Audit: Determining the common medical presenting problems to an accident and emergency department

Armon, Kate

doi:10.1136/adc.84.5.390

Cited by 140 publications

(114 citation statements)

References 11 publications

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“…The study also showed that respiratory symptoms of wheezing and cough were the leading cause of hospital admission and that asthma was the most common diagnosis. This finding is in agreement with other studies [8,9] that asthma was the single most common cause for admission. A study from Australia reported that asthma remained the second most common cause for admission to the paediatric hospital [10].…”

supporting

confidence: 83%

Aetiology of Febrile Illnesses Presenting to a District Hospital

El-Radhi¹,

Patel²

2017

Pediatric Infect Dis

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Little attention has been given to the patterns of diseases in children admitted to a hospital. We retrospectively studied 874 children (477 male, 397 female) who were hospitalised consecutively during a ten months period to determine the incidence and types of their illness with an emphasis on patterns and causes of fever.Respiratory symptoms of cough and wheezing were the single most common presenting cause of admission (20.3%). Fever (defined as one temperature record of >38.0°C or two successive record of 37.8°C) was the second most common presenting cause (15.8%) leading to admission, and within this group fever without focus was most common. Overall, fever was recorded in 35.9% of the study group. Urinary tract infection was the most common bacterial infection. Children with bacterial infections were usually febrile while the majority of those with presumed viral infections were afebrile. The mean body temperature in children with bacterial infections was significantly higher than in those with presumed viral infections. Overall, febrile children stayed significantly longer in hospital and underwent more laboratory tests compared with afebrile children. Although white blood count and C-reactive protein tended to be higher in bacterial than in presumed viral infections, both tests were sometimes normal in serious bacterial infections and abnormally high in presumed viral diseases. Mild hyponatraemia (<135 mmol/L) was a common laboratory finding in febrile illness, and severe hyponatraemia (<130 mmol/L), was more common in bacterial diseases.It is concluded that febrile illnesses are common and only second to respiratory diseases as the leading cause of hospitalisation. Children with bacterial infection are usually febrile and those with high fever should be evaluated for serious bacterial diseases. Those children who present with fever without focus should be evaluated for an underlying urinary tract infection and bacteraemia.

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confidence: 83%

Aetiology of Febrile Illnesses Presenting to a District Hospital

El-Radhi¹,

Patel²

2017

Pediatric Infect Dis

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“…For full details of urine collection methods, see Chapter 2, Urine sample collection, and our protocol paper (see Appendix 3). 106 All 107 index tests and the clinicians' working diagnosis were measured blind to the reference standard.…”

Section: Index Tests and Urine Collectionmentioning

confidence: 99%

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

Hay

Birnie²,

Busby³

et al. 2016

Health Technol Assess

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BackgroundIt is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment.ObjectivesTo develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness.DesignMulticentre, prospective diagnostic cohort study.Setting and participantsChildren < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.MethodsOne hundred and seven clinical characteristics (index tests) were recorded from the child’s past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood (‘clinical diagnosis’) and urine sampling and treatment intentions (‘clinical judgement’) were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 105colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the ‘clinician diagnosis’ AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with ‘clinical judgement’.ResultsA total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, ‘clinical diagnosis’ correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. ‘Clinical diagnosis’ correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut.ConclusionsClinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…Three per cent of all children 6 months to 5 years have a febrile seizure, and 5% of all medical attendances to the accident and emergency department are attributable to seizure. 2 Depending on the hospital attended and the clinician seen, about 70% of these children are admitted and undergo varying degrees of investigation 3 and length of stay in hospital. The Royal College of Paediatrics and Child Health recommends that priority for guideline development be given to aspects of health care that are common, expensive or serious, and where variations in practice occur.…”

mentioning

confidence: 99%

Audit: Determining the common medical presenting problems to an accident and emergency department

Cited by 140 publications

References 11 publications

Aetiology of Febrile Illnesses Presenting to a District Hospital

Aetiology of Febrile Illnesses Presenting to a District Hospital

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

An evidence and consensus based guideline for the management of a child after a seizure

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