

University ED (2009-2016).

PARTICIPANTS, METHODS AND MAIN OUTCOMES

Routine data collected from consecutive children <16 years. Using logistic regression, we assessed the association between hypotension (adjusted for tachycardia) and Shock Index (ratio heart rate/blood pressure [BP]) for serious illness. The predictive accuracy (sensitivity, specificity) for hypotension and Shock Index was determined for serious illness, defined as intensive care unit (ICU) and hospital admissions.

RESULTS

We included 10 698 children with measured BP. According to three age-adjusted clinical cut-offs (Advanced Paediatric Life Support, Paediatric Advanced Life Support and Paediatric Early Warning Score), hypotension was significantly associated with ICU admission when adjusted for tachycardia (range OR 2.6-5.3). Hypotension showed low sensitivity (range 0.05-0.12) and high specificity (range 0.95-0.99) for ICU admission. Combining hypotension and tachycardia did not change the predictive value for ICU admission. Similar results were found for hospitalisation. Shock index was associated with serious illness. However, no specific cut-off value was identified in different age groups.

CONCLUSIONS

Hypotension, adjusted for tachycardia, is associated with serious illness, although its sensitivity is limited. Shock index showed an association with serious illness, but no acceptable cut-off value could be identified. Routine BP measurement in all children to detect hypotension has limited value in the ED. Future studies need to confirm which patients could benefit from BP measurement.

Management of children visiting the emergency department during out-of-office hours: an observational study

BACKGROUND

The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours.

METHODS

We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital.

RESULTS

Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining.

CONCLUSIONS

Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.

A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: a systematic review

Background

Different definitions exist for hypotension in children. In this study, we aim to identify evidence-based reference values for low blood pressure and to compare these with existing definitions for systolic hypotension.

Methods

We searched online databases until February 2019 (including MEDLINE, EMBASE, Web of Science) using a comprehensive search strategy to identify studies that defined age-related centiles (first to fifth centile) for non-invasive systolic blood pressure in healthy children < 18 years. Existing cut-offs for hypotension were identified in international guidelines and textbooks. The age-related centiles and clinical cut-offs were compared and visualized using step charts.

Results

Fourteen studies with population-based centiles were selected, of which 2 addressed children < 1 year. Values for the fifth centile differed 8 to 17 mmHg for age. We identified 13 clinical cut-offs of which only 5 reported accurate references. Age-related cut-offs for hypotension showed large variability (ranging from 15 to 30 mmHg). The clinical cut-offs varied in agreement with the low centiles. The definition from Paediatric Advanced Life Support agreed well for children < 12 years but was below the fifth centiles for children > 12 years. For children > 12 years, the definition of Parshuram’s early warning score agreed well, but the Advanced Paediatric Life Support definition was above the fifth centiles.

Conclusions

The different clinical guidelines for low blood pressure show large variability and low to moderate agreement with population-based lower centiles. For children < 12 years, the Paediatric Advanced Life Support definition fits best but it underestimates hypotension in older children. For children > 12 years, the Advanced Paediatric Life Support overestimates hypotension but Parshuram’s cut-off for hypotension in the early warning score agrees well. Future studies should focus on developing reference values for hypotension for acutely ill children.

Performance of triage systems in emergency care: a systematic review and meta-analysis

OBJECTIVE

To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018.

ELIGIBILITY CRITERIA

Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded.

REVIEW METHODS

Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance.

RESULTS

Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance.

CONCLUSIONS

Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.

Multiple performance measures are needed to evaluate triage systems in the emergency department

OBJECTIVES

Emergency department triage systems can be considered prediction rules with an ordinal outcome, where different directions of misclassification have different clinical consequences. We evaluated strategies to compare the performance of triage systems and aimed to propose a set of performance measures that should be used in future studies.

STUDY DESIGN AND SETTING

We identified performance measures based on literature review and expert knowledge. Their properties are illustrated in a case study evaluating two triage modifications in a cohort of 14,485 pediatric emergency department visits. Strengths and weaknesses of the performance measures were systematically appraised.

RESULTS

Commonly reported performance measures are measures of statistical association (34/60 studies) and diagnostic accuracy (17/60 studies). The case study illustrates that none of the performance measures fulfills all criteria for triage evaluation. Decision curves are the performance measures with the most attractive features but require dichotomization. In addition, paired diagnostic accuracy measures can be recommended for dichotomized analysis, and the triage-weighted kappa and Nagelkerke's R² for ordinal analyses. Other performance measures provide limited additional information.

CONCLUSION

When comparing modifications of triage systems, decision curves and diagnostic accuracy measures should be used in a dichotomized analysis, and the triage-weighted kappa and Nagelkerke's R² in an ordinal approach.

The role of nurses' clinical impression in the first assessment of children at the emergency department

OBJECTIVE

To assess the diagnostic value and determinants of nurses' clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED).

DESIGN

Secondary analysis of a prospective cohort.

SETTING AND PATIENTS

6390 consecutive children <16 years of age presenting to a paediatric ED with a non-surgical chief complaint and complete data available.

MAIN OUTCOME MEASURES

Diagnostic accuracy of nurses' clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses' impression that a child appeared ill.

RESULTS

Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses' clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses' impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

CONCLUSION

The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.

Validity of the Manchester Triage System in emergency care: A prospective observational study

OBJECTIVES

To determine the validity of the Manchester Triage System (MTS) in emergency care for the general population of patients attending the emergency department, for children and elderly, and for commonly used MTS flowcharts and discriminators across three different emergency care settings.

METHODS

This was a prospective observational study in three European emergency departments. All consecutive patients attending the emergency department during a 1-year study period (2010-2012) were included. Validity of the MTS was assessed by comparing MTS urgency as determined by triage nurses with patient urgency according to a predefined 3-category reference standard as proxy for true patient urgency.

RESULTS

288,663 patients were included in the analysis. Sensitivity of the MTS in the three hospitals ranged from 0.47 (95%CI 0.44-0.49) to 0.87 (95%CI 0.85-0.90), and specificity from 0.84 (95%CI 0.84-0.84) to 0.94 (95%CI 0.94-0.94) for the triage of adult patients. In children, sensitivity ranged from 0.65 (95%CI 0.61-0.70) to 0.83 (95%CI 0.79-0.87), and specificity from 0.83 (95%CI 0.82-0.83) to 0.89 (95%CI 0.88-0.90). The diagnostic odds ratio ranged from 13.5 (95%CI 12.1-15.0) to 35.3 (95%CI 28.4-43.9) in adults and from 9.8 (95%CI 6.7-14.5) to 23.8 (95%CI 17.7-32.0) in children, and was lowest in the youngest patients in 2 out of 3 settings and in the oldest patients in all settings. Performance varied considerably between the different emergency departments.

CONCLUSIONS

Validity of the MTS in emergency care is moderate to good, with lowest performance in the young and elderly patients. Future studies on the validity of triage systems should be restricted to large, multicenter studies to define modifications and improve generalizability of the findings.

Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department

OBJECTIVE

To assess the safety of the Manchester Triage System in pediatric emergency care for children who require admission to the intensive care unit (ICU).

STUDY DESIGN

Between 2006 and 2013, 50 062 consecutive emergency department visits of children younger than the age of 16 years were included. We determined the percentage of undertriage, defined as the proportion of children admitted to ICU triaged as low urgent according to the Manchester Triage System, and diagnostic performance measures, including sensitivity, specificity, and diagnostic OR. Characteristics of undertriaged patients were compared with correctly triaged patients. In a logistic regression model, risk factors for undertriage were determined.

RESULTS

In total, 238 (28.7%) of the 830 children admitted to ICU during the study period were undertriaged. Sensitivity of high Manchester Triage System urgency levels to detect ICU admission was 71% (95% CI 68%-74%) and specificity 85% (95% CI 85%-85%). Severity of illness was lower in undertriaged children than correctly triaged children admitted to ICU. Risk factors for undertriage were age <3 months, medical presenting problem, comorbidity, referral by a medical specialist or emergency medical services, and presentation during the evening or night shift.

CONCLUSION

The Manchester Triage System misclassifies a substantial number of children who require ICU admission. Modifications targeted at young children and children with a comorbid condition could possibly improve safety of the Manchester Triage System in pediatric emergency care.