To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED)

Objective: To evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions. Design: Retrospective cohort study. Setting: Alder Hey Children’s NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK. Participants: From October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as ‘GP appropriate’. The natural experiment compared patients triaged as ‘GP appropriate’ and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as ‘GP appropriate’ seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes. Results: 5223 patients were designated as ‘GP appropriate’—18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63–141) for the GP group compared with 113 min (IQR 70–167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95% CI 0.24 to 0.44), wait longer than 4 hours (2.3% vs 5.1%, OR 0.45, 95% CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95% CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95% CI 1.10 to 1.56). Sensitivity analyses yielded similar results. Conclusions: Introducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children’s emergency services

Accuracy of a Modified qSOFA Score for Predicting Critical Care Admission in Febrile Children

BACKGROUND AND OBJECTIVES: The identification of life-threatening infection in febrile children presenting to the emergency department (ED) remains difficult. The quick Sequential Organ Failure Assessment (qSOFA) was only derived for adult populations, implying an urgent need for pediatric scores. We developed and validated a novel, adapted qSOFA score (Liverpool quick Sequential Organ Failure Assessment [LqSOFA]) and compared its performance with qSOFA, Pediatric Early Warning Score (PEWS), and National Institute for Health and Care Excellence (NICE) high-risk criteria in predicting critical care (CC) admission in febrile children presenting to the ED. METHODS: The LqSOFA (range, 0–4) incorporates age-adjusted heart rate, respiratory rate, capillary refill, and consciousness level on the Alert, Voice, Pain, Unresponsive scale. The primary outcome was CC admission within 48 hours of ED presentation, and the secondary outcome was sepsis-related mortality. LqSOFA, qSOFA, PEWS, and NICE high-risk criteria scores were calculated, and performance characteristics, including area under the receiver operating characteristic curve, were calculated for each score. RESULTS: In the initial (n = 1121) cohort, 47 CC admissions (4.2%) occurred, and in the validation (n = 12 241) cohort, 135 CC admissions (1.1%) occurred, and there were 5 sepsis-related deaths. In the validation cohort, LqSOFA predicted CC admission with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval [CI], 0.76 to 0.86), versus qSOFA (0.66; 95% CI, 0.60 to 0.71), PEWS (0.93; 95% CI, 0.90 to 0.95), and NICE high-risk criteria (0.81; 95% CI, 0.78 to 0.85). For predicting CC admission, the LqSOFA outperformed the qSOFA, with a net reclassification index of 10.4% (95% CI, 1.0% to 19.9%). CONCLUSIONS: In this large study, we demonstrate improved performance of the LqSOFA over qSOFA in identifying febrile children at risk for CC admission and sepsis-related mortality. Further validation is required in other settings

Management of non-urgent paediatric emergency department attendances; a retrospective observational study

BACKGROUND: Non-urgent emergency department(ED) attendances are common among children. Primary care management may not only be more clinically appropriate, but also improve patient experience and cost-effectiveness. AIM: To determine the impact of integrating a general practitioner(GP) into a paediatric ED, on admissions, waiting times, antibiotic prescribing, and treatment costs. DESIGN AND SETTING: Retrospective cohort study of non-urgent ED-presentations in an English paediatric ED. METHOD: From October-2015-September-2017, a GP was situated within the ED, from 2pm-10pm, seven-days-a-week. All children triaged green using the Manchester Triage System(non-urgent) were considered ‘GP-appropriate’. In cases of GP non-availability, non-urgent children were managed by ED-staff. We compared clinical, operational outcomes, and healthcare costs, of children managed by GPs and ED-staff over the same timeframe(2pm-10pm), over a two-year period. RESULTS: Of 115,000 children attending the ED over the study period, 13,099 children were designated ‘GP appropriate’, 8,404(64.2%) managed by GPs and 4,695(35.8%) by ED-staff. Median duration of ED-stay was 39min(IQR 16-108) in the GP-group and 165min(IQR 104-222) in the ED-group(p&lt;0.001). The GP-group were less likely to: be admitted as inpatients (OR 0.16,95%CI 0.13-0.2) and wait longer than four-hours (OR 0.1,95%CI 0.08-0.13), but more likely to receive antibiotics (OR 1.42,95%CI 1.27-1.58). Treatment costs were 18.4% lower in the GP-group,p&lt;0.0001. CONCLUSION: Based on retrospective observational data, children seen by the GP waited less time, had fewer inpatient admissions and lower costs, but experienced higher antibiotic prescribing. Given rising demand for children’s emergency services, ‘GP in ED’ care models may improve the management of non-urgent ED presentations, however further research incorporating causative study designs is required

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department.

BACKGROUND: Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. METHODS: We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. RESULTS: Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. CONCLUSION: The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest

Investigation of the thermal and optical performance of a Spatial Light Modulator with high average power picosecond laser exposure for Materials Processing Applications

Spatial light modulators (SLMs) addressed with computer generated holograms (CGHs) can create structured light fields on demand when an incident laser beam is diffracted by a phase CGH. The power handling limitations of these devices based on a liquid crystal layer has always been of some concern. With careful engineering of chip thermal management, we report the detailed optical phase and temperature response of a liquid cooled SLM exposed to picosecond laser powers up to 〈P〉  =  220 W at 1064 nm. This information is critical for determining device performance at high laser powers. SLM chip temperature rose linearly with incident laser exposure, increasing by only 5 °C at 〈P〉  =  220 W incident power, measured with a thermal imaging camera. Thermal response time with continuous exposure was 1–2 s. The optical phase response with incident power approaches 2π radians with average power up to 〈P〉  =  130 W, hence the operational limit, while above this power, liquid crystal thickness variations limit phase response to just over $\pi$ radians. Modelling of the thermal and phase response with exposure is also presented, supporting experimental observations well. These remarkable performance characteristics show that liquid crystal based SLM technology is highly robust when efficiently cooled. High speed, multi-beam plasmonic surface micro-structuring at a rate R  =  8 cm2 s−1 is achieved on polished metal surfaces at 〈P〉  =  25 W exposure while diffractive, multi-beam surface ablation with average power 〈P〉  =100 W on stainless steel is demonstrated with ablation rate of ~4 mm3 min−1. However, above 130 W, first order diffraction efficiency drops significantly in accord with the observed operational limit. Continuous exposure for a period of 45 min at a laser power of 〈P〉  =  160 W did not result in any detectable drop in diffraction efficiency, confirmed afterwards by the efficient parallel beam processing at 〈P〉  =  100 W. Hence, no permanent changes in SLM phase response characteristics have been detected. This research work will help to accelerate the use of liquid crystal spatial light modulators for both scientific and ultra high throughput laser-materials micro-structuring applications