Characteristics of revisits of children at risk for serious infections in pediatric emergency care.

In this study, we aimed to identify characteristics of (unscheduled) revisits and its optimal time frame after Emergency Department (ED) discharge. Children with fever, dyspnea, or vomiting/diarrhea (1 month-16 years) who attended the ED of Erasmus MC-Sophia, Rotterdam (2010-2013), the Netherlands, were prospectively included. Three days after ED discharge, we applied standardized telephonic questionnaires on disease course and revisits. Multivariable logistic regression analysis was used to identify independent characteristics of revisits. Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with revisits (n = 527) in children at risk for serious infections discharged from the ED (n = 1765). Children revisited the ED within a median of 2 days (IQR 1.0-3.0), but this was proven to be shorter in children with vomiting/diarrhea (1.0 day (IQR 1.0-2.0)) compared to children with fever or dyspnea (2.0 (IQR 1.0-3.0)). CONCLUSION: Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with emergency health care revisits in children with fever, dyspnea, and vomiting/diarrhea. These characteristics could help to define targeted review of children during post-discharge period. We observed a disease specific and differential timing of control revisits after ED discharge. What is Known • Fever, dyspnea, and vomiting/diarrhea are major causes of emergency care attendance in children. • As uncertainty remains on uneventful recovery, patients at risk need to be identified on order to improve safety netting after discharge from the ED. What is New • In children with fever, dyspnea, and vomiting/diarrhea, young age, parental concern and chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea help to define targeted review of children during the post-discharge period. • A revisit after ED discharge is disease-specific and seems to be shorter for children with vomiting/diarrhea than others.

How to Predict Oral Rehydration Failure in Children With Gastroenteritis.

OBJECTIVES: Oral rehydration is the standard in most current guidelines for young children with acute gastroenteritis (AGE). Failure of oral rehydration can complicate the disease course, leading to morbidity due to severe dehydration. We aimed to identify prognostic factors of oral rehydration failure in children with AGE. METHODS: A prospective, observational study was performed at the Emergency department, Erasmus Medical Centre, Rotterdam, The Netherlands, 2010-2012, including 802 previously healthy children, ages 1 month to 5 years with AGE. Failure of oral rehydration was defined by secondary rehydration by a nasogastric tube, or hospitalization or revisit for dehydration within 72 hours after initial emergency department visit. RESULTS: We observed 167 (21%) failures of oral rehydration in a population of 802 children with AGE (median 1.03 years old, interquartile range 0.4-2.1; 60% boys). In multivariate logistic regression analysis, independent predictors for failure of oral rehydration were a higher Manchester Triage System urgency level, abnormal capillary refill time, and a higher clinical dehydration scale score. CONCLUSIONS: Early recognition of young children with AGE at risk of failure of oral rehydration therapy is important, as emphasized by the 21% therapy failure in our population. Associated with oral rehydration failure are higher Manchester Triage System urgency level, abnormal capillary refill time, and a higher clinical dehydration scale score.

Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department.

Acute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children's hospital in The Netherlands ( 2010-2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09-4.31 p < 0.05). We observed no differences in other outcome measures. CONCLUSION: Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures. What is Known: • Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments. • Guidelines advocate standardized oral treatment in children with mild to moderate dehydration, but appear to be applied infrequently in clinical practice. What is New: • Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility, resulting in a more standardized ORS use in children with mild to moderate dehydration, compared to usual care. • Given the challenges to perform research in emergency care setting, the ED should be experienced and adequately equipped, especially during peak times.

Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care.

CONTEXT: Follow-up strategies after emergency department (ED) discharge, alias safety netting, is often based on the gut feeling of the attending physician. OBJECTIVE: To systematically identify evaluated safety-netting strategies after ED discharge and to describe determinants of paediatric ED revisits. DATA SOURCES: MEDLINE, Embase, CINAHL, Cochrane central, OvidSP, Web of Science, Google Scholar, PubMed. STUDY SELECTION: Studies of any design reporting on safety netting/follow-up after ED discharge and/or determinants of ED revisits for the total paediatric population or specifically for children with fever, dyspnoea and/or gastroenteritis. Outcomes included complicated course of disease after initial ED visit (eg, revisits, hospitalisation). DATA EXTRACTION: Two reviewers independently assessed studies for eligibility and study quality. As meta-analysis was not possible due to heterogeneity of studies, we performed a narrative synthesis of study results. A best-evidence synthesis was used to identify the level of evidence. RESULTS: We summarised 58 studies, 36% (21/58) were assessed as having low risk of bias. Limited evidence was observed for different strategies of safety netting, with educational interventions being mostly studied. Young children, a relevant medical history, infectious/respiratory symptoms or seizures and progression/persistence of symptoms were strongly associated with ED revisits. Gender, emergency crowding, physicians' characteristics and diagnostic tests and/or therapeutic interventions at the index visit were not associated with revisits. CONCLUSIONS: Within the heterogeneous available evidence, we identified a set of strong determinants of revisits that identify high-risk groups in need for safety netting in paediatric emergency care being related to age and clinical symptoms. Gaps remain on intervention studies concerning specific application of a uniform safety-netting strategy and its included time frame.

Impact analysis of an evidence-based guideline on diagnosis of urinary tract infection in infants and young children with unexplained fever.

UNLABELLED: Several guidelines exist on urinary tract infection (UTI) in children. The objectives of this study were to (1) implement an evidence-based diagnostic guideline on UTI and evaluate determinants of successful implementation, and (2) determine compliance to and impact of the guideline in febrile, non-toilet trained children at the emergency department (ED). We performed a prospective cross-sectional observational study, with observations before and after implementation. Children aged 1 month to 2 years, presenting at the ED with unexplained fever (temperature above 38.5 °C), were included. We excluded children with a chronic underlying disease. Primary outcome measure was compliance to the standardized diagnostic strategy and determinants influencing compliance. Secondary outcome parameters included the following: number of used dipsticks, contaminated cultures, number of genuine UTI, frequency of prescribed antibiotic treatment, and hospitalization. The pre-intervention group {169 children (male 60.4 %, median age 1.0 [range 0.1-2.0])} was compared with the post-intervention group {150 children (male 54.7 %, median age 1.0 [range 0.1-1.9])}. In 42 patients (24.9 %), there was compliance to local guidelines before implementation, compared with 70 (46.7 %) after implementation (p-value < 0.001). Improvement in compliance after implementation was higher in patients 3-24 months and outside the office hours (p < 0.001). CONCLUSION: Implementation of a guideline for diagnosing UTI in febrile children at the ED has led to a significantly better compliance, especially in children aged 3-24 months. However, this study also underlines the need for a well-defined implementation strategy after launching an (inter)national guideline, taking determinants influencing implementation into account.

[Alarm symptoms of meningitis in children with fever]. / Alarmsymptomen van meningitis bij kinderen met koorts.

A 15-year-old girl presented with fever and pain in her legs. A viral infection was suspected, but within 24 hours she became confused and developed meningeal signs, based on which she was diagnosed as having meningitis. Within a few hours a 6-month-old boy developed fever, a grey colour, bulging fontanel, cold hands and feet, and was groaning. He too appeared to have meningitis. It is important to recognize this serious infection in children with fever, since delay of diagnosis and treatment may result in serious complications. Recognition is difficult because of non-specific symptoms on presentation and a lack of alarm symptoms early in the course of the disease. Alarm symptoms of serious infection in children are cyanosis, rapid breathing, decreased capillary refill, petechial rash, meningeal signs, leg pain and decreased consciousness. If serious infection is uncertain in a child with fever, parents should be advised on the potential course of the disease, the alarm symptoms and the need to seek medical help in time.