This is the 163rd #WILTW
Nearly a year ago I wrote on Sepsis and Self-Doubt
The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.
I highlighted the importance of doubt in decision making. It is not possible to admit all children who have features of infection. We must select those with high risk signs/symptoms for investigation & treatment and discharge low risk cases with adequate safety netting. This in itself is a conundrum and it is important that senior clinicians wrestle with this balance of risk. For not to do so results in either over-treatment, or in-appropriately conservative management. This is a significant cognitive and emotional drain, and in the context of spiralling presentations, it’s imperative we reduce the decision making load on acute and emergency clinicians.
It was for this reason I reacted strongly to a piece on the potential reasons behind the ever increasing access of emergency care by children and young people. In retrospect I was a little OTT in my concerns regarding an inference that there is a financial incentive to admit patients to hospital (see comment at the end of the article). With all due respect to Quality Watch they responded and amended the text. We are both agreed the current financial model (where hospitals receive a set payment for each child admitted) sadly does mean there is little incentive to change the system.
The original version had hit a nerve because inappropriate admission to hospital makes diagnosing serious illness harder. A rising patient load of a potentially high risk group of children makes case selection on admission units and wards even harder. While there is much work to do in educating professionals and parents on the core features of common illnesses, neither group wishes children or young people to be in hospital unless they really have to be.
Over the last year it has become increasingly apparent to me that we are probably too focused on the identification of illness in the initial stages of a patient journey. Would it be easier to spot the needle if the haystack was smaller? Should the paradigm be spotting the well child early (and discharging) rather than the sick child late? We endeavour to create more specific scoring systems, biomarkers and analytics to identify the most unwell when we probably need none of these things to identify the well. It may be argued that discharging normality is a core function of medicine, I would challenge whether we truly operate out of that mindset. And if we wanted a different form of incentive, wouldn’t rewarding the rapid, but safe, recognition of the most well be in everyone’s best interest?
What have you learnt this week? #WILTW
A video exploring this theme: