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The role of nurses’ clinical impression in the first assessment of children at the emergency department
  1. Joany M Zachariasse,
  2. Dominique van der Lee,
  3. Nienke Seiger,
  4. Evelien de Vos-Kerkhof,
  5. Rianne Oostenbrink,
  6. Henriëtte A Moll
  1. Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
  1. Correspondence to Professor Henriëtte A Moll, Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Postbus 2060, 3000 CB, Rotterdam, The Netherlands; h.a.moll{at}erasmusmc.nl

Abstract

Objective To assess the diagnostic value and determinants of nurses’ clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED).

Design Secondary analysis of a prospective cohort.

Setting and patients 6390 consecutive children <16 years of age presenting to a paediatric ED with a non-surgical chief complaint and complete data available.

Main outcome measures Diagnostic accuracy of nurses’ clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses’ impression that a child appeared ill.

Results Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses’ clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses’ impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

Conclusion The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.

  • Accident & Emergency
  • Epidemiology

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Footnotes

  • Contributors JMZ contributed to the conceptualisation and design of the study, carried out the analyses and drafted the initial manuscript. DvdL contributed to the conceptualisation and design of the study, carried out the analyses and critically reviewed the manuscript. NS, EdV-K and RO contributed to the conceptualisation and design of the study, co-ordinated the data collection, contributed to interpretation of the data and critically reviewed the manuscript. HAM contributed to the conceptualisation and design of the study, co-ordinated and supervised data collection, supervised the analyses, contributed to the interpretation of data and critically reviewed the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval The Medical Ethical Committee of the Erasmus MC.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

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