Every paediatric doctor has a fear of sending home a young, septic child or missing meningitis. We constantly review our practice and guidelines on how to identify the septic child amongst the thousands of febrile two-year-olds that present to ED. But what are the consequences if we do miss one?
This study looked at children with meningitis or septicaemia to see if they had presented to the hospital in the days preceding their eventual diagnosis.
Vaillancourt S, Guttmann A, Li Q, Chan IYM, Vermeulen MJ, Schull MJ. Repeated Emergency Department Visits Among Children Admitted With Meningitis or Septicemia: A Population-Based Study. Ann Emerg Med. 2014.
Who was studied?
This was a retrospective cohort study looking at all non-elective hospital admissions in Ontario, Canada over a five-year period (following the implementation of the pneumococcal vaccine programme).
Included patients were:
- aged 30 days to 5 years
- with a diagnosis of meningitis or septicaemia
- had a length of hospital stay of at least 4 days (or died in hospital)
There were 521 children included. Patients were excluded if they had been discharged from the hospital in the preceding 14 days
What were the patients?
There were two groups – those who had previous ED presentations (in the preceding five days), and those who were admitted on the first presentation to ED.
What were the outcomes measured?
The primary outcomes were: length of stay; critical care admission; mortality.
Secondary outcomes measured included: the type of ED for the previous presentation; time of registration in ED; and triage acuity.
What did the results show?
125 of the 521 children (24%) admitted with meningitis or septicaemia had an ED presentation in the 5 days prior to admission.
Over 2/3 of the repeat presentation group were given one of the following diagnoses initially: fever; otitis media; upper respiratory tract infection; viral infection; gastroenteritis; urinary disorder, and seizures.
96.4% of patients returned within 72 hours.
Both groups had similar lengths of stay, similar rates of critical care admission, and similar mortality rates.
Those who were treated in a community ED without review by a paediatric specialist were more likely to be in the repeat presentation group.
How do I know what happens to my patients after I discharge them?
29.8% of the repeat presentation group had their repeat presentations in different EDs. This emphasises that it is hard for us as clinicians to receive feedback on our patients and improve our practice. It’s important to have good communication between hospitals in similar geographic areas
Was this a good study?
1. Did the study address a clearly focused issue?
Sort of – at the start, the study aim is set out as ‘How often do children visit the emergency department in the 5 days before diagnosis of meningitis or septicaemia?‘. Actually what the authors are asking is ‘Does having repeat presentations prior to admission for meningitis or septicaemia affect outcome?‘.
The authors do not directly answer the first question, although it appears from the data that all 114 children were admitted on the second presentation to the hospital.
2. Was the cohort recruited in an acceptable way?
Yes – retrospectively via the patient database using diagnosis at admission.
3. Were the outcomes accurately measured to minimise bias?
Yes – retrospectively collected and independently verified.
4. Have the authors identified and taken into account confounding factors?
The authors identify that prior presentations to Primary Care services could affect the groups but this is not able to be accounted for.
5. Was the follow-up long enough?
Yes – patients were followed up until discharge or death.
6. Do you believe the results?
The authors identify some factors that may skew the results – for example, patients admitted on the first presentation are likely to be more acutely unwell and therefore it may make that group appear to have worse outcomes. Also, information about previous treatment/antibiotics could have an impact on the outcomes too.
7. Can the results be applied to our local population?
8. Do the results fit in with the other available evidence?
It is reassuring to think that discharging a child with meningitis or septicaemia does not affect that child’s overall outcome. However, some more information about the initial clinical encounter would have been helpful – for example, the patient’s initial clinical symptoms, observations, and investigations/results.
My first impression of this study was that it showed ED physicians are often missing sepsis and meningitis in children (25%!), but as the above comment points out its impossible to know what portion of the children who later received a diagnosis of sepsis met the criteria on their first visit. It does sound a cautionary note about sending home children whose initial presentation doesn’t seem to reflect serious illness. Is there some criteria that would have allowed us to identify at initial presentation who was likely to go on to develop serious illness? What percentage of those with similar initial presentations did not go on to develop a more serious illness? I note that the children that were sent home initially had “lower triage scores”; does this somehow affect the results related to similar progression and outcomes when compared with the children who received a diagnosis of serious illness on first presentation?
Hi – I’m not sure about the premise of this study!
Isn’t it to be expected that some children with sepsis will have had an illness that was rumbling along for a few days? Maybe they had otitis media or minor gastroenteritis?
Isn’t the important question *should the doctor have done anything differently on the child’s initial visit’? And for that we need to see obs, any bloods, and get a feel for the quality of the history and examination?
Yes Steve, I completely agree. There’s only so much we can conclude from this without knowing more clinical information about the repeat presenters. What it does give us overall though is some broad stats about the consequences of sending home someone who actually has a serious illness. And it does emphasise the importance of safety-netting.