G348(P) Use of the ‘step-by-step’ approach in identifying low risk febrile infants in the emergency department

Abstract

Aims The European ‘Step-by-Step’ algorithm (Gomez et al) has been shown to be superior in the management of febrile infants compared with the Rochester and Lab-Score criteria, especially identifying low risk patients. If we applied the ‘Step-by-Step’ algorithm retrospectively to an audit could we identify areas to improve our capability and confidence of recognising low risk patients, including the use Procalcintonin (PCT). Methods An audit over 6 months from November 2016 to April 2017 at Evelina Children’s Hospital Paediatric Emergency Department recorded the investigation and management of all infants aged 1–3 months who had a fever recorded at triage or a history of fever recorded in nursing triage. We excluded patients less than 4 weeks old as fever in the neonatal period is treated as high risk. Results Sixteen infants aged 1–3 months presented with a fever (only two with a fever >24 hours), thirteen were admitted and given intravenous antibiotics, the average length of admission was twenty-eight hours. Only one had a CRP >20, two had leukocytouria and none had a raised WCC or neutrophil count. Forty-two infants aged 1–3 months were triaged with a history of fever, nineteen were admitted for intravenous antibiotics, the average length of admission was fifteen hours. Two had a rise in CRP, three showed leukocytouria and two showed raised neutrophils. No cases of isolated bacterial pathogen in blood or CSF were identified in either group. Using the ‘Step-by-Step’ approach seven (54%) with fever and six (32%) with a history of fever who were admitted and treated could be identified as low risk. The most reliable identification for high risk is clinical appearance. Conclusion The ‘Step-by-Step’ approach is a valuable and a more applicable tool than previous methods in the management of febrile infants. This approach shows we can improve our method of identification of low risk patients in infants aged 1–3 months that present with fever, possibly reducing admissions. PCT could also be a further useful step in identifying low risk patients. Reference . Gomez, et al. Validation of the ‘step-by-step’ approach in management of young febrile infants. Paediatrics2016;138. doi:10.1542/ped.2015-4381