The Kern Fever in the Emergency Department Study (Kern FEDS): Clinical appearance, serious bacterial illness, and the meaning of uncertainty.
Author and article information
Abstract
Background: Emergency department (ED) fever management algorithms require the clinician to categorize febrile children as ‘ill’ or ‘not ill’ appearing when determining the risk for serious bacterial illness (SBI). This study describes a natural experiment where an ED pediatric chart allowed clinicians a third option, ‘unsure’. Hypotheses: We hypothesized (1) that chart prompts would improve documentation of clinical appearance, and (2) that exam findings and prevalence of serious bacterial illness in infants categorized as ‘unsure’ would be intermediate between those who were ill and not ill appearing. Design: We conducted a retrospective study of 3005 ED patients aged 0-24 months who had microbiology testing for fever in the ED between 1/1/2006 and 11/30/2009. We modeled overall appearance as the dependent and individual physical findings as the independent variables with ordinal logistic regression to help establish the validity of clinical appearance as a concept. We then compared the prevalence of the components of SBI, bacterial meningitis, pneumonia, urinary tract infection (UTI) and positive blood cultures, between the categorizations, not ill appearing, unsure and ill appearing. Results: Clinical appearance was documented in 60/583 (10.3%) whose encounter was recorded on the template without prompts versus 2036/2420 (84%) with prompts (p<0.001). Age odds ratio (OR) 1.04 (95% CI 1.01, 1.07) weight (quintile) OR 0.81 (95% CI 0.70, 0.95), dehydration OR 9.68 (95% CI 7.17, 13.01), tachycardia OR 1.31 (95% CI 1.04, 1.68), tachypnea OR 2.44 (95% CI 1.61, 3.68), prior antipyretics OR 0.65 (95% CI 0.52, 0.83) and prior antibiotics OR 2.56 (95%CI 1.71, 3.82) were associated with appearance. There was an ordinal relationship between appearance and the prevalence of bacterial meningitis and pneumonia for the categories ill appearing, unsure, and not ill appearing. The prevalence of positive blood cultures among children categorized as ‘not ill appearing' and 'unsure' was similar. Urinary tract infection (UTI) prevalence was similar regardless of appearance. Conclusion: Charting prompts increased documentation of clinical appearance. There was an ordinal relationship between the prevalence of meningitis, and pneumonia, across the categories 'ill appearing', 'unsure' and 'not ill appearing'. This was not the case for blood cultures or UTI.
Cite this as
2014. The Kern Fever in the Emergency Department Study (Kern FEDS): Clinical appearance, serious bacterial illness, and the meaning of uncertainty. PeerJ PrePrints 2:e527v1 https://doi.org/10.7287/peerj.preprints.527v1Author comment
This is a submission to PeerJ for review.
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Supplemental Information
Sample Demographics and baseline characteristics
Description of sample. HR, heart rate; AMA, against medical advice; IQR, interquartile range.
Details of ordinal logistic regression model and alternative model described in Table 2
Additional Information
Competing Interests
The authors declare they have no competing interests.
Author Contributions
Paul Walsh conceived and designed the experiments, performed the experiments, analyzed the data, wrote the paper, prepared figures and/or tables, reviewed drafts of the paper.
Allan Capote conceived and designed the experiments, performed the experiments, reviewed drafts of the paper.
Davinder Garcha performed the experiments, analyzed the data, reviewed drafts of the paper.
Vu Nguyen performed the experiments, reviewed drafts of the paper.
Yvette Sanchez performed the experiments, reviewed drafts of the paper.
Nanse Mendoza performed the experiments, reviewed drafts of the paper.
Christina Thabit performed the experiments, reviewed drafts of the paper.
Valerie Aguilar performed the experiments, reviewed drafts of the paper.
James Pusavat conceived and designed the experiments, performed the experiments, reviewed drafts of the paper.
Human Ethics
The following information was supplied relating to ethical approvals (i.e., approving body and any reference numbers):
The Kern Medical Center institutional review board approved this study and granted a waiver of consent. Approval # 09011
Funding
This work was supported by in part by The Pediatric Emergency Medicine Research Foundation, Long Beach, CA and by Award Number 5K12HL108964-02 from the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes for Health (NIH), and the National Center for Advancing Translational Sciences, NIH, through grant number UL1 TR000002. The content is solely the responsibility of the authors and does not necessarily represent the official views of NHLBI or the NIH or The Pediatric Emergency Medicine Research Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
