Objectives: To study the determinants and appropriateness of hospitalisation of febrile children in a paediatric emergency department.
Design: An observational prospective study.
Setting and subjects: Patients presenting to the emergency department of the Edinburgh Royal Hospital for Sick Children over nine consecutive weeks.
Methods: Clinical and laboratory data were collected from patients presenting with an infectious illness. A three point scale was used to assess both the degree of severity of illness and the probability of bacteraemic illness. Patients who received the following therapies in hospital were identified: intravenous antibiotics, intravenous fluids, oxygen therapy, upper airway suctioning or nasogastric feeding. The clinical and laboratory characteristics of patients admitted to the hospital were studied.
Results: A third of the five thousand and twenty one patients seen presented with an infectious illness. Of these, 42% were febrile, while 22% had a high temperature (> 38.5 degrees C). Forty one per cent were hospitalised and of these only 44% received one or more of the treatments mentioned above. Only the illness-severity--score predicted the requirement for such treatment. This clinical scoring was also a powerful predictor of bacterial infection. The positive predictive value of a high temperature (> 38.5 degrees C) in predicting bacterial infection was 40%. The negative and positive predictive values for neutrophilia (> 10 x 10(9)/1) were 47% and 77% respectively. Forty three per cent of the admitted patients were investigated with blood culture and 2.5% of blood cultures were positive for a pathogenic organism. There were no Hib isolates. The positive and negative predictive values of a high temperature for bacteraemic illness were 5% and 99% respectively.
Conclusion: A large proportion of paediatric patients is perhaps unnecessarily hospitalised. Inappropriate hospitalisation may be prevented by the development and implementation of guidelines based on objective criteria. Enhancement of the role of ambulatory paediatrics in the care of febrile children may be more cost-effective than anticipatory hospitalisation.