Defining significant childhood illness and injury in the Emergency Department: a consensus of UK and Ireland expert opinion

Abstract

BackgroundClarifying whether paediatric early warning scores (PEWS) accurately predict significant illness is a research priority for UK and Ireland paediatric emergency medicine (EM). However, a standardised list of significant conditions to benchmark these scores does not exist.ObjectivesTo establish standardised significant illness endpoints for use in determining the performance accuracy of PEWS and safety systems in emergency departments (ED), using a consensus of expert opinion in the UK and Ireland.DesignBetween July 2017 and February 2018, three online Delphi rounds established a consensus on ‘significant’ clinical conditions, derived from a list of common childhood illness/injury ED presentations. Conditions warranting acute hospital admission in the opinion of the respondent were defined as ‘significant’, using a 5-point Likert scale. The consensus was a priori ≥80% (positive or negative). 258 clinical conditions were tested.Participants and settingsEligible participants were consultants in acute or EM paediatrics, or adult EM, accessed via 53 PERUKI (Paediatric Emergency Research in the UK and Ireland)’s research collaborative sites, and 27 GAPRUKI (General and Adolescent Paediatric Research in the UK and Ireland)’s sites, 17 of which overlap with PERUKI.Main outcome measuresTo create a list of conditions regarded as ‘significant’with ≥80% expert consensus.Results43 (68%) of 63 PERUKI and GAPRUKI sites responded; 295 experts were invited to participate. Participants in rounds 1, 2 and 3 were 223 (76%), 177 (60%) and 148 (50%), respectively; 154 conditions reached positive consensus as ‘significant’; 1 condition reached a negative consensus (uncomplicated Henoch-Schönlein purpura); and 37 conditions achieved non-consensus.ConclusionsA list of significant childhood conditions has been created using UK and Irish expert consensus, for research purposes, for the first time. This will be used as the benchmark endpoint list for future research into PEWS/safety systems performance in EDs.

Consensus on patient cases for hospitalised children with a high paediatric track and trigger tool score that raises no mounting concern: a Delphi process study

“…The differences between the opinions of the non-consensus patient cases were echoed in the wide range of median scores in the responses, which ranged from 1 (strongly disagree) to 8 (agree). This complexity was also highlighted in a study by Lillitos et al , 22 who aimed to establish a benchmark list defining significant acute paediatric conditions that warrant acute hospital admission from the emergency department, using a Delphi method. They failed to achieve consensus on 37 statements because assessment of sick children’s conditions may vary and depend on many factors, such as the healthcare professional’s experience and the child’s clinical presentation.…”

“…They failed to achieve consensus on 37 statements because assessment of sick children’s conditions may vary and depend on many factors, such as the healthcare professional’s experience and the child’s clinical presentation. In the study by Lillitos et al , 22 the authors identified many neutral answers in round 1 and therefore added the response category ‘I don’t look after children with this condition’. We also identified many patient cases in which the healthcare professionals did not have sufficient experience to answer the question, which underscores the complexity of paediatrics.…”

Differentiating vaccine reactions from invasive bacterial infections in young infants presenting to the emergency department in the 4CMenB era: a retrospective observational comparison

“…An obvious omission is comparison of Paediatric Early Warning Scores (PEWS) between groups. Currently, there is no consensus nationally on PEWS observations and scoring,21 22 so this analysis was not performed. Finally, due to the descriptive focus of this study, we have not used multiple-testing corrections, so significant comparisons must be interpreted with caution.…”

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

“…There is no existing gold-standard outcome measure for the decision to admit or discharge a child or young person from the ED, 5 and the decision to admit is a complex one, which can vary between clinicians and hospitals. One EWS system, the Paediatric Observation Priority Score (POPS), recommended by the Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings 6 has shown initial promise in aiding recognition of unwell children but also aiding safe discharge decisions.…”