A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

Abstract

Background To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department. Methods and findings A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit (‘index’ visit), in 2012–2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65–0.74) and summary calibration slope of 0.83 (95% CI 0.67–0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87–5.01) and specificity 0.96 (95% CI 0.95–0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25–0.35), sensitivity 0.88 (95% CI 0.86–0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68–0.75) and summary calibration slope of 0.84 (95% CI 0.71–0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded. Conclusion We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Improving the Safety of the Manchester Triage System for Children with Congenital Heart Disease

“…A four-level outcome severity index (OSI), similar to existing reference standard classi cation systems [3][4][5]16], was developed to evaluate the validity of the MTS at the emergency unit of the Department of Pediatrics and Adolescent Medicine, Medical University, Vienna. The OSI ranked priority based on diagnostic investigations (laboratory tests, chest radiography, ultrasonography, electrocardiogram, echocardiography, computed tomography scan), medical interventions at the emergency unit (e.g., intravenous medication or uid, inhalation, nebulization, monitoring), hospital admission (intensive care unit (ICU) or inpatient ward), or a follow-up visit at the outpatient clinic or pediatrician's o ce.…”

A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods

“…The visit-revisit interval was classified as follows: revisit to the ED within 1, 3, and 7 days. Most studies on ED revisits of pediatric patients use a visit-revisit interval of 3 to 7 days [ 13 , 16 , 26 ]. However, we also included revisits within 1 day because, according to Perry et al, ED revisits within 24 h could represent serious deficiencies in emergency health care [ 21 ].…”

“…A few studies on ED revisits were conducted on pediatric patients. In previous studies, the ED revisit rates of pediatric patients varied from 2.2% to 8.0% [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ], and the number of pediatric revisits to EDs was reported to increase each year [ 19 ]. The ED revisit rates were high among infants, toddlers [ 9 , 12 , 14 , 17 , 18 , 19 ], and children with chronic diseases [ 11 , 20 ].…”

Improving the safety of the Manchester triage system for children with congenital heart disease

“…A four-level outcome severity index (OSI), similar to existing reference standard classification systems [ 3 – 5 , 16 ], was developed to evaluate the validity of the MTS at the emergency unit of the Department of Pediatrics and Adolescent Medicine, University Hospital Vienna. The OSI ranked priority based on diagnostic investigations (laboratory tests, chest radiography, ultrasonography, electrocardiogram, echocardiography, computed tomography scan), medical interventions at the emergency unit (e.g., intravenous medication or fluid, inhalation, nebulization, monitoring), hospital admission (intensive care unit (ICU) or inpatient ward), or a follow-up visit at the outpatient clinic or pediatrician’s office.…”