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A retrospective review of vital signs and clinical outcomes of febrile infants younger than 3 months old presenting to the emergency department.

ABSTRACT: Febrile infants younger than 3 months old present a diagnostic dilemma to the emergency physician. We aim to describe a large population of febrile infants less than 3 months old presenting to a pediatric emergency department (ED) and to assess the performance of current heart rate guidelines in the prediction of serious infections (SI).We performed a retrospective review of febrile infants younger than 3 months old, between March 2015 and Feb 2016, in a large tertiary pediatric ED. We documented the primary outcome of SI for each infant, as well as the clinical findings, vital signs, and Severity Index Score (SIS). We assessed the performance of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS), Advanced Pediatric Life Support (APLS) guidelines and Fleming normal reference values, using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under receiver operating characteristics curve (AUC).1057 infants were analyzed, with 326 (30.6%) infants diagnosed with SI. High temperature, tachycardia, and low SIS score were significantly associated with SI. Item analysis showed that the SIS performance was driven by the presence of mottling (p = 0.003) and high temperature (p<0.001). The APLS guideline had the highest sensitivity (66.0%, 95% CI 60.5-71.1%), NPV (73.3%, 95% CI 69.7-76.5%) and AUC (0.538), while the PaedCTAS (2 standard deviation from normal) had the highest specificity (98.5%, 95% CI 97.3-99.3%) and PPV (55.2%, 95% CI 32.7-71.0%).Current guidelines on infantile heart rates have a variable performance. In our study, the APLS heart rate guidelines performed with the highest sensitivity, but no individual guideline predicted for SIs satisfactorily.

SUBMITTER: Chong SL

PROVIDER: S-EPMC5755800 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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A retrospective review of vital signs and clinical outcomes of febrile infants younger than 3 months old presenting to the emergency department.

Chong Shu-Ling SL Ong Gene Yong-Kwang GY Chin Wendy Yi Wen WYW Chua John Mingzhou JM Nair Praseetha P Ong Alicia Shu Zhen ASZ Ng Kee Chong KC Maconochie Ian I

PloS one 20180105 1

<h4>Objectives</h4>Febrile infants younger than 3 months old present a diagnostic dilemma to the emergency physician. We aim to describe a large population of febrile infants less than 3 months old presenting to a pediatric emergency department (ED) and to assess the performance of current heart rate guidelines in the prediction of serious infections (SI).<h4>Materials and methods</h4>We performed a retrospective review of febrile infants younger than 3 months old, between March 2015 and Feb 201 ...[more]

PMID: 29304160

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Project description:IntroductionChildren often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events.MethodsWe performed a retrospective chart review encompassing a 44-month period of all pediatric patients (aged two months to 17 years) who were discharged from the ED with an abnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local quality assurance database to identify pre-defined adverse events after discharge in this population. Our primary aim was to determine the proportion of children discharged with abnormal vital signs and the frequency and nature of adverse events. Additionally, we performed a sub-analysis comparing the rate of adverse events in children discharged with normal vs. abnormal vital signs, as well as a standardized review of the nature of each adverse event.ResultsOf 33,185 children discharged during the study period, 5,540 (17%) of these patients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse events in the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events in the children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related to the index visit, was potentially preventable by a 23-hour hospital observation, and caused permanent disability.ConclusionIn our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice. Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverse events that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additional research is needed in broader populations to better determine the rate of adverse events and possible methods of avoiding them.

Project description:IntroductionRapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients' vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.MethodsWe conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.ResultsA total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25-3.27]), tachypneic (OR 2.92, 95% CI [1.73-4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42-3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65-4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08-2.72] for low BP and OR 1.82, 95% CI [1.19-2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44-7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43-3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03-77.87]), invasive interventions (OR 5.49, 95%CI [3.82-7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60-11.24]), and mortality at one month (OR 4.02, 95%CI [2.44-6.62]).ConclusionAfter matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

Project description:ObjectiveDevelopment and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance.Materials and methodsFebrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019.ResultsThe derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI.ConclusionBoth CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.

Dataset Information

A retrospective review of vital signs and clinical outcomes of febrile infants younger than 3 months old presenting to the emergency department.

Publications

A retrospective review of vital signs and clinical outcomes of febrile infants younger than 3 months old presenting to the emergency department.

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