Patient characteristics.

<p>* Absolute number (percentage).</p><p>^a Median (25–75 percentiles).</p><p>^{# ‘}Other’ includes secondary care and after telephone contact.</p><p>^{<b>^ ‘</b>}Urgent’ includes very urgent/ urgent; ‘Non-urgent’ includes standard/ non-urgent.</p><p>^{^^} Others includes for example. Influenza, chicken-pox, stomatitis.</p><p>Patient characteristics.</p

Impact of a Clinical Decision Model for Febrile Children at Risk for Serious Bacterial Infections at the Emergency Department: A Randomized Controlled Trial

<div><p>Objectives</p><p>To assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED).</p><p>Methods</p><p>Randomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n=219) or the control group (usual care; n=220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for “pneumonia” and “other SBI”. Nurses were guided by the intervention to initiate additional tests for high-risk children. The clinical decision model was evaluated by 1) area-under-the-receiver-operating-characteristic-curve (AUC) to indicate discriminative ability and 2) feasibility, to measure nurses’ compliance to model recommendations. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs.</p><p>Results</p><p>The decision model had good discriminative ability for both pneumonia (n=33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n=22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination were observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value<0.05) and more urine-dipstick testing (71% vs. 61%, p-value<0.05).</p><p>Conclusions</p><p>In contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved, however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing.</p><p>Trial Registration</p><p>Nederlands Trial Register <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2381" target="_blank">NTR2381</a></p></div

Clinical decision model.

<p>Clinical decision model with its predictors (above) and recommendations (below).</p

Patient and process outcome.

<p>SBI = serious bacterial infection.</p><p>UTI = urinary tract infection.</p><p>^a Median (25–75 percentiles).</p><p>^# including hemoglobin, leukocyte, thrombocyte and differential count.</p><p>^~including feces culture, nasal swab, throat culture and cerebrospinal fluid (CSF) culture.</p><p>*Chi-square, p-value <0.05.</p><p>^± Overall diagnostics minus urine-dipstick analysis.</p><p>^$1 In 17 of 19 children with pneumonia chest-radiography was performed.</p><p>^$2 In 12 of 14 children with pneumonia chest-radiography was performed.</p><p>^$3 In 175 of 200 children without pneumonia no chest-radiography was performed.</p><p>^$4 In 190 of 206 children without pneumonia no chest-radiography was performed.</p><p>^$5 In 6 of 6 children with UTI a urine-culture was performed.</p><p>^$6 In 8 of 9 children with UTI a urine-culture was performed.</p><p>^$7 In 201 of 213 children without UTI no urine-culture was performed.</p><p>^$8 In 202 of 211 children without UTI no urine-culture was performed.</p><p>Patient and process outcome.</p