A comparison of fever management by pediatric-trained and non–subspecialty-trained emergency physicians

Abstract

Study objectives: In 1993, the American Academy of Pediatrics and the American College of Emergency Medicine jointly published guidelines for the management of fever without a source in infants and young children. Despite widespread recognition in the literature, actual compliance with these guidelines has produced a far different picture and demonstrates that acceptance has been less than robust. Our null hypothesis is that no differences exist between general emergency physicians and pediatric emergency physicians in evaluating infants and young children with fever. Methods: The research protocol was approved by the Inova Fairfax institutional review board. The Inova Fairfax Hospital emergency department (ED) is a general ED with an annual pediatric census of 21,000. The emergency pediatric section consists of 10 subspecialty-trained emergency physicians. Consecutive medical records of febrile children younger than 36 months were retrospectively examined between December 1, 2003, and March 31, 2004. Evaluation and management of fever in the well-appearing child by physicians with advanced pediatric training and general emergency medicine training were compared with accepted published guidelines. Fever thresholds used were 38.0°C for children younger than 1 month, 38.2°C for children aged 31 to 90 days, and 38.5°C for children older than 3 months of age. General emergency physician and pediatric emergency physician practices were compared for diagnostic studiesials. Nominal data were analyzed using either χ² or Fisher's exact tests. Parametric continuous data were analyzed using a <i>t</i> test. Means and confidence intervals (CIs) were calculated. α Was set at 0.05 for all comparisons. Results: Of 184 records examined, 101 (55%) were seen by pediatric specialists and 83 (45%) by general emergency physicians. No significant differences in adherence to generally accepted fever guidelines were detected between general emergency physicians and pediatric emergency physicians. The violation rates were 38 of 101 (38%, 95% CI 28% to 48%) for pediatric specialists and 31 of 83 (37%; 95% CI 27% to 49%) for general emergency physicians; the 2 groups were not significantly different. Five of 38 (13%; 95% CI 4% to 28%) violations were related to inappropriate treatment. The other 33 of 38 (87%; 95% CI 72% to 96%) were omissions of indicated laboratory studies. Although there was a trend toward increased use of diagnostic studies by general emergency physicians, nothing approached statistical significance; however, the number of viral antigen studies ordered by general emergency physicians was of interest: pediatric emergency physicians 38% (95% CI 28% to 48%) versus general emergency medicine 52% (95% CI 41% to 63%). Disposition and management between general emergency physicians and pediatric emergency physicians also were similar: antibiotic administration rates for pediatric emergency physicians were 52% (95% CI 42% to 62%) versus general emergency physicians 48% (95% CI 37% to 59%), and hospital admission rates for pediatric emergency physicians were 19% (95% CI 12% to 28%) versus general emergency physicians 18% (95% CI 11% to 28%). Conclusion: In a busy practice where general emergency physicians are treating children alongside specialty-trained pediatric emergency physicians, the management of pediatric fever is equivalent. General emergency physicians do not differ from their pediatric emergency physicians colleagues in terms of deviation from published guidelines, disposition, or management of febrile children 0 to 36 months of age.