Where can I find this paper?

http://www.ncbi.nlm.nih.gov/pubmed/25458981

What is this paper about (what is the research question)?

How often have children, subsequently diagnosed with meningitis or septicaemia, attended an ED and been discharged in the preceding five days?

Summary of the Paper

Design: retrospective cohort study using pan-Toronto hospital database

Objective: to ascertain the proportion of children with an ultimate diagnosis of meningitis and septicaemia who had attended an Emergency Department in the five preceding days

Outcome of interest: proportion of reattendances; ED factors in the group with preceding attendance compared with those admitted at first attendance

Participants: children (aged 30 days to 5 years) with a diagnosis of meningitis or septicaemia with linked data regarding prior attendances in the period 06/04/2005-01/03/2010.

• Inclusions: children with an ultimate diagnosis of meningitis or septicaemia and a minimum inpatient stay of 4 days (or death in hospital)
• Exclusions: length of stay <4 days, patients discharged within the preceding 14 days of admission with meningitis/septicaemia

Results: 521 children were admitted with a final diagnosis of meningitis/septicaemia during the study period. 125 had attended an ED in the preceding 5 days with 114 attending with apparent infection. Those with repeated visits had similar lengths of stay, critical care use and 30-day mortality.

Authors’ Conclusions:

Our study reveals that despite the imperative to provide early diagnosis and treatment to children and infants with critical infections, current practices differ markedly from this goal, with 1 in 5 children having repeated ED presentations before admission with meningitis or septicaemia.

On the study design

This was a retrospective cohort study which depended on ICD-10 reporting of diagnoses and database correlation to link admissions with meningitis or septicaemia with prior ED attendances. As with all such studies, findings are dependent on the quality of data recorded, even more so when the analysis is performed on retrospective data.

Nonetheless the study asks a valid question about how good we are at identifying serious bacterial illness the first time around.

What were the results and what does this mean?

 

The low prevalence of serious bacterial infection is interesting; there is no data given about the number of ED attendances for children who were not given a diagnosis of meningitis or septicaemia, so this reinforces the “needle-in-a-haystack” feeling we have in the UK. These diseases are thankfully rare but identifying them early is a clinical priority.

That 125 children reattended (after not being admitted at first attendance) does not resonate with me in the same way as they authors. I feel this rather reflects my experiences that patients who have severe illness do not always suddenly present acutely unwell but rather at a time point along a clinical trajectory, at which reliable clinical signs may or may not be present. Notably children who reattended had lower acuity scores at first presentation, which supports this.

Unfortunately much of the analysis is focused on whether attending a department with dedicated paediatric consultants made a difference. I suspect that this is association rather than causation and would be difficult to prove. In any case we would need to see the background rates of paediatric attendances to each unit to determine whether these district general hospitals were genuinely outliers. There may also be a parental tendency to reattend at a “specialist” hospital or a clinician tendency to admit more patients at a specialist hospital due to a higher acuity presenting there – the paper does not answer this question.

What can we take from this paper into clinical practice?

What this study seems to tell us is that diagnosis is tricky and that time and observation is valuable – and that we should not only make the most of opportunities to observe and review patients but that we should safety-net properly. Any child with any apparently benign illness may re-present with a deterioration in condition and we must ensure that parents feel confident in returning to us if that occurs.

More questions to ask

• How on earth can we identify serious bacterial illness in children? Answers on a postcard for a Nobel prize… 🙂

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