Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda – a validation and inter-rater reliability study

Abstract

Introduction There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap. Objectives to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1–12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used. Methods A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant. Results 100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98–0.99) and 0.980 (0.97–0.99). The convergent validity (Pearson’s correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92–0.99, p<0.001) and 0.880 (CI: 0.80–0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively. Conclusion LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.

External Validation of the Discriminative Validity of the ReSVinet Score and Development of Simplified ReSVinet Scores in Secondary Care

“…The original study that proposed the score retrospectively validated it in a small sample of 170 infants (<24 months) hospitalised in 3 centres in Spain with an acute respiratory infection; in this study they demonstrated that the score had good internal consistency, strong inter-rater reliability (between investigators and, between investigators and parents) and moderate construct validity [1]. Subsequently, a number of prospective external validation studies have been conducted showing similar results; studies assessing the validity of the clinician version of the ReSVinet score, that we are aware of, are summarised in Supplementary Table 1 [1,[5][6][7][8]. As such it currently appears to be one of the most promising and best validated severity scores for acute respiratory infections in infants.…”

“…For this study, we made use of three existing datasets. One recently published dataset was used to develop candidate simplified scores [11,12], and these scores were subsequently externally validated in three additional datasets, all of which have already been used to validate the original ReSVinet score and their findings published [5,13]. Further detail on each dataset can be found below; the inclusion and exclusion criteria of the datasets are listed in Supplementary Table 2.…”

“…Subsequently we externally validated the simplified scores in two datasets, henceforth referred to as the Camacho-Cruz and Hakizimana datasets respectively. In this section, we provide a high-level summary of each dataset; however more detailed information on the methods can be found in the original study publications [5,13].…”

“…The Hakizimana dataset was collected in a prospective cross-sectional study conducted in four tertiary hospitals (n=4) in Rwanda where infants (1-12 months) presenting with signs of respiratory distress were opportunistically enrolled to externally validate the ReSVinet score and the Liverpool Infant Bronchiolitis Severity Score (LIBSS) [5].…”

Emergency Department Initiative to Decrease High-flow Nasal Cannula Use for Admitted Patients with Bronchiolitis

“…[10][11][12] There are several validated scoring tools, though no tool has been universally recommended. [13][14][15] A large multicentre study found that protocols to limit HFNC decreased the odds of initiating HFNC and reduced the duration of HFNC and hospital LOS. 16 At our institution, HFNC is often initiated in the pediatric emergency department for patients with m/m disease, with significant variability among providers.…”