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Published on: February 2, 2017
Clinicians' overestimation of febrile child risk assessment
Evelien deVos-Kerkhof1, Damian Roland2, Esther de Bekker-Grob3
1Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80 room Sp-1541, 3015 CN, Rotterdam, The Netherlands.
Insights
Clinicians
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Clinical Decision Making
Background:
- Serious bacterial infections (SBI) are rare in febrile children presenting to emergency departments.
- Clinicians often rely on clinical cues due to low prevalence of SBI.
- Established risk thresholds for SBI management are lacking.
Purpose of the Study:
- To estimate clinicians' risk thresholds for managing febrile children with suspected SBI.
- To identify factors influencing these management decisions.
- To compare clinician thresholds with the Feverkidstool prediction model.
Main Methods:
- 42 international pediatricians/emergency clinicians assessed 21 video vignettes of febrile children.
- Participants provided risk scores for SBI and management decisions using visual analogue scales.
- Feverkidstool risk scores were calculated based on clinical data and C-reactive protein.
Main Results:
- Clinicians managed vignettes as SBI with a median risk of 60%, versus 16% when not managed as SBI.
- Ill appearance and aberrant circulatory signs most influenced management decisions.
- Clinician risk thresholds for withholding SBI management were more consistent than for initiating it.
Conclusions:
- Clinicians' SBI management decisions are primarily driven by 'ill appearance' and 'aberrant circulation'.
- Clinicians appear to use a stepwise approach to risk assessment, differing from the Feverkidstool.
- Clear uniform risk thresholds for initiating SBI management in febrile children remain undefined.
Unlabelled:
We aimed to estimate clinicians' based risk thresholds at which febrile children would be managed as serious bacterial infections (SBI) to determine influencing characteristics and to compare thresholds with prediction model (Feverkidstool) risk estimates. Twenty-one video vignettes of febrile children visiting the emergency department (ED) were assessed by 42 (40.4 %) international paediatricians/paediatric emergency clinicians. Questions were related to clinical risk scores of the child having SBI and SBI management decisions on visual analogue scales. Feverkidstool risk scores were based on clinical signs/symptoms and C-reactive protein. Amongst vignettes assigned to SBI management, the median risk was 60 % (interquartile range (IQR) 30.0-80.5) and 16.0 % (IQR 5.0-32.0) when vignettes were not managed as SBI. Ill appearance and aberrant circulatory signs were the most influencing factors, as age and duration of fever were the least influencing factors on SBI management decisions. Feverkidstool risk scores varied from 13 % (IQR 7.7-28.1) for SBI management to 7.3 % (IQR 5.7-16.3) for no SBI management.
Conclusion:
Clinicians assigned high risk scores to children who they would have managed as SBI, mostly influenced by ill appearance and aberrant circulation. In contrast to SBI risk assessment of the Feverkidstool, clinicians' appeared to apply a more stepwise assessment of the risk of presence/absence of SBI at different steps in the diagnostic and therapeutic process. Uniform risk thresholds at which one should start SBI management in febrile children remains unclear; risk thresholds at which we refrained from SBI management were more consistent.
What Is Known:
•Only a small proportion of febrile children presenting to the emergency department will have serious bacterial infections (SBI) and uniform risk thresholds to start or withhold SBI treatment are not known. •The low prevalence of SBI and consequently the low exposure of clinicians to these infections make them rely more on alarming signs or clinical decision rules. What is New: •Previously identified model predictors for SBI appeared to be significantly influencing factors in clinicians' febrile child management in emergency care. •Clinicians' wielded higher risk thresholds regarding SBI febrile child management than reflected by the clinical prediction model while smaller differences in risk thresholds between clinical and model prediction were observed when clinicians refrained from SBI management.
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