Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study

Abstract

Background

In high-income countries, critical illness in children is rare, and often difficult for physicians to distinguish from common minor illness until late in the disease. Parents or caregivers are well positioned to detect early and subtle signs of deterioration, but the relationship between their concerns and patient outcomes is unknown. We aimed to examine the relationship between documented caregiver concern about clinical deterioration and critical illness in children presenting to hospital.

Methods

This prospective observational cohort study was conducted in the tertiary paediatric emergency department and inpatient paediatric wards at Monash Children's Hospital, Melbourne, Australia. We included patients younger than 19 years with a complete medical record, with a documented response to the question “Are you worried your child is getting worse?” asked to caregivers during their child's emergency department visit or hospital admission. The primary objective of this study was to examine the relationship between caregiver concern for clinical deterioration and critical illness, defined as intensive care unit admission, in paediatric patients presenting to hospital. Secondary objectives were to determine the relationship between caregiver concern for clinical deterioration and mechanical ventilation or death of the child, and to compare documented caregiver concern for deterioration with standard predictors of deterioration, such as abnormal vital signs. Multivariable analysis assessed whether caregiver concern for clinical deterioration was associated with intensive care unit (ICU) admission, mechanical ventilation, or death for all included patients.

Findings

In 26 months, from Nov 1, 2020 to Dec 31, 2022, 79 166 children younger than 19 years presented to the emergency department. 433 children were excluded due to transfer to a different hospital and 4888 were excluded as there were no sets of vital signs recorded after triage. Of the remaining 73 845 children with eligible emergency department presentations, 24 239 had at least one documented response for parent or caregiver concern (11 431 [47·2%] males and 12 808 [52·8%]) females). There were a total of 189 708 responses, and 8937 (4·7%) of these indicated concern for clinical deterioration. Compared with patients with caregivers without documented concerns, those with a caregiver reporting concern for clinical deterioration were more likely to be admitted to the ICU (6·9% [326/4721] vs 1·8% [352 of 19 518]), to be mechanically ventilated (1·1% [53 of 4721] vs 0·2% [48 of 19 518]), or die during admission (0·1% [five of 4721] vs 0·02% [four of 19 518]). Multivariable analysis showed caregiver concern for clinical deterioration was associated with ICU admission (adjusted odds ratio [aOR] 1·72 (1·40–2·11) and mechanical ventilation (aOR 1·85 (1·36–3·15), but not death (aOR 1·02 (0·18–5·81). After adjustment for other variables, caregiver concern (aOR 1·72 [95% CI 1·40–2·11]) was more strongly associated with ICU admission than any abnormal vital sign (ranging from aOR 1·12 [95% CI 1·08–1·17] for abnormal heart rate to aOR 1·26 [1·21–1·32] for abnormal respiratory rate).

Interpretation

Caregiver concern for clinical deterioration is associated with critical illness in paediatric patients and, after adjusting for variables including abnormal vital signs, had a strong association with ICU admission and mechanical ventilation. Rapid response systems should incorporate proactive assessment of parent or caregiver concerns for deterioration.

Funding

Australian Government Medical Research Future Fund and Equity Trustees: The Monash Partners Children's Acute Care Data Project.