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G301(P) Overtreating bronchiolitis: The price to pay for managing sepsis?
  1. H Dunlop,
  2. J Ross
  1. Paediatric Accident & Emergency, Chelsea and Wetsminster Hospital, London, UK

Abstract

Aims The publication of the NICE Sepsis guideline has provided Paediatric Emergency Departments (PED) with an early warning system (EWS) and a default management plan. This allows for identification of almost all cases of sepsis. However, there is a cost. In common with many EWS, the guideline lacks specificity which may result in those without sepsis undergoing unnecessary investigations and treatment. Bronchiolitis is a common presentation. The NICE Bronchiolitis guideline recommends not performing any investigations or treatments in almost all cases. As such, there is risk that children presenting with bronchiolitis will be over investigated and overtreated is considered at risk of sepsis.

Methods We identified 200 consecutive infants<1 years old, presenting to PED from 01/01/2016, with a diagnosis of bronchiolitis at discharge and a completed nursing triage. Children were identified through the trusts electronic database with electronic and paper records reviewed. The initial observations and nursing triage were assessed using the NICE Sepsis risk stratification tool to identify the children considered at ‘high risk’ of sepsis.

Results 213 patients were identified, 13 were excluded due to an incomplete nursing triage.

Of the 200 patients:

  1. 100 infants (50%) had at least one high risk criteria (stratified as high risk of sepsis)

  2. 43 (21.5%) had more than one criteria

The most common criteria was tachycardia (39.5%).

Of the sickest group (43 with more than one criteria):

  1. 19 (44.2%) admitted,

  2. 9 (21.9%) blood tests

  3. 4 (9.3%) intravenous antibiotics (all<3 months)

In none of the cases was the child subsequently diagnosed with sepsis, and of the 4 who received antibiotics, all cultures were negative.

Conclusion 50% of infants with bronchiolitis were stratified as high risk. The NICE Sepsis guideline, being a default management plan bolted on to an EWS, may potentially result in inappropriate antibiotics and unnecessary investigations being performed. To deviate from the default management plan requires review by a senior clinical decision makes (ST4 or above). This review may represent a logistic challenge in many busy PED making the default plan, antibiotics and all, the path of least resistance. While this is the strength of the guideline in managing sepsis, quantifying the harm it may cause in other conditions is key.

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