| Abstract |
Background Overcrowding in Emergency Departments (ED) is a global phenomenon that has intensified in recent decades. Specifically, for pediatric EDs, the majority of the studies that have dealt with triage so far have shown that the majority of cases are children in good general condition, with mild self-limiting diseases. At the same time, however, a small group of seriously ill children who need immediate medical evaluation and intervention is identified. Numerous strategies have been developed to address the problem, including the use of assessment and severity classification scores under the term early warning scores (EWS), mainly for use in the adult population. As for pediatric patients, such scores are mainly used to predict severity and clinical deterioration in hospitalized children. This gap in the literature was identified by a group of researchers who published in early 2020 the first pediatric early warning score in order to be used in pediatric ED (ED-PEWS). At the same time, another aspect of the pediatric practice that raises concerns is the increasing use of laboratory and imaging examinations in the management and treatment of pediatric patients. In particular, especially in primary and secondary health structures, the usual practice is to order specific examination panels, the usefulness of which is questionable. In frequent pediatric diagnoses that require hospitalization such as pneumonia or gastroenteritis, it is strongly supported by the modern literature that they do not always contribute to the diagnosis, and especially to the treatment and outcome, while their implementation requires human and financial resources. Objective of this study was to record the frequencies of disorders in laboratory and imaging procedures performed on children at their admission time and to investigate whether there is a correlation between them and treatment and outcome factors. In addition, we attempted to record the severity of ED-PEWS score upon arrival of children who eventually needed admission and to investigate the extent to which the urgency category of the score predicts the presence of disorders in admission control and determines severity and outcome of the disease.
Methods This a retrospective study of hospitalized children in the Pediatric Department of Rethymno General Hospital during the period 2019-2020, regardless of cause of admission. Demographic data, clinical features and urgency category based on the ED-PEWS score were recorded upon admission. Specifically, those of the original study were used as cut off limits for the classification of children in severity categories. That is, value below 6 was classified as low urgency, value more than 15 was classified as high urgency, while values (6-15) were classified as intermediate urgency. Furthermore, laboratory data and acid-base balance parameters were recorded, as well as any imaging tests performed. Finally, the therapeutic interventions as well as the outcome factors were collected, ie the duration of hospitalization, the need for transportation in another hospital or PICU or re-admission. The aforementioned data were collected from patients' files followed by statistical analysis of results, comparison of subgroups and correlation testing. Results The study included 214 children aged 30 days-16 years who were admitted in the pediatric ward as emergencies. Upon patients‟ admission, the most common affected systems were the respiratory (88, 41.1%), gastrointestinal (50, 23.4%) and neurological (26, 12.1%) and respectively, the commonest diagnosis was pneumonia, followed by acute gastroenteritis and poisoning. The value of the ED-PEWS score was calculated in 197/214 (92%) children based on the available recorded data upon their admission to the clinic. According to the definition of severity categories, most often (88.3%) the patients of the emergency department admitted to the clinic belonged to the moderate severity category of emergency (55.3%) or high priority emergency (33%). The value of ED PEWS score showed significant correlation (r = 0.36, p <0.001) with the duration of hospitalization. Regarding the laboratory tests on hospital admission, the value of potassium (p = 0.002), urea (p = 0.014), creatinine (p = 0.007) and glucose (p <0.001) showed a significant difference between the groups. As for imaging tests, the percentage of chest radiographs requested in patients with high urgency scores was much higher and the probability of pathological findings in this group was also significantly higher, reaching 87.9% compared to 63.2 and 25% (p < 0.001) in the other two groups. Patients in the moderate group were more likely to receive fluid infusions (0.9% NaCl), a finding consistent with the most common diagnosis of gastroenteritis in this group. Among the clinical or laboratory tests, the ED-PEWS score was best correlated with the assessment of the child as ill appearing upon admission to the clinic (AUROC 0.71 (95% CI 0.63-79), p <0.001), hyperglycaemia (AUROC 0.75 (95% CI 0.67-83, p <0.001), and the need for radiography (AUROC 0.66 (95% CI 0.57-75, p = 0.001), antibiotic administration (AUROC 0.59 (95% CI 0.51-68, p = 0.04), or other treatment (AUROC 0.68 (95% CI 0.60-76, p <0.001). Conclusions The ED-PEWS score was higher in children who needed admission to the department. In addition, the children with increased scores needed longer hospitalization, with increased needs for laboratory and imaging examinations. The ED-PEWS score is a reliable tool for classifying children who present to the Emergency Department into urgency categories.
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