Original Contribution

Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome

Vei-Ken Seow MD^a, Aming Chor-Ming Lin MD^a, I-Yin Lin MD^a, Cien-Chih Chen MD^a, Kuo-Chih Chen MD^a,b, Tzong-Luen Wang MD, PhD^a,b, Chee-Fah Chong MS, MD^a,b,*

^aEmergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan

^bSchool of Medicine, Fu Jen Catholic University, Taipei 242, Taiwan

Received 13 February 2007; accepted 1 March 2007

Abstract

Objective: The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed.

Methods: Medical records of patients 3 to 36 months of age who presented to the ED with fever of indefinite source from June 1 to December 31, 2006, were retrospectively reviewed on day 5 after the patient’s First visit. At the same time, telephone follow-up was carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Variation in practice patterns were compared for the number of laboratory tests, ED length of stay , and the rate of immediate admission. Patient outcomes were measured as the rate of unschedulED revisit within 72 hours and the rate of subsequent admission. Compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) R398C (group B), and (3) nontoxic patients with BT below 398C (group C).

Results: A total of 345 patients who met the inclusion and exclusion criteria were enrolled into this study. Pediatric physicians and EPs treated 163 and 182 febrile children, respectively. In group A, PPs admitted more patients than EPs (41% vs 12 %), whereas more unschedulED revisits were seen in EP-treated patients (44% vs 10%). In group B, PPs ordered more laboratory tests than EPs (2.3 vs 0.7 tests per patient), and their patients also had a longer ED LOS (3.4 F 3.2 vs 1.5 F 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit. In group C, PPs admitted more patients (15% vs 0%) and ordered more laboratory tests (2.0 vs

* Corresponding author. Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan, ROC. Tel.: +886 2 28332211; fax: +886 2 28353547.

E-mail address: [email protected] (C.-F. Chong).

0735-6757/$ - see front matter D 2007 doi:10.1016/j.ajem.2007.03.001

0.5 tests/patient) than EPs. Longer ED LOS (3.3 F 3.9 vs 1.0 F 1.4 hours) was also noted among PP-treated patients. However, no difference was noted in their rates of unscheduled revisit. In all groups, the rates of subsequent admission were similar.

Conclusion: Compliance with existing practice guidelines (admit the toxic cases and work up those with BT R398C) was higher among PPs, which resulted in a lower rate of unscheduled revisit, but no significant difference was found in the rate of subsequent admission.

D 2007

Introduction

Fever, usually defined as temperature of 388C or greater, is one of the most common chief complaints of children visiting the emergency department (ED) [1,2]. Although practice guidelines were introduced for managing fever without source in children [3,4], considerable variation in management remains obvious among physicians, as found in several previous studies [5-9].

Our primary objective was to compare different practice patterns for managing febrile children between pediatric physicians (PPs) and emergency physicians (EPs). Their adherence to existing practice guidelines was also com- pared. Our secondary objective was to determine whether the differences in fever management have an impact on patient outcomes. To our knowledge, this is the first full article in the English literature that aims to evaluate patient outcomes stem from different patterns for managing febrile children in the ED between PPs and EPs.

Methods

This is a retrospective study conducted in the ED of a teaching hospital, which provides urban tertiary care in Taipei city, Taiwan. This ED has an annual census of 75000 visits, 20% of which are children. Up to 99% of the population carried the National Health Insurance. Children presented to the ED were managed on by PPs and EPs on an alternating monthly basis.

From June 1 to December 31, 2006, all children 3 to

36 months of age presenting to the ED with fever of indefinite source were enrolled into this study. Fever was defined as a triage tympanic temperature of 38.08C (100.48F) or greater. All medical records of the enrolled patients were retrospectively reviewed on day 5 after the patient’s first visit. At the same time, telephone follow-up was also carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Patients were excluded if they had a definite focal bacterial infection on presentation, history of immu- nodeficiency, or chronic diseases. Those who visited another clinic or hospital within 3 days and those who received antibiotics in the past 72 hours were also left out (Table 1).

Variation in practice patterns were compared for the number of laboratory tests, ED length of stay , and the

rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours and the rate of subsequent admission. Finally, compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) R398C (group B), and (3) nontoxic patients with BT below 398C (group C).

Comparisons between the study groups were done using t tests for continuous data and v² or Fisher exact tests for categorical data. All analyses were carried out with SPSS for Windows (version 12.0, SPSS, Chicago, Ill). Statistical significance was set at P b .05 (2-tailed).

Results

During the study period, 1391 children presented to the ED with fever; 818 patients were excluded because they were less than 3 months or more than 3 years of age;

Table 1 Exclusion criteria Exclusion criteria

Age b3 months or N3 years

With definite focal bacterial infection on presentation Pneumonia

Acute bronchitis or bronchiolitis Urinary tract infection

acute otitis media acute gastroenteritis

Acute tonsillitis or pharyngitis Meningitis

Cellulitis

Bone or joint infections Others

History of immunodeficiency HIV infection

Diabetes mellitus Under chemotherapy Chronic disease

Cancer such as anemia Steroid-dependent asthma Others

Visited another clinic or hospital in the past 72 hours Antibiotic use in the past 72 hours

Fig. 1 Flow diagram depicting the process of inclusion and exclusion.

228 patients were subsequently excluded based on the exclusion criteria listed in Table 1. Finally, 345 patients who met the inclusion and exclusion criteria were enrolled into this study, in which PPs and EPs treated 163 and 182 febrile children, respectively. All eligible patients were carrying the National Health Insurance of Taiwan. Fig. 1 represents a flow diagram that illustrates the process of patient inclusion and exclusion in this study. No differences in sex, age, body weight, presenting temperature, and toxic appearance were noted between the 2 groups (Table 2). All children would be admitted if parenteral antibiotic treatment was considered necessary. Practice patterns, adherence to existing guide- lines, and patient outcomes between PP- and EP-treated patients were compared (Tables 3 and 4), in reference to the following subgroups of patients:

Group A (fever with toxic appearance)

According to existing guidelines, all patients in this group should be admitted for septic workup or treatment. However, adherence to this recommendation was poor in our study, with only 41% admission rate among PPs and 12% among EPs. Although there was no significant difference in the number of laboratory tests ordered by PPs and EPs, patients treated by EPs had a significant longer period of stay in the ED. In terms of outcome, although unscheduled revisits (within 72 hours) were more common in patients treated by EPs (44% vs 10%), the rates of subsequent admission were similar between PPs and EPs.

Group B (fever >=398C and nontoxic)

In this group, the guidelines suggest septic workup such as complete blood count , urinalysis, chest radio- graphs, and others. Pediatric physicians ordered more CBCs, biochemistries, blood cultures, and urinalysis than EPs (2.3 vs 0.7 tests per patient). Patients treated by PP also had a longer ED LOS (3.4 F 3.2 vs 1.5 F 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit.

Group C (fever b398C and nontoxic)

No solid guidelines exist for the management of children in this group. Physicians may only give antipyretics and follow up these patients in the next 24 hours. However, PPs

Significance defined as P b .05.

Table 2 Demographics
Characteristic	PP (n = 163)	EP (n = 182)	P
Male (%)	45	49	.39
Age (y)	1.64 F 0.79	1.71 F 0.80	.40
Body Weight (kg)	12.9 F 4.7	13.2 F 4.3	.52
Temperature (8C)	37.9 F 1.2	38.1 F 1.1	.11
Patients with temperature	21	23	.71

R39.08C (%)
Patients with toxic appearance (%)	18	19	.83

	Toxic patients				Nontoxic patients (n = 282)
	Group A (n = 63) BT R388C				Group B (n = 38) BT R398C			Group C (n = 244) BT b398C
	PP (29)	EP (34)	P	PP (18)		EP (20)	P	PP (116)	EP (128)	P
Laboratory tests
Urinalysis	17	22	NS	9		2	.01*	28	12	b.01*
Urine culture	2	3	NS	1		0	NS	3	1	NS
CBC	15	18	NS	7		1	.02*	50	6	b.01*
Blood culture	15	17	NS	7		1	.02*	45	6	b.01*
Biochemistry	13	16	NS	7		1	.02*	50	6	b.01*
Chest radiograph	24	24	NS	5		6	NS	30	21	NS
KUB film	1	2	NS	2		1	NS	11	13	NS
Throat culture	1	2	NS	2		1	NS	2	0	NS
ABGs	14	15	NS	1		0	NS	13	1	b.01*
No. of test per patient	3.0	3.5		2.3		0.7		2.0	0.5
ED Length of stay (hr)	3.9 F 3.1	7.4 F 4.3	b.01*	3.4 F 3.2		1.5 F 1.1	.02*	3.3 F 3.9	1.0 F 1.4	b.01*
Immediate admission	12	4	b.01*	2		0	NS	17	0	b.01*

still admitted more patients (15% vs 0%) and ordered more CBCs, biochemistries, arterial blood gasses, blood cultures, and urinalysis than EPs (2.0 vs 0.5 tests per patient). Longer ED LOS (3.3 F 3.9 vs 1.0 F 1.4 hours) was also noted among PP-treated patients. Yet, no difference was noted in the rates of unscheduled revisit and the rates of subsequent admission.

Table 3 Table comparing practice patterns between pediatric physicians (PP) and emergency physicians (EP)

ABG, arterial blood gas; NS, not significant.

* Significant at P b .05.

Discussion

Pediatric patients in Taiwan are seen by PPs in one ED and by EPs in another ED. Alternating PP and EP visiting schedules in the ED also exist, as presented in this study. bFever phobiaQ commonly exists among parents who lack knowledge in managing febrile children [10-13]. Under the system of Taiwan’s National Health Insurance, parents are free to bring their febrile children to the ED if a high temperature was noted. Unscheduled revisits for children within 48 to 72 hours of an initial ED visit were around 3% in published literature [14,15]. Remarkably higher rates of unscheduled revisit were found in our study, 40% (72/182) for EPs and 28% (45/163) for PPs. The increased unscheduled pediatric revisits and overcrowding of adult patients in the ED might have worsened EPs’ performance in the management of pediatric patients.

Our results showed that PPs had a higher compliance with the existing practice guidelines than EPs for managing children with fever of indefinite focus. Pediatric physicians tended to admit more patients and ordered more laboratory tests than EPs regardless of their triage temperature or toxicity. These differences in practice patterns may be the reason of a lower rate of unscheduled revisit among patients treated by PPs. However, no significant difference was found on the rates of subsequent admission.

Isaacman et al showed that PPs more frequently ordered CBCs, blood culture, and urine cultures than did EPs and were less likely to order chest radiographs and perform Lumbar punctures than EPs [5]. In our study, EPs did less blood tests and urinalysis, as compared with PPs. There may be several reasons for this occurrence. First, most Tertiary EDs in Taiwan are overcrowded. Emergency physicians are required to treat both adult and pediatric patients. On the other hand, PPs treat infants or children only. Complete evaluation of fever can be time-consuming. Emergency physicians confront with the pressure of overwhelming patient load and may inadvertently discharge seemingly well patients without time-consuming fever workup. Second, comprehensive assessment of fever in children tends to be invasive. Procedures such as Blood draws, urinary catheter- izations, and lumbar taps need experienced skill for success. Emergency physicians may be less skillful and lack

Table 4 Table comparing outcomes between patients treated by PPs and EPs Group A (n = 63) Group B (n = 38) Group C (n = 244)
	PP (29)	EP (34)	P		PP (18)	EP (20)	P value		PP (116)	EP (128)	P
Unscheduled Revisit (%)	3 (10)	15 (44)	b.05*		3 (17)	8 (40)	NS		39 (34)	47 (37)	NS
Subsequent Admission (%)	1 (4)	2 (6)	NS		1 (6)	1 (5)	NS		5 (4)	4 (3)	NS
* Significant at P b .05.

confidence for such procedures. This may be one of the reasons why EPs ordered less laboratory tests than PPs.

Another difference in practice between PPs and EPs is the length of stay (LOS) of their patients in the ED. Patients who appeared toxic had a shorter ED LOS when they were treated by PPs but longer if they were treated by EPs. This may be due to a lower threshold for admitting toxic patients by PPs as reflected by their higher admission rate. Patients seen by EPs, on the other hand, would stay longer in the ED before they were admitted because some laboratory studies and formal consultations with attending pediatricians were necessary before admission.

Conversely, nontoxic patients treated by PPs had a longer ED LOS, which may be due to more laboratory tests being ordered. Although, the shorter LOS of EP-treated children may be due to a faster discharge of patients by EPs because of heavy patient load. This would help to explain the higher rate of unscheduled revisits among patients treated by EPs.

Currently, no consensus has been reached for evaluation and management of fever without focus of infection in children, although practice guidelines had been introduced by Baraff [3,4]. Compliance with the practice guidelines seems to be unsatisfied [16-18]. No single laboratory test has been shown to reliably identify children at high risk for having serious bacterial infection [19]. Thus, more pro- spective studies should be carried out in the future, assessing whether more laboratory tests and increased adherence with practice guidelines would be helpful in improving patient outcome. Unnecessary laboratory tests may bring unreliable confidence to both clinicians and parents but suffering to children.

This study has some limitations. First, the quality of data obtained in a retrospective study is only as accurate as that which was recorded and stored. Second, the structure of Taiwan’s National Health Insurance provides a great influence on physicians’ practice patterns, for instance, all children would be admitted if parenteral antibiotics were considered. A large-scale, multicenter, prospective study should be undertaken to confirm our findings.

In conclusion, our study shows that PPs in a tertiary ED have higher agreement with current practice guidelines for managing febrile children (admit the toxic cases and work up those with BT R398C). Such adherence to guidelines might result in a lower rate of unscheduled revisit but has no significant impact on the rate subsequent admission.

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