Aim: To assess the appropriateness of investigations and their impact on management of acute paediatric admissions. Method: All investigations performed within the first six hours in all consecutive paediatric admissions (n=138) over a 6 week period, in a teaching general hospital, were recorded retrospectively and the results were analysed for normality/ abnormality and effect on patient management. Results: Out of a total of 480 emergency investigations performed on 89 patients, the complete blood count, electrolytes and chest X-rays were the three investigations most likely to be deranged and influenced management in 5% (n=3), 25% (n=8) and 46% (n=6) of subjects with an abnormal result, respectively. Impact on management was more evident on analysing a subgroup admitted with mild gastroenteritis, in whom serum electrolytes were abnormal in 50% (n=19), and 42% (n=8) of these needed a change in their management. Conclusion: Rationalising the number of investigations in acute paediatric admissions would result in less discomfort to children and in a significant cost benefit.peer-reviewe

Attard Montalto, Simon

Pace, David

Said Conti, Valerie

English

OAR@UM

8 Malta Medical Journal    Volume 19   Issue 02   June 2007David Pace, Valerie Said Conti, Simon Attard MontaltoOriginal ArticleAre routine investigations in acute paediatric admissions justified?Abstract:Aim: To assess the appropriateness of investigations and their impact on management of acute paediatric admissions.Method: All investigations performed within the first six hours in all consecutive paediatric admissions (n=138) over a 6 week period, in a teaching general hospital, were recorded retrospectively and the results were analysed for normality/abnormality and effect on patient management.Results: Out of a total of 480 emergency investigations performed on 89 patients, the complete blood count, electrolytes and chest X-rays were the three investigations most likely to be deranged and influenced management in 5% (n=3), 25% (n=8) and 46% (n=6) of subjects with an abnormal result, respectively. Impact on management was more evident on analysing a subgroup admitted with mild gastroenteritis, in whom serum electrolytes were abnormal in 50% (n=19), and 42% (n=8) of these needed a change in their management. Conclusion: Rationalising the number of investigations in acute paediatric admissions would result in less discomfort to children and in a significant cost benefit.Simon Attard Montalto* MD, FRCPCHDepartment of Paediatrics, St Luke’s Hospital, Guardamangia, MaltaEmail: simon.attard-montalto@gov.mtDavid Pace MD, MRCPCHDepartment of Paediatrics, St Luke’s Hospital, Guardamangia, MaltaValerie Said Conti MD, MRCPDepartment of Paediatrics, St Luke’s Hospital, Guardamangia, Malta* corresponding authorKey wordsAcute admissions, gastroenteritis, paediatrics, routine  investigations IntroductionMore than 90% of children admitted to our general hospital have an acute medical condition, and are investigated using the emergency laboratory services. The choice of investigations for some disorders is guided by protocols, that have been formulated on internationally accepted recommendations, and which are readily available to paediatric staff. Those admissions whose work up is not guided by a protocol are managed according to the clinical judgment of the admitting paediatrician, a practice that may lead to an appropriate or inappropriate number of investigations. Under investigation may result in a missed/wrong diagnosis and over investigation may upset the child unnecessarily and results in misuse of resources. This retrospective observational study was set up with the specific aim of auditing the number and type of acute investigations in the paediatric age-group, their impact on management and use of health care resources.MethodsThe case notes of all children (n=153) admitted consecutively over a period of six weeks (July to August 2000) to two general paediatric wards were retrieved. Children who were: a) admitted to the medical ward because of lack of space on the paediatric surgical ward (n=7), b) transferred from the neonatal/paediatric intensive care unit (n=2), and c) admitted for planned day-case management were not included in the study (n=6), since these children were not suffering from an acute medical condition. In order to ascertain that the admissions included during the study period were representative of the general workload of the unit, the study cohort was compared with the total number and diagnostic spread of admissions for the whole year.1The following data was recorded: age, sex, clinical signs, diagnosis, investigations and results, management and change in management. The results of the investigations were compared with accepted normal values according to age and standard references.2,3 Change in management was documented whenever a result had an impact on the treatment of the child. Those patients who were investigated according to the hospital protocols were excluded from the study. Protocols were available for the management of urinary tract infections, seizures, diabetic ketoacidosis, visceral leishmaniasis, febrile neutropenia and poisoning. The rest of the subjects were included in the study group which was also subdivided into smaller subgroups according to diagnosis. Malta Medical Journal    Volume 19   Issue 02   June 2007 9Statistical analysisThe percentage of abnormal results was calculated for the investigations performed on all the subjects as well as for any subgroup with sufficient numbers. The impact of any abnormal result on subsequent management was analysed and compared between one investigation and another, using chi-squared analysis. Yates correction (Y) or Fisher’s Exact (FE) test was applied when comparing small numbers. A p value of <0.05 was taken to represent statistical significance. ResultsDuring the six week study period there were 138 eligible admissions of which 16 were excluded since their management was guided by established hospital protocols. Of the remaining 122 subjects, data was incomplete in 4, leaving a total of 118 that were included in the study group. The diagnostic spread, mean age and gender distribution of the subjects in the study group was compared with the total number of paediatric admissions (n=3149) for the whole year (1 January 2000 to 31 December 2000).1  On analysis, the relative percentages of all these parameters were not significantly different in the group over the six week study period and all patients admitted over twelve months. However, significance may not have been achieved due to the relatively small number in the study group.Study groupA total of 118 children were recruited. Of these, 67 were males and 51 females and their ages varied from 3 days to 13 years (mean 4.3 years). Whereas 29 children did not require any investigations, a total of 480 investigations were carried out in the remaining 89 children. This group was analysed as (a) a whole and (b) by subspeciality if numbers were sufficiently large.a. Total cohort As shown in table 1, the following investigations were most frequently carried out: electrolytes in 81% of cases, complete blood count (CBC) in 79%, serum creatinine in 72%, urea in 68%, blood glucose in 50%, blood cultures in 31%, chest X-ray in 29% and stool cultures in 21%. Considerable variations were observed in the percentage of abnormal results. CBC was abnormal in 77% (54/70), serum electrolytes in 44% (32/72), urea in 5% (3/61) and blood glucose in 9% (4/45). There were no abnormal results for serum creatinine (0/64). Micro-organisms were identified from blood cultures in 25% (7/28), of which only one was clinically significant (1/28 = 4%), urine cultures in 27% (4/15) and stool cultures in 16% (3/19). Chest X-rays were found to be abnormal in 50% (13/26). The effect of abnormal results on managementMost of the abnormalities in the CBC amounted to very minor deviations from the normal range for haemoglobin. Management was only influenced in 5% (Table 1), who were coincidentally found to have a low haemoglobin concentration and were subsequently investigated for iron deficiency or for β thalassaemia trait. In contrast, serum electrolytes were abnormal in 44% (Table 1) but, of these, management was altered in 25% (8/32).  Alterations in management included the addition of potassium supplements or a change in the sodium content of the intravenous fluid. Similarly, although chest X-rays were carried out in a relatively small number of patients, the image was reported as abnormal by the admitting doctor in 50% Investigation Total Abnormal Change in   result management  N % N %Haematology     Complete blood count 70 54 77 3 5Blood picture 5 4 80 0 0APTT 1 0 0 0 0INR 1 0 0 0 0Biochemistry     Urea 61 3 5 0 0Electrolytes 72 32 44 8 25Creatinine 64 0 0 0 0Random glucose 45 4 9 0 0Liver function tests 4 1 25 0 0Direct bilirubin 1 0 0 0 0Amylase 1 1 100 0 0VBG 2 0 0 0 0Complement, C3, C4 1 1 100 0 0CSF biochemistry 3 0 0 0 0Urinalysis  and microscopy 17 7 41 0 0Microbiology     Blood cultures 28 7 25 0 0Urine C&S 15 4 27 0 0Stool C&S 19 3 16 0 0Stool rotavirus 9 2 22 0 0CSF C&S 3 0 0 0 0CRP 9 1 11 0 0ESR 3 2 67 0 0EBV antibodies 4 0 0 0 0Mycoplasma IgM 9 3 33 0 0TORCH 1 0 0 0 0ASOT 1 0 0 0 0     Imaging/other     Chest X-ray 26 13 50 6 46X-ray lower limb 1 0 0 0 0ECG 1 0 0 0 0CSF cytology 3 1 33 1 100Total 480 4  8Table 1: Investigations carried out in the Study Group**Total number of subjects=89N: number of subjectsAPTT=Activated Partial Thromboplastin Time; ASOT=Antistreptolysin O titre; C&S=Culture and Sensitivities; CRP=C-Reactive Protein; CSF=Cerobrospinal fluid; EBV=Epstein Barr Virus; ECG=Electrocardiogram; ESR=Erythrocyte Sedimentation Rate; IgM=Immunoglobulin M; INR=International Normalised Ratio; TORCH=Toxoplasma, Rubella, Cytomegalovirus, Hepatitis antibodies; VBG=Venous Blood GasesMalta Medical Journal    Volume 19   Issue 02   June 2007 2and influenced the initiation of antibiotics in those with a lower respiratory tract infection in 46% (6/13).  Abnormal electrolyte results were more likely to result in a change in treatment than abnormal CBC values (χ2 (FE)=5.1, p<0.05). b. Subgroups within the study groupThe whole study cohort was broken down into different diagnostic categories, namely gastroenteritis, asthma, upper and lower respiratory tract infections, other infections, feeding problems, cardiac problems and miscellaneous diagnoses. Only the subgroup of children admitted with gastroenteritis was sufficiently large to allow further analysis. Out of a total of 45 children (25 males and 20 females, aged between 5 months and 12 years, with a mean age of 4.8 years) admitted with acute gastroenteritis, all had mild to moderate dehydration (3-5%)4, and 38 underwent urgent investigations (Table 2).  Deranged results were seen in 80% (28/35) of the CBC, 50% (19/38) of the serum electrolytes and 5% (2/38) of the serum urea. The effect of abnormal results on management Complete blood counts were more likely to be abnormal than serum electrolytes. However, analysis of these abnormal blood counts revealed that none were clinically significant as the derangements were only slight deviations from the normal range and did not influence any of the patients’ management. In contrast, the sodium content of the intravenous fluid (i.e. 5% dextrose in 0.45% saline or 5% dextrose in 0.225% saline or 5% dextrose in 0.18% saline) was changed or potassium supplements were added in 42% (8/19) of the subjects with abnormal electrolytes. The difference in the change in management as a result of deranged electrolytes was statistically significant when compared to the effect on management resulting from deranged CBC results (χ2(FE)=12, p<0.001). DiscussionThe aim of this study was to audit the current practice of acute investigations in children admitted to two general paediatric wards, where there is a tendency for investigations to be taken ‘routinely’ once intravenous access is established. This study has shown that 75% (89/118) of all acute paediatric admissions undergo some form of investigation. Out of a total of 480 investigations, just 143 (30%) were abnormal and, more importantly, a small minority of just 18 (4%) had any bearing on the acute management of the child. The complete blood count and electrolyte assay were the two investigations most commonly requested. Whilst the CBC was noted to be frequently deranged, the abnormalities were only minor deviations in haemoglobin, white cell or platelet counts and were almost totally ignored when it came to influencing management. In contrast, serum electrolytes were abnormal in 44% (32/72) of subjects but, of these, management was altered in 25% (8/32). Incidentally these 8 subjects all suffered from gastroenteritis and were the same 8 children who made up 42% of the children in the gastroenteritis subgroup (8/19) in whom management was altered as a result of abnormal electrolytes. Similarly, chest X-rays were abnormal in half of the cases investigated and affected the initiation of antibiotics in 46% (the number of abnormal chest X-rays could have possibly been overestimated as these were not reported by a radiologist). Although 22% of the 101 microbiological tests taken were abnormal, almost all of these results were available more than 24 hours after admission and, as a result, few had a bearing on the immediate acute management of the patient. However, microbiological investigations are still essential in the management of infections as they might influence the subsequent management of the infected child and will be required for Public Health surveillance.This study allowed for a detailed assessment of those admitted with gastroenteritis with approximately 3-5% dehydration4. At present, children admitted to our hospital with this diagnosis and in whom an intravenous infusion is set up, are ‘routinely’ investigated by means of a CBC, urea, electrolytes and creatinine. This study has shown that, in these patients, serum electrolytes affected management in 42% of patients. This observation is similar, if not more pronounced, when compared with similar studies5,6 and systematic reviews on the management of gastroenteritis in children.7-9 Moreover, the findings in this study are consistent with guidelines recommended by the American Academy of Paediatrics in justifying routine serum electrolytes in children with mild/moderate gastroenteritis in whom intravenous fluids are commenced, particularly to identify problems with hypernatraemia.7,8,10,11 This position would not be that dissimilar, though may support rather more intervention, when compared with guidelines issued by the Royal College of Paediatrics and Child Health.12 In contrast, although many CBC results were marginally ‘abnormal’, this investigation had virtually no bearing on acute management.  Similarly, serum urea and creatinine results were rarely or never abnormal and neither was instrumental in management.  Hence, this study Table 2: Investigations carried out in children  admitted with gastroenteritis*Urea 38 2 0Electrolytes 38 19 8Complete blood count 35 28 0Creatinine 33 0 0Random blood glucose 24 3 0Stool rotavirus 9 2 0Stool culture 18 3 0Urinalysis & microscopy 2 1 0Urine culture 1 1 0Blood cultures 4 1 0Total 202 60 8*    Out of a total of 45 children admitted with gastroenteritis, 38 underwent urgent investigationsInvestigation Total Abnormal Change in   result management  N % N %22 Malta Medical Journal    Volume 19   Issue 02   June 2007would strongly support the argument that the routine request for CBC, urea and creatinine in this subgroup of patients is totally unnecessary. A restriction of routine investigations to just electrolytes alone, in those with gastroenteritis with 3-5% dehydration, would have resulted in a cost saving of Lm621 in this particular cohort of patients (table 3) and, given approximately 300 patients with gastroenteritis per year, would translate into a saving of approximately Lm4,130 per annum. By limiting investigations to only those which are likely to have an influence on patient management would result in a much higher overall cost saving for the entire study group.Hospital protocols help in standardising the management of diseases and guide doctors to carry out only the necessary blood investigations. Although automated blood analysers perform multiple tests on single blood specimens, even on small volume capillary samples, the process of blood extraction remains a cause of too much distress in children. Pain at the site of needle puncture may be reduced by the application of a local anaesthetic and distraction procedures may help in reducing distress13, however on many occasions blood sampling is still emotionally traumatic to children. Limiting the number of blood investigations to only those which are really necessary, might help in alleviating some of the associated psychological distress.ConclusionAlthough the number of subjects included in our observational retrospective study was small and biased by the lack of a control group, several important points can be observed. For those conditions without a designated protocol, routine investigations are often inappropriate and unnecessary. Many of these investigations, although marginally abnormal, have no bearing whatsoever on patient management. This study would support routine electrolytes alone in children with mild/moderate gastroenteritis but all the other tests should only be carried out on the basis of a specific clinical indication and not simply ‘routinely.’ Altering practice as a result of evidence-based audit would result in a significant cost saving for the unit in our hospital and, similarly, in those hospitals with a comparable acute paediatric practice. AcknowledgementsWe would sincerely like to thank all the medical students who helped collect the data.  We would also like to acknowledge our paediatric colleagues who, in one way or another, were involved in the care of the patients enrolled in this study.References1. Attard Montalto S. Annual Report, Department of Paediatrics, St. Luke’s Hospital, Malta, 20002. Stevens RF. Haematology and Oncology. In: Stroobant J, Field D, editors. Handbook of Paediatric Investigations. London: Churchill Livingstone; 2002. p. 42-833. Nicholson JF, Pesce MA. Reference ranges for laboratory tests and procedures.  In: RE Behrman, RM Kliegman, HB Jenson, editors.  Nelson Textbook of Paediatrics.  Philadelphia: W.B. Saunders Company; 2000.           p. 2181–2244. Duggan C, Refat M, Hashem M, Wolff M, Fayad I, Santosham M. How valid are clinical signs of dehydration in infants? J Pediatr Gastroenterol Nutr. 1996 Jan;22(1):56-615. Jenkins HR, Ansari BM. Management of gastroenteritis. Arch Dis Child. 1990;65:939-416. Conway SP, Phillips RR, Panday S. Admission to hospital with gastroenteritis. Arch Dis Child. 1990;65:579-847. Murphy MS. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch Dis Child. 1998;79:279-848. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child. 2001;85:132-429. World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers. 4th revision Geneva, Switzerland; World Health Organization; 2005. Available from http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/ISBN_92_4_159318_0.pdf10. American Academy of Pediatrics, Provisional Committee on Quality Improvement Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996; 97(3) 424-3611. Guidelines for diarrhoea and vomiting. Royal Childrens’ Hospital, Melbourne, Australia, 2001. Available from http://www.pier.shef.ac.uk12. Guidelines for the management of mild gastroenteritis. Royal College of Paediatrics and Child Health, London, UK, 200313. Tak JH, van Bon WH. Pain- and distress-reducing interventions for venepuncture in children. Child Care Health Dev. 2006 May;32(3):257-68Table 3: Cost saving for subgroup with gastroenteritisLm: Malta liri*: Number of children admitted with gastroenteritis amounts to 300 per yearNote: Cost of emergency tests obtained from Billing Section, St. Luke’s Hospital, Malta. All totals may be reduced by 25% if investigative tests are costed as non-urgent rather than urgent/emergency investigations.Investigation Cost per emergency test (Lm) Number of investigationsin 45 subjectsCost saving (Lm)Projected saving per annum (all admissions with gastroenteritis*) (Lm)Complete blood count 5.50 35 193 1283Urea 4.50 38 171 1140Creatinine 4.50 33 149 990Random blood glucose 4.50 24 108 720Total - 135 621 4,133

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Are routine investigations in acute paediatric admissions justified?

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Are routine investigations in acute paediatric admissions justified?

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