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Can we trust naked eye assessments of the capillary refill test in children? An experimental study
Frida Meyer1, Jonatan Stahre2, Joakim Henricson3
1Department of Emergency Medicine in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 85, Sweden. frida.meyer@liu.se.
Insights
Naked eye assessment of capillary refill time (CR time) in children is subjective and unreliable. This study found poor agreement among healthcare professionals and weak correlation with objective measurements, questioning its routine use in pediatric emergencies.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Assessment Tools
- Medical Diagnostics
Background:
- The capillary refill test (CR time) is a common but debated assessment in pediatric emergency medicine.
- Current practice relies on naked eye estimation, lacking standardized validation.
- Objective quantification methods are needed to assess CR time accuracy.
Purpose of the Study:
- To compare naked eye CR time estimations with objective quantified CR time (qCR time) in pediatric patients.
- To evaluate the interobserver and intra-observer consistency of naked eye CR time assessments.
- To determine the reliability of CR time as a clinical indicator in pediatric emergencies.
Main Methods:
- Sixty-two healthcare professionals viewed videos of CR tests from 15 pediatric patients.
- Observers estimated CR time in seconds and categories, compared to objective qCR time via polarized reflectance imaging.
- Interobserver and intra-observer agreement were analyzed, with tests repeated for consistency checks.
Main Results:
- Poor interobserver agreement was observed across all professional groups (nurses, pediatricians, etc.).
- Intra-observer agreement for both time and descriptive CR time assessments was limited.
- A weak correlation was found between naked eye assessments and the objective qCR time.
Conclusions:
- Naked eye CR time assessment in children is highly subjective and lacks reproducibility among pediatricians and nurses.
- The findings indicate significant variability and poor consistency in visual CR time evaluations.
- Routine use of naked eye CR time assessment in pediatric emergencies should be reconsidered due to its unreliability.
Background:
The capillary refill test is widely used in pediatric emergency medicine and critical care although its validity and reliability are debated. Naked eye estimation is the recommended method for capillary refill time (CR time) assessment. The goal of this study was to compare naked eye estimations of the CR time in pediatric patients to quantified capillary refill time (qCR time) using polarized reflectance imaging as an objective reference, and to investigate interobserver and intra-observer consistency of naked eye assessments of CR time.
Method:
A film sequence comprising videos of capillary refill tests from 15 emergency pediatric patients was shown under standardized conditions to 62 observers (pediatricians, nurses, assistant nurses, and medical secretaries). The observers' estimations of CR time in seconds and in descriptive categorizations were compared to objectively derived qCR time. Three tests were shown twice without the observers' knowledge.
Results:
There was poor interobserver agreement in all professions, with limits of agreement ranging from 1.17 s (assistant nurses) to 2.00 s (secretaries). Intra-observer agreement for estimations of both time and descriptive categorizations was limited. The correlation between naked eye assessments and qCR time was weak.
Conclusion:
This study shows that naked eye assessment of CR time in children is highly subjective with poor reproducibility in pediatric nurses and pediatricians, as well as in comparison to a quantitative method. Based on the lack of both inter- and intra-observer consistency in the assessments, these findings suggest that CR time assessed by naked eye should be questioned as a routine test in pediatric emergencies.
