Observational cohort study with internal and external validation of a predictive tool for identification of children in need of hospital admission from the emergency department : the Paediatric Admission Guidance in the Emergency department (PAGE) score

Abstract

Objectives: To devise an assessment tool to aid discharge and admission decision making in relation to children and young people in hospital urgent and emergency care facilities, and thereby improve the quality of care that patients receive, using a clinical prediction modelling approach Design: Observational cohort study with internal and external validation of a predictive tool Setting: Two general emergency departments and an urgent care centre in the North of England. Participants: The eligibility criteria were children and young people 0-16 years of age who attended one of the three hospital sites within one NHS Trust. Children were excluded if they opted out of the study, were brought to the emergency department (ED) following their death in the community, or arrived in cardiac arrest when the heart rate and respiratory rate would be unmeasurable. Main outcome measures: Admission or discharge. A participant was defined as being admitted to hospital if they left the ED to enter the hospital for further assessment, (including being admitted to an observation and assessment unit or hospital ward), either on first presentation or with the same complaint within seven days. Those who were not admitted were defined as having been discharged. Results: The study collected data on 36365 participants. 15328 participants were included in the final analysis cohort (21045 observations) and 17710 participants were included in the validation cohort (23262 observations). There were 14 variables entered into the regression analysis. Of the 13 that remained in the final model, 10 were present in all 500 bootstraps. The resulting Paediatric Admission Guidance in the Emergency department (PAGE) score demonstrated good internal validity. The C-index (AUROC) was 0.779 (95% CI 0.772 to 0.786). Conclusions: For units without the immediate availability of paediatricians the PAGE score can assist staff to determine risk of admission. Cut off values will need to be adjusted to local circumstance