Management of fever and acute painful crises in children with sickle cell disease in emergency departments: a tertiary hospital experience

Sickle Cell Disease (SCD) is highly prevalent in Saudi Arabia with variable demographics and access to health care facilities including emergency departments. Literature reviews for locally published articles are deficient in the in-depth evaluation of current emergency practices in managing patients with SCD. The study aims to assess the current emergency practice in managing SCD patients in tertiary hospitals. We reviewed data of 212 visits by patients with SCD over three years and assessed the current emergency department practices in managing common SCD crises, such as vaso-occlusive (VOC) and febrile episodes. Our findings revealed that 47.2%, 37.7%, and 15% of the patients presented with pain, fever, or both, respectively. The patients were triaged level III according to the Canadian triage and acuity scale system in 89% of the visits. The Median time for patients to see healthcare providers was 22 min. In the first 2 h, 86% of the patients received at least one fluid bolus and 79% of them received appropriate analgesia for pain crises. Approximately 41.5% of the patients with fever were admitted and received ceftriaxone as single intravenous antimicrobial agent. However, none of the patients had bacteremia. Only 2.4% of the patients had either urinary tract infection or osteomyelitis based on imaging. ED management is a key factor in the successful management of patients with SCD in a timely manner by providing fluids, analgesia, and antibiotics. Adopting evidence-based guidelines and avoiding unnecessary admissions are suggested in clinically well patients with fever in the era of completed vaccination, antibiotic prophylaxis, and good access to care for patients with a clear viral infection focus.

Efficacy of patient discharge instructions: A pointer toward caregiver friendly communication methods from pediatric emergency personnel

Background:

Discharge instructions are vital in postemergency patient care to help the caregiver understand the diagnosis and identify symptoms which require prompt readmission. In general, oral or written instructions are provided on discharge. However, there is a dearth of information on the efficacy of discharge instructions provided by physicians in KSA.

Objectives:

To evaluate the efficacy of discharge instructions for postpediatrics emergency visit.

Materials and Methods:

This observational cross-sectional survey conducted in the Department of Paediatric Emergency at King Abdul Aziz Medical City, Riyadh, KSA, included 173 literate adult caregivers who had given their consent. Those who had been on admission earlier and been discharged from the emergency department were excluded. Demographic data and variables like knowledge of medicine and treatment follow-up were collected using a structured questionnaire and analyzed using SPSS version 16.

Results:

Verbal only, written only, or both verbal and written discharge instructions were provided. Written and verbal instructions, when provided together, were the most effective modes of communication with caregivers. The majority of the respondents were unaware of the follow-up plan (64.16%), unable to identify problems that would necessitate a follow-up (58.96%), and unable to identify the signs and symptoms that would require a revisit (62.43%) irrespective of the mode of instruction. However, more attention is necessary because of the 34.68% of the subjects who left the hospital without discharge instructions.

Conclusions:

Instructions given both verbally and in writing were observed to be more effective than verbal only or written only. The effectiveness of discharge instructions was highly influenced by the level of education of the caregivers. Improved caregiver friendly methods of communication from the pediatric emergency health-care team are necessary for the delivery of discharge instructions.

Delayed identification of pediatric abuse-related fractures

OBJECTIVES

Because physicians may have difficulty distinguishing accidental fractures from those that are caused by abuse, abusive fractures may be at risk for delayed recognition; therefore, the primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse.

METHODS

Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team were included in this retrospective review. The main outcome measures included the proportion of children who had abusive fractures and had at least 1 previous physician visit with diagnosis of abuse not identified and predictors that were independently associated with missed abuse.

RESULTS

Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. The median time to correct diagnosis from the first visit was 8 days (minimum: 1; maximum: 160). Independent predictors of missed abuse were male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department.

CONCLUSIONS

One fifth of children with abuse-related fractures are missed during the initial medical visit. In particular, boys who present to a primary care or a general emergency department setting with an extremity fracture are at a particularly high risk for delayed diagnosis.

The crying infant: diagnostic testing and frequency of serious underlying disease

OBJECTIVE

To determine the proportion of children evaluated in an emergency department because of crying who have a serious underlying etiology. Secondary outcomes included the individual contributions of history, physical examination, and laboratory investigations in determining a diagnosis.

PATIENTS AND METHODS

We performed a retrospective review of all afebrile patients <1 year of age who presented with a chief complaint of crying, irritability, screaming, colic, or fussiness. All children with a serious underlying illness were identified by using a priori defined criteria. Chart review was conducted to determine if history, physical examination, or investigation data contributed to establishing the child's diagnosis.

RESULTS

Enrollment criteria were met by 237 patients, representing 0.6% of all visits. A total of 12 (5.1%) children had serious underlying etiologies with urinary tract infections being most prevalent (n = 3). Two (16.7%) of the serious diagnoses were only made on revisit. Of the 574 tests performed, 81 (14.1%) were positive. However, only 8 (1.4%) diagnoses were assigned on the basis of a positive investigation. History and/or examination suggested an etiology in 66.3% of cases. Unwell appearance was associated with serious etiologies. In only 2 (0.8%) children did investigations in the absence of a suggestive clinical picture contribute to the diagnosis. Both of these children were <4 months of age and had urinary tract infections. Among children <1 month of age, the positive rate of urine cultures performed was 10%. Ocular fluorescein staining and rectal examination with occult blood testing were performed infrequently, and results were negative in all cases. Successful follow-up was completed with 60% of caregivers, and no missed diagnoses were found.

CONCLUSIONS

History and physical examination remains the cornerstone of the evaluation of the crying infant and should drive investigation selection. Afebrile infants in the first few months of life should undergo urine evaluation. Other investigations should be performed on the basis of clinical findings.