The goal of this study was to evaluate parents’ capability to assess their febrile child’s severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers.
This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006–2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms).
Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75–2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers.
Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child’s illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.
We read van Ierland and colleagues article (1) with great interest, especially their findings that children with fever referred by their GP were twice as likely to require intensive diagnostic or therapeutic management as those self-referred by their parents.
We recently performed a similar analysis in a different cohort of pediatric patients. Over a 6 month period we looked at all 299 neonates presenting to the Emergency Department of a district general hospital in London. We were prompted to do this after the introduction of a '6 hour discharge' whereby neonates leave hospital quickly post-delivery, leaving little time to educate parents on problems traditionally addressed during longer postnatal stays. We anticipated this might lead to an increased number of unnecessary self-referrals within this patient group during the first few weeks of life.
51% (n=153) of total presentations were self-referrals, while 30% (n=89) and 19% (n=57) were referred by their GP and midwife respectively. As expected, we found presentation rates declined with increasing age. Referral rates were highest in the first week of life (65% of total), which is the commonest time for poor feeding or jaundice to manifest during midwifery checks. Beyond this time period neonates were more likely to have self-referred (OR 2.89, P 0.001), particularly if presenting out- of-hours (P 0.000). Similarly to van Ierland et al (1) we found neonates referred by community-based healthcare professionals were significantly more likely to require admission (OR 2.14, P 0.003) and further interventions, such as nasogastric feeding, phototherapy and intravenous antibiotics or fluids (OR 2.18, P 0.003).
Van Ierland et al (1) report that as 1 in 4 self-referred febrile children required some form of intervention, parents should not be discouraged to self-present. Although our study produced similar results, with 23% of self-referred neonates being admitted, we would still draw slightly different conclusions: 16% (n=48) of neonates had no features of concern in the history and no discernible signs on examination. This presentation was significantly more common in the self-referral group (23% vs 9% in referred group, P 0.004). A further 16% of self-referred neonates (n=25) had non-urgent or normal conditions such as nappy rash, erythema toxicum or mild coryzal symptoms: these attendances in particular may have been avoided with better postnatal education or easier access to community healthcare.
Although we would never aim to discourage parents from bringing their neonates directly to the ED if concerned - parental instinct should undoubtedly not be ignored - reducing unnecessary visits to a hospital emergency department not only reduces the workload, but also prevents these vulnerable patients from being exposed to other potentially infectious agents. The majority of self-referred neonates (76%) needed no interventions beyond verbal advice or reassurance and were discharged home direct from ED. We would therefore advocate a simple educational program for parents, preferably prior to discharge from the postnatal ward, covering common benign neonatal conditions and the community-based healthcare options available to them so the Emergency Department is not the first port of call for this vulnerable cohort of pediatric patients.
Sincerely,
Lucinda C Winckworth (MA BMBCh), Arabella L Simpkin (MA BMBCh), Sarah MB Walton (MA MBBChir)
Conflict of Interest:
None declared