What I learnt this week: Admission is not the ‘safe’ option #WILTW

This is the 53rd #WILTW

This week I spent time at two conferences with a theme of spotting ‘sickness’ in patients. The first was the Rapid Responses Conference, dedicated to developing new systems to identify deteriorating patients in hospital, and the second Sepsis Unplugged highlighting the importance of recognising sepsis.

There is a challenge of being able to decide which patients, child or adult, need further investigation and treatment, and which don’t. In the Rapid Reponse Conference (#METConf15) Paediatric Early Warning Systems (PEWS) were an area of discussion.

Throughout the world parents bring their children to Emergency Departments with a variety of illnesses and injuries. In the majority of cases advice or simple treatments can be given and the family can be discharged. In some the child is so unwell urgent intervention is needed and the patient will be admitted for ongoing assessment. The challenge comes in the group where the decisions are not clear cut i.e there is not an obvious infection or the source of the illness is not clear. Quite rightly junior medical and nursing staff, having been trained not to miss the sick child, will admit these infants or children to a paediatric admssions unit or ward for further observation. Furthermore there are a number of protocols and national guidance supporting this approach. A recent paper in pediatrics published this week should give all health services pause for thought though.

The study used data from six academic hospitals in the United States. The results may not be directly applicable to the UK but trends between the two countries are often very similar. The work highlighted 40 ‘harms’ for every 100 patients admitted. Harm in the study was defined as an

unintended physical injury (resulting from or contributed to) by medical care that required additional monitoring, treatment, or hospitalization, or that resulted in death.” (Adverse Events in Hospitals: Methods for Indentifying Events

Harm is not an infrequent event in hospitals. There then becomes an uncomfortable consequence of admitting a patient ‘just’ because you can. The risk of potential for harm in hospital maybe greater than the risk of harm occuring because they weren’t admitted i.e. you are making the situation worse rather than better. There are many other reasons of course why unncessary admission results in a poor experience. Parents don’t want their children to be admitted to hospital but this is more than just simply not wanting to see their loved ones unwell. There are not inconsiderable social and financial implications to missing work or providing child care if you are in hospital.

A great deal of time is spent on spotting the sick child. This is something we remain poor at doing. The harrowing story from Sam Morrish’s mother at Sepsis Unplugged highlights how we need to considerably improve our communication and understanding of parental concern. But this comes with a secondary challenge. We can not, and should not, put more children into a healthcare system which is overburdened and continually stressed. We need to be able to determine which children are safe to go home and I would argue being mindful of this challenge will improve the recognistion of serious illness in children, not diminish it.

Observation is an investigation

I will always contend that observation is the bed-rock of paediatric practice. This paper does not change my views on that.  I am also mindful of the #FOAMed communities large number of resources on highighting key conditions with the sub-text: “you don’t want to miss this!” I now find a reponsibility to deliver materials that encourage “you don’t want to admit this”. Certainly I am inspired to improve our recognition of the most sick, and most well, with even more fervour.

What have you learnt this week? #WILTW

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