Analysis of emergency department prediction tools in evaluating febrile young infants at risk for serious infections

2019 ◽  
pp. emermed-2018-208210 ◽  
Author(s):  
Sarah Hui Wen Yao ◽  
Gene Yong-Kwang Ong ◽  
Ian K Maconochie ◽  
Khai Pin Lee ◽  
Shu-Ling Chong
Keyword(s):  
At Risk ◽  
Emergency Department ◽  
Clinical Assessment ◽  
Low Risk ◽  
Assessment Tools ◽  
Predictive Values ◽  
Nice Guideline ◽  
Risk Criteria ◽  
Young Infants ◽  
Serious Infections

ObjectiveFebrile infants≤3 months old constitute a vulnerable group at risk of serious infections (SI). We aimed to (1) study the test performance of two clinical assessment tools—the National Institute for Health and Care Excellence (NICE) Traffic Light System and Severity Index Score (SIS) in predicting SI among all febrile young infants and (2) evaluate the performance of three low-risk criteria—the Rochester Criteria (RC), Philadelphia Criteria (PC) and Boston Criteria (BC) among well-looking febrile infants.MethodsA retrospective validation study was conducted. Serious illness included both bacterial and serious viral illness such as meningitis and encephalitis. We included febrile infants≤3 months old presenting to a paediatric emergency department in Singapore between March 2015 and February 2016. Infants were assigned to high-risk and low-risk groups for SI according to each of the five tools. We compared the performance of the NICE guideline and SIS at initial clinical assessment for all infants and the low-risk criteria—RC, PC and BC—among well-looking infants. We presented their performance using sensitivity, specificity, positive, negative predictive values and likelihood ratios.ResultsOf 1057 infants analysed, 326 (30.8%) were diagnosed with SI. The NICE guideline had an overall sensitivity of 93.3% (95% CI 90.0 to 95.7), while the SIS had a sensitivity of 79.1% (95% CI 74.3 to 83.4). The incidence of SI was similar among infants who were well-looking and those who were not. Among the low-risk criteria, the RC performed with the highest sensitivity in infants aged 0–28 days (98.2%, 95% CI 90.3% to 100.0%) and 29–60 days (92.4%, 95% CI 86.0% to 96.5%), while the PC performed best in infants aged 61–90 days (100.0%, 95% CI 95.4% to 100.0%).ConclusionsThe NICE guideline achieved high sensitivity in our study population, and the RC had the highest sensitivity in predicting for SI among well-appearing febrile infants. Prospective validation is required.

Implementation of a Clinical Pathway to Avoid Lumbar Puncture in Febrile Young Infants Aged 29-56 Days Meeting a Set of Low Risk Criteria

PEDIATRICS ◽  
2016 ◽  
Vol 137 (Supplement 3) ◽  
pp. 282A-282A
Author(s):  
Payal K. Gala ◽  
Ashlee L Murray ◽  
Aileen P. Schast ◽  
Christian Minich ◽  
Ashley L. Woodford ◽  
...  
Keyword(s):  
Lumbar Puncture ◽  
Clinical Pathway ◽  
Low Risk ◽  
Risk Criteria ◽  
Young Infants

Febrile Infants at Low Risk for Serious Bacterial Infection—An Appraisal of the Rochester Criteria and Implications for Management

PEDIATRICS ◽  
1994 ◽  
Vol 94 (3) ◽  
pp. 390-396 ◽  
Author(s):  
Julie A. Jaskiewicz ◽  
Carol A. McCarthy ◽  
Amy C. Richardson ◽  
Kathleen C. White ◽  
Donna J. Fisher ◽  
...  
Keyword(s):  
Confidence Interval ◽  
High Power ◽  
Microscopic Examination ◽  
Bacterial Infections ◽  
Antimicrobial Agents ◽  
Low Risk ◽  
High Power Field ◽  
Urine Sediment ◽  
Predictive Values ◽  
Risk Criteria

Objective. Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria. Methods. Febrile infants (rectal T ≥ 38°C) ≤60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 109 cells/L (5000-15 000/mm3), band form count≤ 1.5 x 109 cells/L (≤1500/mm3), ≤10 WBC per high power field on microscopic examination of spun urine sediment, and ≤5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated. Results. Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia. Conclusions. These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.

Comparative Prospective Study of the Performance of Chest Pain Scores and Clinical Assessment in an Emergency Department Cohort in Singapore

2020 ◽  
Author(s):  
Ng Mingwei ◽  
Hong Jie Gabriel Tan ◽  
Fei Gao ◽  
Jack Wei Chieh Tan ◽  
Swee Han Lim ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Clinical Assessment ◽  
Clinical Judgment ◽  
Low Risk ◽  
Major Adverse Cardiovascular Events ◽  
Coronary Syndrome ◽  
Pain Scores ◽  
Pain Patients

Abstract Background Chest pain scores allow emergency physicians to identify low-risk patients for whom discharge can be safely expedited. While their utility have been extensively studied and validated in Western cohorts, data in patients of Asian heritage is lacking. This study aimed to determine the accuracy of HEART, EDACS and GRACE in risk-stratifying which emergency patients with chest pain or angina-equivalent symptoms are at risk of major adverse cardiovascular events (MACE) within 30 days (composite of all-cause mortality, acute myocardial infarction, and coronary revascularization). This single-centre prospective cohort-study enrolling 1200 patients was conducted by a large urban tertiary centre in Singapore. The chest pain scores were reported prior to disposition by research assistants blinded to the physician’s clinical assessment. Outcome adjudication was performed by an independent blinded cardiologist and emergency physician, while a second cardiologist adjudicated in the case of discrepancies. \Results Of 1200 patients enrolled, 5 withdrew consent and were excluded from analyses. 135 patients (11.3%) suffered MACE within 30 days. HEART, which ruled-out acute coronary syndrome in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled-out acute coronary syndrome in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment which ruled-out acute coronary syndrome in 73.0% of patients with 85.5% sensitivity. GRACE was weaker – ruling-out acute coronary syndrome in 79.2% of patients but with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was also superior to EDACS (69.9%) and GRACE (69.2%). Conclusions HEART more accurately identified low-risk chest pain patients in an Asian emergency department who were suitable for expedited discharge and demonstrated comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients in the emergency department.

Supporting decisions to increase the safe discharge of children with febrile illness from the emergency department: a systematic review and meta-analysis

2015 ◽  
Vol 101 (3) ◽  
pp. 259-266 ◽  
Author(s):  
A D Irwin ◽  
J Wickenden ◽  
K Le Doare ◽  
S Ladhani ◽  
M Sharland
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Prediction Models ◽  
Decision Rules ◽  
Febrile Illness ◽  
Low Risk ◽  
Prediction Rules ◽  
Serious Infections ◽  
Empirical Antibiotics ◽  
Rule Out

BackgroundDespite fewer serious infections presenting to the children's emergency department (ED), hospital admissions of children with febrile illness have increased. We review evidence for the use of decision rules to increase the safe discharge of these children from the ED.MethodsA systematic review of prospective studies of decision rules for the discharge of children with febrile illness, and prediction rules for the diagnosis of serious infections in children presenting to ED. We reviewed the MEDLINE database, Cochrane Library and hand searched the bibliographies of related studies. The search was limited to the English language.ResultsThirty-three studies were identified. Fourteen reported low-risk criteria to rule out serious bacterial infection (SBI) in infants less than 3 months of age. In this group, clinical tools such as the Rochester and Philadelphia criteria support the safe discharge of low-risk infants without empirical antibiotics. Seventeen studies reported prediction rules in older children, though only four included children over 3 years. Two impact studies based upon multivariable prediction models failed to demonstrate any impact on rates of discharge from ED.ConclusionsThe use of clinical prediction models can improve discrimination between serious and self-limiting infections in children. The application of low-risk thresholds may help to rule out serious infections and discharge children from the ED without empirical antibiotics. A growing evidence base for prediction rules has so far failed to translate into validated rules to aid decision-making. Future work should evaluate decision rules in well designed impact studies, focusing on the need for hospital admission and antibiotic therapy.

scholarly journals The Use of Different Muscle Assessment Techniques to Assess Validity of Global Leadership Initiative on Malnutrition (GLIM)

2021 ◽  
Vol 5 (Supplement_2) ◽  
pp. 1273-1273
Author(s):  
Dayana El Chaar ◽  
Cosette Fakih El Khoury ◽  
Krystel Ouaijan ◽  
Lama Mattar
Keyword(s):  
At Risk ◽  
Food Intake ◽  
Handgrip Strength ◽  
High Sensitivity ◽  
High Specificity ◽  
Global Leadership ◽  
Assessment Tools ◽  
Muscle Loss ◽  
Predictive Values ◽  
Assessment Techniques

Abstract Objectives To assess which combination of indicators in the Global Leadership Initiative on Malnutrition (GLIM) diagnostic tool better predicts malnutrition. Additionally, to compare the validity of GLIM upon the use of different muscle assessment techniques for the assessment of muscle loss. Methods Nutritional screening was performed through the Nutrition Risk Screening-2002 (NRS-2002) or the Mini-Nutrition Assessment-Full Form (MNA-FF). Nutritionally at-risk patients were assessed for malnutrition using the GLIM criterion. Fat free muscle index (FFMI), nutrition focused physical examination (NFPE) and handgrip strength (HG) were used to identify muscle loss. Sensitivity, specificity, positive and negative predictive values were calculated for GLIM with each of the three muscle assessment tools. Results 579 patients were screened for malnutrition and 121(20.90%) patients were considered nutritionally at risk. GLIM criterion showed close percentages of malnourished patients: 117(20.21%), 110(19.0%) and 110 (19.0%) when using NFPE, FFMI, and HG respectively. With three different muscle assessment techniques, 10 different combinations of indicators in GLIM were retrieved. The combination of muscle loss, assessed through NFPE, with either one of the two etiologic criteria yielded the highest numbers of malnourished patients among all three techniques [NFPE + reduced food intake/assimilation: 113(19.52%) and NFPE + Inflammation: 117(20.21%)], while the use of FFMI resulted in the lowest [FFMI + reduced food intake/assimilation: 37(6.39%) and FFMI + Inflammation: 40(6.91%)]. All three tools, GLIM + NFPE, GLIM + FFMI, and GLIM + HG reported high specificity [98.9% (97.45–99.64), 99.1% (97.76–99.76) and 99.1% (97.78–99.76) respectively]. However, results revealed moderate sensitivity for GLIM + FFMI [89.8% (82.91–94.63)]and GLIM + HG [89.1% (82.04–94.05)] yet a high sensitivity for GLIM + NFPE [93.3% (87.29–97.08)]. Conclusions The combination of NFPE with either of the etiologic criteria identified more malnourished patients than the combinations including FFMI or HG. A high degree of validity was reported for all three muscle assessment tools in GLIM criterion. Funding Sources None.

scholarly journals Anxiety Screening in the Emergency Department

2018 ◽  
Vol 1 (1) ◽  
Author(s):  
Michelle Pinto ◽  
Paul Musey, Jr., MD
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Depression Scale ◽  
Low Risk ◽  
Assessment Tools ◽  
Full Data ◽  
Convenience Sample ◽  
Chief Complaints ◽  
Anxiety Levels ◽  
Anxiety Screening

Background and Hypothesis:  Preliminary research completed in the Indiana University Health Methodist Emergency Department (ED) determined that the prevalence of undetected or unaddressed abnormal anxiety levels in patients with low-risk chest pain was greater than 45%. This subset was noted to have abnormal anxiety symptoms that persisted following visits and increased ED recidivism. We hypothesize that the prevalence of abnormal anxiety in the general ED population will be similar to the subset of patients with low-risk chest pain shown previously.   Methods:  We enrolled a convenience sample of adult patients with non-psychiatric chief complaints who presented to IUH Methodist and Eskenazi Emergency Departments. Participants were assessed for abnormal anxiety levels using the Generalized Anxiety Disorder 7-item Scale (GAD-7) and the Hospital Anxiety Depression Scale (HADS). Subjects will also complete these assessment tools at 30-days post-enrollment via phone or REDCap survey. Data regarding ED disposition, discharge diagnosis, and ED utilization over the previous 12 months and the 30 days post-enrollment will be collected from the electronic medical record (EMR).  Results:  Over four weeks, 108 patients were screened and 37 gave informed consent and were enrolled. Preliminary analysis shows that 21 subjects (56%) had a GAD-7 score ≥10, indicating abnormal anxiety levels. Full data analysis including comparison of HADS and GAD-7 scores will take place after 50 subjects have been enrolled, completed their 30-day follow-up surveys, and EMR review has taken place.   Conclusion:  Given data regarding ED visits in patients with low-risk chest pain, identification of anxiety and referral may reduce ED utilization.

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