Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study

Abstract

BACKGROUND The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes. METHODS This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE. RESULTS Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness (P < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%. CONCLUSIONS AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.

Canadian infants presenting with Brief Resolved Unexplained Events (BRUEs) and validation of clinical prediction rules for risk stratification: a protocol for a multicentre, retrospective cohort study

“…Eligibility criteria were adapted from the BRUE-QIRC study. 6 Patients will be included if they are an infant (<365 days old) who experienced an event which the observer describes as a sudden, brief and now-resolved episode involving one or more of (1) cyanosis or pallor, (2) apnoea or irregular respirations, (3) change in tone or (4) altered level of consciousness with no clinical explanation after a full history and physical examination. 5 …”

“…The CRF has been pilot tested in the US study completed by the BRUE-QIRC. 6 Each site investigator will identify a research assistant (a medically trained trainee/student/nurse) and train that individual in data identification and extraction. Trained individuals will enter deidentified data directly using the electronic CRF into a secure REDCap online database managed at BC Children’s Hospital Research Institute in Vancouver, BC.…”

“…Documented event recurrence, defined as one or more events consistent with a BRUE during the index ED visit or hospital admission. 6 …”

“…In 2018, 15 children’s hospitals across the USA convened to create BRUE Quality Improvement and Research Collaborative (BRUE-QIRC) network. 6–8 10 11 Using an administrative database (Pediatric Health Information System), the collaboration was able to retrospectively identify the largest cohort of patients with BRUE described to date (n=3283). The collaborative developed and validated an approach to identifying BRUE patients based on diagnostic codes.…”

“…Following the publication of the AAP guidelines, studies showed that while the majority of infants presenting with a BRUE (87%–92%) met at least one higher-risk criteria, only a small proportion have a serious underlying diagnosis (4%) 2 6–8. Analysis of the AAP criteria identified a history of a similar event, event clusters, CPR use and abnormal medical history to be associated with a serious underlying diagnosis.…”