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Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs
Josephine Winter1, Michael J Waxman1, George Waterman1
1Albany Medical College, Department of Emergency Medicine, Albany, New York.
Insights
Many children leave the emergency department (ED) with abnormal vital signs, but adverse events are rare. This study found that 17% of pediatric patients discharged from the ED had abnormal vital signs, with a low rate of associated adverse events.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Quality Improvement
Background:
- Children frequently present to the emergency department (ED) with minor illnesses and may have abnormal vital signs upon discharge.
- Concerns exist regarding the safety of discharging pediatric patients with abnormal vital signs.
Purpose of the Study:
- To determine the proportion of children discharged from the ED with abnormal vital signs.
- To assess the frequency and nature of adverse events in this patient population.
- To compare adverse event rates between children discharged with normal versus abnormal vital signs.
Main Methods:
- Retrospective chart review of pediatric patients (2 months to 17 years) discharged from the ED over 44 months.
- Identification of patients with abnormal pulse rate, respiratory rate, temperature, or oxygen saturation.
- Utilized a quality assurance database to track post-discharge adverse events.
Main Results:
- 17% (5,540/33,185) of discharged children had at least one abnormal vital sign.
- Adverse events occurred in 0.43% of children with abnormal vital signs versus 0.17% with normal vital signs.
- Only one severe adverse event was potentially preventable by observation and related to the index visit.
Conclusions:
- Discharging pediatric patients with abnormal vital signs from the ED is common (17%) but associated with a low rate of adverse events (0.43%).
- Abnormal heart rate was the most frequent vital sign linked to adverse events.
- Severe adverse events potentially related to abnormal vital signs are exceedingly rare, warranting further research in diverse populations.
Introduction:
Children 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.
Methods:
We 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.
Results:
Of 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.
Conclusion:
In 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.
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