title: Self-referral and serious illness in children with fever.
abstract: OBJECTIVE
  The goal of this study was to evaluate parents' capability to assess their febrile child's severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers.
  
  
  METHODS
  This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006-2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms).
  
  
  RESULTS
  Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75-2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers.
  
  
  CONCLUSIONS
  Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child's illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.
authors.affiliation: Department of General Pediatrics, Erasmus MC/Sophia Children’s Hospital, Rotterdam, Netherlands. y.vanierland@erasmusmc.nl
authors.forename: Yvette
authors.initials: Y
authors.lastname: van Ierland
authors.forename: Nienke
authors.initials: N
authors.lastname: Seiger
authors.forename: Mirjam
authors.initials: M
authors.lastname: van Veen
authors.forename: Alfred H J
authors.initials: AH
authors.lastname: van Meurs
authors.forename: Madelon
authors.initials: M
authors.lastname: Ruige
authors.forename: Rianne
authors.initials: R
authors.lastname: Oostenbrink
authors.forename: Henriëtte A
authors.initials: HA
authors.lastname: Moll
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D003657:Decision Making; D059026:Diagnostic Self Evaluation; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000628:therapy; D058006:General Practice / Q000379:methods / Q000706:statistics & numerical data*; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D008297:Male; D009426:Netherlands; D016017:Odds Ratio; D010287:Parent-Child Relations; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index