Abstract
IntroductionChildren often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events.MethodsWe performed a retrospective chart review encompassing a 44-month period of all pediatric patients (aged two months to 17 years) who were discharged from the ED with an abnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local quality assurance database to identify pre-defined adverse events after discharge in this population. Our primary aim was to determine the proportion of children discharged with abnormal vital signs and the frequency and nature of adverse events. Additionally, we performed a sub-analysis comparing the rate of adverse events in children discharged with normal vs. abnormal vital signs, as well as a standardized review of the nature of each adverse event.ResultsOf 33,185 children discharged during the study period, 5,540 (17%) of these patients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse events in the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events in the children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related to the index visit, was potentially preventable by a 23-hour hospital observation, and caused permanent disability.ConclusionIn our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice. Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverse events that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additional research is needed in broader populations to better determine the rate of adverse events and possible methods of avoiding them.
Highlights
Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs
In our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice
Heart rate was the most common abnormal vital sign leading to an adverse event
Summary
Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events. Tachycardia, and tachypnea are frequently seen in pediatric emergency department (ED) patients.[1,2] Experience suggests that children presumed to have a minor illness are often discharged from the ED despite having one or more abnormal vital signs and that they generally do not experience an adverse outcome. Using vital signs for risk stratification has been postulated as one potential mechanism for identifying children at high risk for sepsis. Several studies have been published evaluating the diagnostic and predictive utility of vital sign abnormalities at the time of presentation and during an ED visit in pediatric patients.[2,3,4,5] several pediatric clinical prediction rules have included vital signs in their analysis of the likelihood of sepsis in febrile children.[6,7,8,9,10,11,12,13,14,15,16,17,18] we are unaware of any literature examining the practice of discharging children from the ED who have abnormal vital signs at the time of discharge
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