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Interobserver variability of croup scoring in clinical practice
1Departments of Pediatrics and Community Health and Epidemiology, Dalhousie University and the Clinical TrialsResearch Centre - Infectious Diseases, IWK Health Centre, Halifax, Nova Scotia.
Insights
Clinical assessment of croup in children using scores shows fair to moderate agreement among healthcare providers. Stridor and retractions were found to be the most reliable indicators for croup in pediatric emergency departments.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Medicine
- Clinical Assessment and Diagnostics
Background:
- Viral laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in young children.
- Current clinical assessment often relies on croup scores, but these lack validation in real-world clinical settings.
Purpose of the Study:
- To evaluate the reliability of clinical observation items used in croup scoring systems within a pediatric emergency department (ED).
Main Methods:
- A literature review identified 10 key observation variables for croup assessment.
- A prospective cohort study involving 158 children (3 months to 5 years) with croup was conducted over 13 months.
- Interobserver agreement among triage nurses and ED physicians was analyzed using Cohen's quadratic weighted kappa.
Main Results:
- Interobserver agreement for all clinical observation items was statistically significant but ranged from fair to moderate (kappa values 0.2–0.6).
- The study assessed 158 children with croup, with observations made by three independent healthcare providers before treatment.
Conclusions:
- Significant interobserver variability exists in assessing respiratory signs of croup among healthcare providers in busy pediatric EDs.
- Stridor and retractions emerged as the most reliable clinical indicators for croup assessment based on this study and prior research.
Background:
Viral laryngotracheobronchitis croup is the most common cause of acute upper airway obstruction in young children. Clinical assessment of children with croup is often performed using 'croup scores'; however, these scores have not been validated outside of the research setting.
Objective:
To determine the reliability of clinical observation items in croup scores in a paediatric emergency department (ED) setting.
Design:
Literature review identified 12 observation items (level of consciousness or mental status, inspiratory breath sounds, air entry, stridor, cough, cyanosis or colour, anxiety or air hunger, retractions and/or flaring, respiratory rate and heart rate, oxygen saturation and respiratory distress); overlapping items were combined, yielding 10 variables. In a prospective cohort study over 13 months, patients presenting with croup were observed independently, and croup scores were assigned by the triage nurse, ED nurse and the ED physician before treatment. Agreement among observers for clinical observations was analysed using Cohen's quadratic weighted kappa.
Setting:
University-affiliated, paediatric hospital ED providing primary care to an urban area (population 330,000).
Patients:
Children aged three months to five years presenting with viral croup (preceding history of at least one day of upper respiratory tract symptoms associated with barking cough and/or hoarseness and/or stridor).
Results:
One hundred fifty-eight children meeting inclusion criteria for croup were assessed by three observers within 1 h of each other's assesments and before treatment. Interobserver agreement among the three observers using weighted kappa was greater than chance for all clinical observation items and ranged from fair to moderate (0.2 to 0.4 and 0.4 to 0.6, respectively).
Conclusions:
In the busy practice setting of a paediatric ED, substantial interobserver variability exists among health care providers in the measurement of respiratory signs associated with croup in young children. Based on the present study in a practice setting and two research studies, the most reliable items of all of the published items included in croup scoring systems were stridor and retractions.
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