Modified systemic inflammatory response syndrome and provider gestalt predicting adverse outcomes in children under 5\xa0years presenting to an urban emergency department of a tertiary hospital in Tanzania

Meera R Nariadhara,Victor Mwafongo,Hendry R Sawe,Brittany L Murray,Michael S Runyon

doi:10.1186/s41182-019-0136-y

Abstract

BackgroundModified systemic inflammatory response syndrome (mSIRS) criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes. However, this has not been studied in low-income countries. We investigated the ability of mSIRS and provider gestalt to predict mortality and morbidity among children presenting to the ED of a tertiary level hospital in Tanzania.MethodsThis prospective observational study enrolled a convenience sample of children under 5 years old, presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2015 to April 2016. Trained researchers used a structured case report form to record patient demographics, clinical presentation, initial provider gestalt of severity of illness, and the mSIRS criteria. Primary outcomes were 24-h mortality and overall in-hospital mortality. Data was analyzed using simple descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and chi-squared tests.ResultsWe enrolled 1350 patients, median age 17 months (interquartile range 8–32 months), and 58% were male. Provider gestalt estimates of illness severity were recorded for all patients and 1030 (76.3%) had complete data for mSIRS categorization. Provider gestalt classified 97 (7.2%) patients as healthy, 546 (40.4%) as mildly ill, 457 (33.9%) as moderately ill, and 250 (18.5%) as severely ill. Of the patients, classifiable by mSIRS, 411/1030 (39.9%) had ≥ 2 mSIRS criteria. In predicting 24-h mortality, the ≥ 2 mSIRS and gestalt “severely ill” had sensitivities of 82% and 81%, respectively, and specificity of 61% and 84%, respectively. In predicting overall in-hospital mortality, the ≥ 2 mSIRS and gestalt “severely ill” had sensitivities of 66% and 70% with a specificity of 62% and 86% respectively.ConclusionBoth the mSIRS and provider gestalt were highly specific for predicting 24-h and overall in-hospital mortality in our patient population. The clinical utility of these assessment methods is limited by the low positive predictive value.

Highlights

Modified systemic inflammatory response syndrome criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes
Where some countries utilize the predictive value of the modified systemic inflammatory response syndrome (mSIRS) criteria for severity of illness and outcome in patients, some utilize provider gestalt to a greater degree, yet others use them in combination to predict the severity of illness and make management decisions in pediatric patients
Children categorized into being assessable by the mSIRS criteria were found to be younger than those who could not be categorized by the mSIRS criteria (p < 0.0001) and were more likely to present with hypoxia (Table 1)

Summary

Introduction

Modified systemic inflammatory response syndrome (mSIRS) criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes. This has not been studied in low-income countries. The modified systemic inflammatory response syndrome (mSIRS) criteria and provider gestalt are recognized assessment tools providing critical information to guide early, lifesaving interventions [9,10,11,12,13,14,15]. Multiple studies documented in the past have established the significance of the mSIRS criteria and/ or provider gestalt in better predicting the severity of illness in patients seen at emergency departments (EDs) [17]

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