Discharge criteria for inpatient paediatric asthma: a narrative systematic review.

INTRODUCTION: Criteria-led discharges (CLDs) and inpatient care pathways (ICPs) aim to standardise care and improve efficiency by allowing patients to be discharged on fulfilment of discharge criteria. This narrative systematic review aims to summarise the evidence for use of CLDs and discharge criteria in ICPs for paediatric inpatients with asthma, and summarise the evidence for each discharge criterion used. METHODS: Database search using keywords was performed using Medline, Embase and PubMed for studies published until 9 June 2022. Inclusion criteria included: paediatric patients <18 years old, admitted to hospital with asthma or wheeze and use of CLD, nurse-led discharge or ICP. Reviewers screened studies, extracted data and assessed study quality using the Quality Assessment with Diverse Studies tool. Results were tabulated. Meta-analysis was not performed due to heterogeneity of study designs and outcomes. RESULTS: Database search identified 2478 studies. 17 studies met the inclusion criteria. Common discharge criteria include bronchodilator frequency, oxygen saturation and respiratory assessment. Discharge criteria definitions varied between studies. Most definitions were associated with improvements in length of stay (LOS) without increasing re-presentation or readmission. CONCLUSION: CLDs and ICPs in the care of paediatric inpatients with asthma are associated with improvements in LOS without increasing re-presentations or readmissions. Discharge criteria lack consensus and evidence base. Common criteria include bronchodilator frequency, oxygen saturations and respiratory assessment. This study was limited by a paucity of high-quality studies and exclusion of studies not published in English. Further research is necessary to identify optimal definitions for each discharge criterion.

Differentiating vaccine reactions from invasive bacterial infections in young infants presenting to the emergency department in the 4CMenB era: a retrospective observational comparison.

BACKGROUND: Differentiating infants with adverse events following immunisation (AEFIs) or invasive bacterial infection (IBI) is a significant clinical challenge. Young infants post vaccination are therefore often admitted to the hospital for parenteral antibiotics to avoid missing rare cases of IBI. METHODS: During a service evaluation project, we conducted a single-centre retrospective observational study of infants with IBI, urinary tract infection (UTI) or AEFI from two previously published cohorts. All patients presented to hospital in Oxfordshire, UK, between 2011 and 2018, spanning the introduction of the capsular group-B meningococcal vaccine (4CMenB) into routine immunisation schedules. Data collection from paper and electronic notes were unblinded. Clinical features, including National Institute for Health and Care Excellence (NICE) 'traffic light' risk of severe illness and laboratory tests performed on presentation, were described, and comparisons made using regression models, adjusting for age and sex. We also compared biochemical results on presentation to those of well infants post vaccination, with and without 4CMenB regimens. RESULTS: The study included 232 infants: 40 with IBI, 97 with probable AEFI, 24 with possible AEFI, 27 with UTI and 44 post vaccination 'well' infants. C-reactive protein (CRP) was the only discriminatory blood marker, with CRP values above 83 mg/L only observed in infants with IBI or UTI. NICE risk stratification was significantly different between groups but still missed cases of IBI, and classification as intermediate risk was non-differential. Fever was more common in probable AEFI cases, while seizures and rashes were equally frequent. Diarrhoea and clinician-reported irritability or rigours were all more common in IBI. CONCLUSIONS: Clinical features on presentation may aid risk stratification but cannot reliably differentiate IBI from AEFI in infants presenting to the emergency department. Blood results are generally unhelpful due to post vaccination inflammatory responses, particularly in children receiving 4CMenB vaccination. Improved biomarkers and clinical prediction tools are required to aid management in febrile infants post vaccination.