Abstract
BackgroundFever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children.MethodsClinical recommendations were extracted from five CPGs and formulated into 47 clinical indicators for use in auditing adherence. Indicators were categorised by phase of care: assessment, diagnosis and treatment. Patient records from children aged 0 to 15 years were sampled from general practices (GP), emergency departments (ED) and hospital admissions in randomly-selected health districts in Queensland, New South Wales and South Australia during 2012 and 2013. Paediatric nurses, trained to assess eligibility for indicator assessment and adherence, reviewed eligible medical records. Adherence was estimated by individual indicator, phase of care, age-group and setting.ResultsThe field team conducted 14,879 eligible indicator assessments for 708 visits by 550 children with fever in 58 GP, 34 ED and 28 hospital inpatient settings. For the 33 indicators with sufficient data, adherence ranged from 14.7 to 98.1%. Estimated adherence with assessment-related indicators was 51.3% (95% CI: 48.1–54.6), 77.5% (95% CI: 65.3–87.1) for diagnostic-related indicators and 72.7% (95% CI: 65.3–79.3) for treatment-related indicators. Adherence for children < 3 months of age was 73.4% (95% CI: 58.0–85.8) and 64.7% (95% CI: 57.0–71.9) for children 3–11 months of age, both significantly higher than for children aged 4–15 years (53.5%; 95% CI: 50.0–56.9). The proportion of adherent care for children attending an ED was 77.5% (95% CI: 74.2–80.6) and 76.7% (95% CI: 71.7–81.3) for children admitted to hospital, both significantly higher than for children attending a GP (40.3%; 95% CI: 34.6–46.1).ConclusionsThis study reports a wide range of adherence by clinicians to 47 indicators of best practice for the management of febrile children, sampled from urban and rural regions containing 60% of the Australian paediatric population. Documented adherence was lowest for indicators related to patient assessment, for care provided in GP settings, and for children aged 4–15 years.
Highlights
Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection
The proportion of adherent care received by children attending an emergency departments (ED) was 77.5% and 76.7% for children admitted to hospital, both significantly higher than for children attending a general practices (GP) (40.3%; 95% CI: 34.6–46.1); see Table 4
One explanation for the lower adherence for children aged 4–15 years may be that as clinical practice guideline (CPG) are focussed on care for children who are under 5 years old or less [10,11,12,13,14], clinicians may be less likely to use them as a guide for older children
Summary
Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children. Most children present as mildly unwell, so the key challenge for clinicians is to quickly triage those few with serious underlying infections who are at risk of deterioration, whilst avoiding over-investigation and overmedication of the many children whose fever will resolve and only require symptomatic support and reassurance. Clinical practice guidelines (CPGs), prediction rules and pathways aim to assist clinician judgement in distinguishing self-limiting viral conditions from more serious illnesses, including life-threatening sepsis, and in managing care appropriately
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