1
|
Nama N, DeLaroche AM, Neuman MI, Mittal MK, Herman BE, Hochreiter D, Kaplan RL, Stephans A, Tieder JS. Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments. Acad Emerg Med 2024. [PMID: 38426635 DOI: 10.1111/acem.14881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/20/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). METHODS Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. RESULTS Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). CONCLUSIONS BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.
Collapse
Affiliation(s)
- Nassr Nama
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Manoj K Mittal
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bruce E Herman
- Division of Pediatric Emergency Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniela Hochreiter
- Department of Pediatrics, Division of Hospital Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ron L Kaplan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Allayne Stephans
- Division of Pediatric Hospital Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Joel S Tieder
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| |
Collapse
|
2
|
Raschein TS, Lammers S, Nickel A, Louie JP, Bergmann KR. Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department. J Pediatr 2024:113960. [PMID: 38369236 DOI: 10.1016/j.jpeds.2024.113960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/25/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, utilizing data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS In total, 94,884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI: 0.66, 0.75) and 26% (aOR 0.74; 95% CI: 0.69, 0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI: 0.73, 0.86) and 22% (aOR 0.78; 95% CI: 0.71, 0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly higher among Asian children (aOR 2.12; 95% CI: 1.19, 3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.
Collapse
Affiliation(s)
- Taryn S Raschein
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Amanda Nickel
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Jeffrey P Louie
- Division of Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN;.
| |
Collapse
|
3
|
Boles LH, Noorbakhsh KA, Smith T, Ramgopal S. Hospitalization and evaluation of brief resolved unexplained events (BRUEs) from a statewide sample. Am J Emerg Med 2023; 74:90-94. [PMID: 37802000 DOI: 10.1016/j.ajem.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE The 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown. The purpose of this study is to examine changes in the diagnosis and management of BRUE in a statewide sample of non-pediatric hospitals following publication of the CPG. METHODS This is a retrospective study of encounters of infants (<1 year) presenting to 178 non-pediatric Illinois Emergency Departments (EDs) between 2013 and 2019 with an International Classification of Disease (ICD) 9th and 10th revision billing code of ALTE or BRUE (799.82, ICD-9; R68.13, ICD-10). Our primary outcomes were counts of ALTE/BRUE and the percent of patients with ALTE/BRUE admitted and/or transferred to another facility. Our secondary outcome was clinical testing. We used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes. Results were stratified into academic and community EDs. RESULTS This study included 4639 ED encounters for infants with BRUE that presented to academic EDs (2229; 48.0%) or community EDs (2410; 52.0%). At academic EDs, ALTE/BRUE diagnoses were increasing by 2.3 per quarter prior to the CPG publication and decreased by 0.5 per quarter after the CPG publication, representing a change in slope of -2.8 per quarter (p < 0.01). The percent of ALTE/BRUE patients admitted/transferred was decreasing by 0.1% per quarter in the pre-intervention period and decreased by 0.3% per quarter in the post-intervention period, representing a change in slope of 0.7% (p = 0.03). At community EDs, ALTE/BRUE diagnoses were increasing by 2.9 per quarter prior to the CPG publication and increased by 1.4 per quarter after the CPG publication, a non-significant change in slope. The percent of ALTE/BRUE patients admitted/transferred was decreasing by 1.6% in the pre-intervention period and decreased by 0.9% in the post-intervention period, a non-significant change in slope. At academic EDs, there was no significant change in clinical testing. At community EDs, a lower proportion of patients in the post-intervention period had chest radiographs, blood cultures, metabolic panels, blood counts, and urine testing, while a higher proportion had pertussis testing and respiratory pathogen testing. CONCLUSIONS Counts of BRUE diagnoses and the overall proportion of children admitted or transferred showed a consistent decrease at academic EDs but had a nonsignificant change in trend at community EDs following the CPG publication in 2016. There was no significant change in clinical testing at academic EDs while community EDs had a significant decrease in some testing and an increase in other types of testing. Our findings suggest the need for greater implementation efforts in non-pediatric settings, specifically community EDs, where pediatric patients with BRUE present infrequently in order to optimize care for these children.
Collapse
Affiliation(s)
- Lindsay H Boles
- Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States of America.
| | - Kathleen A Noorbakhsh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
| | - Tracie Smith
- Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| |
Collapse
|
4
|
Raffaele JL, Sharma M, Berger S, Mitchell M, Lee C, Morrison J, Prasad M, Combs MD, Molas-Torreblanca K, Wood JK, Van Meurs A, Westphal K, Sawani A, Banker SL, Lee J, King C, Halvorson EE, Potisek NM. Prevalence of Invasive Bacterial Infection in Hypothermic Young Infants: A Multisite Study. J Pediatr 2023; 258:113407. [PMID: 37023947 DOI: 10.1016/j.jpeds.2023.113407] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/03/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To determine the prevalence of bacteremia and meningitis (invasive bacterial infection [IBI]) in hypothermic young infants, and also to determine the prevalence of serious bacterial infections (SBI) and neonatal herpes simplex virus and to identify characteristics associated with IBI. STUDY DESIGN We conducted a retrospective cohort study of infants ≤90 days of age who presented to 1 of 9 hospitals with historical or documented hypothermia (temperature ≤36.0°C) from September 1, 2017, to May 5, 2021. Infants were identified by billing codes or electronic medical record search of hypothermic temperatures. All charts were manually reviewed. Infants with hypothermia during birth hospitalization, and febrile infants were excluded. IBI was defined as positive blood culture and/or cerebrospinal fluid culture treated as a pathogenic organism, whereas SBI also included urinary tract infection. We used multivariable mixed-effects logistic regression to identify associations between exposure variables and IBI. RESULTS Overall, 1098 young infants met the inclusion criteria. IBI prevalence was 2.1% (95% CI, 1.3-2.9) (bacteremia 1.8%; bacterial meningitis 0.5%). SBI prevalence was 4.4% (95% CI, 3.2-5.6), and neonatal herpes simplex virus prevalence was 1.3% (95% CI, 0.6-1.9). Significant associations were found between IBI and repeated temperature instability (OR, 4.9; 95% CI, 1.3-18.1), white blood cell count abnormalities (OR, 4.8; 95% CI, 1.8-13.1), and thrombocytopenia (OR, 5.0; 95% CI, 1.4-17.0). CONCLUSIONS IBI prevalence in hypothermic young infants is 2.1%. Further understanding of characteristics associated with IBI can guide the development decision tools for management of hypothermic young infants.
Collapse
Affiliation(s)
- Jennifer L Raffaele
- Department of Pediatrics, University of South Carolina School of Medicine Greenville, Prisma Health Children's Hospital-Upstate, Greenville, NC.
| | - Meenu Sharma
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL
| | - Stephanie Berger
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL
| | - Meredith Mitchell
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - Clifton Lee
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - John Morrison
- Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madhuri Prasad
- Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Monica D Combs
- Department of Pediatrics, Keck School of Medicine of USC, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kira Molas-Torreblanca
- Department of Pediatrics, Keck School of Medicine of USC, Children's Hospital Los Angeles, Los Angeles, CA
| | - Julie K Wood
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Annalise Van Meurs
- Department of Pediatrics, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR
| | - Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Ali Sawani
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Sumeet L Banker
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY
| | - Jennifer Lee
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY
| | - Coleton King
- Department of Psychology, Clemson University, Clemson, SC
| | - Elizabeth E Halvorson
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Nicholas M Potisek
- Department of Pediatrics, University of South Carolina School of Medicine Greenville, Prisma Health Children's Hospital-Upstate, Greenville, NC; Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| |
Collapse
|
5
|
Nama N, Hosseini P, Lee Z, Picco K, Bone JN, Foulds JL, Gagnon JA, Sehgal A, Quet J, Drouin O, Luu TM, Vomiero G, Kanani R, Holland J, Goldman RD, Kang KT, Mahant S, Jin F, Tieder JS, Gill PJ. Canadian infants presenting with Brief Resolved Unexplained Events (BRUEs) and validation of clinical prediction rules for risk stratification: a protocol for a multicentre, retrospective cohort study. BMJ Open 2022; 12:e063183. [PMID: 36283756 PMCID: PMC9608523 DOI: 10.1136/bmjopen-2022-063183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Brief Resolved Unexplained Events (BRUEs) are a common presentation among infants. While most of these events are benign and self-limited, guidelines published by the American Academy of Pediatrics inaccurately identify many patients as higher-risk of a serious underlying aetiology (positive predictive value 5%). Recently, new clinical prediction rules have been derived to more accurately stratify patients. This data were however geographically limited to the USA, with no large studies to date assessing the BRUE population in a different healthcare setting. The study's aim is to describe the clinical management and outcomes of infants presenting to Canadian hospitals with BRUEs and to externally validate the BRUE clinical prediction rules in identified cases. METHODS AND ANALYSIS This is a multicentre retrospective study, conducted within the Canadian Paediatric Inpatient Research Network (PIRN). Infants (<1 year) presenting with a BRUE at one of 11 Canadian paediatric centres between 1 January 2017 and 31 December 2021 will be included. Eligible patients will be identified using diagnostic codes.The primary outcome will be the presence of a serious underlying illness. Secondary outcomes will include BRUE recurrence and length of hospital stay. We will describe the rates of hospital admissions and whether hospitalisation was associated with an earlier diagnosis or treatment. Variation across Canadian hospitals will be assessed using intraclass correlation coefficient. To validate the newly developed clinical prediction rule, measures of goodness of fit will be evaluated. For this validation, a sample size of 1182 is required to provide a power of 80% to detect patients with a serious underlying illness with a significance level of 5%. ETHICS AND DISSEMINATION Ethics approval has been granted by the UBC Children's and Women's Research Board (H21-02357). The results of this study will be disseminated as peer-reviewed manuscripts and presentations at national and international conferences.
Collapse
Affiliation(s)
- Nassr Nama
- Division of General Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Parnian Hosseini
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Zerlyn Lee
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kara Picco
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey N Bone
- Research Informatics, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Josée Anne Gagnon
- Department of Pediatrics, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Olivier Drouin
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joanna Holland
- Department of Pediatrics, Division of General Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ran D Goldman
- The Pediatric Research in Emergency Therapeutics (PRETx) Program, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Emergency Medicine, Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kristopher T Kang
- Division of General Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Falla Jin
- Clinical Research Support Unit, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Joel S Tieder
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Peter J Gill
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Patra KP, Hall M, DeLaroche AM, Tieder JS. Impact of the AAP Guideline on Management of Brief Resolved Unexplained Events. Hosp Pediatr 2022; 12:780-791. [PMID: 35965275 DOI: 10.1542/hpeds.2021-006427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES In May 2016, the American Academy of Pediatrics published a clinical practice guideline (CPG) defining apparent life-threatening events (ALTEs) as brief resolved unexplained events (BRUEs) and recommending risk-based management. We analyzed the association of CPG publication on admission rate, diagnostic testing, treatment, cost, length of stay (LOS), and revisits in patients with BRUE. METHODS Using the Pediatric Health Information Systems database, we studied patients discharged from the hospital with a diagnosis of ALTE/BRUE from January 2012 to December 2019. We grouped encounters into 2 time cohorts on the basis of discharge date: preguideline (January 2012-January 2016) and postguideline (July 2016-December 2019). We used interrupted time series to test if the CPG publication was associated with level change and change in slope for each metric. RESULTS The study included 27 941 hospitalizations for ALTE/BRUE from 36 hospitals. There was an early decrease in 12 diagnostic tests that the CPG strongly recommended against. There was a positive change in the use of electrocardiogram (+3.5%, P < .001), which is recommended by CPG. There was a significant reduction in admissions (-13.7%, P < .001), utilization of medications (-8.3%, P < .001), cost (-$1146.8, P < .001), and LOS (-0.2 days, P < .001), without a change in the revisit rates. In the postguideline period, there were an estimated 2678 admissions avoided out of 12 508 encounters. CONCLUSIONS Publication of the American Academy of Pediatrics BRUE CPG was associated with substantial reductions in testing, utilization of medications, admission rates, cost, and LOS, without a change in the revisit rates.
Collapse
Affiliation(s)
- Kamakshya P Patra
- West Virginia University Medicine Children's Hospital, Morgantown, West Virginia
| | | | | | - Joel S Tieder
- University of Washington and Seattle Children's Hospital, Seattle Washington
| |
Collapse
|
7
|
Nama N, Hall M, Neuman M, Sullivan E, Bochner R, De Laroche A, Hadvani T, Jain S, Katsogridakis Y, Kim E, Mittal M, Payson A, Prusakowski M, Shastri N, Stephans A, Westphal K, Wilkins V, Tieder J. Risk Prediction After a Brief Resolved Unexplained Event. Hosp Pediatr 2022; 12:772-785. [PMID: 35965279 DOI: 10.1542/hpeds.2022-006637] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence. METHODS We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model. RESULTS Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03). CONCLUSIONS Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).
Collapse
Affiliation(s)
- Nassr Nama
- Division of General Pediatrics, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Mark Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Erin Sullivan
- Department of Pediatrics, University of Washington, Seattle Children's Core for Biomedical Statistics, Seattle, Washington
| | - Risa Bochner
- SUNY Downstate Health Sciences University/New York City Health and Hospitals/Kings County Hospital, New York City, New York
| | - Amy De Laroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Teena Hadvani
- Division of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Shobhit Jain
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Edward Kim
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Manoj Mittal
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | | | - Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Joel Tieder
- Division of Pediatric Hospital Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
8
|
Oddo ER, Picco K, Gill PJ. Brief Resolved Unexplained Events (BRUEs): New Name, Similar Challenges. Hosp Pediatr 2022; 12:e303-e305. [PMID: 35965272 DOI: 10.1542/hpeds.2022-006742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Elizabeth R Oddo
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Kara Picco
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Hall M, Attard TM, Berry JG. Improving Cohort Definitions in Research Using Hospital Administrative Databases-Do We Need Guidelines? JAMA Pediatr 2022; 176:539-540. [PMID: 35312756 DOI: 10.1001/jamapediatrics.2022.0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Matt Hall
- Children's Hospital Association, Lenexa, Kansas.,Department of Pediatrics, Children's Mercy Kansas, Kansas City, Missouri
| | - Thomas M Attard
- Gastroenterology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Brady PW. The Second Decade of Hospital Pediatrics. Hosp Pediatr 2021; 11:659-661. [PMID: 34193587 DOI: 10.1542/hpeds.2021-006035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Patrick W Brady
- Division of Hospital Medicine and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|