title: Impact of a clinical decision model for febrile children at risk for serious bacterial infections at the emergency department: a randomized controlled trial.
abstract: OBJECTIVE
  To assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED).
  
  
  METHODS
  Randomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n = 219) or the control group (usual care; n = 220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for "pneumonia" and "other SBI". Nurses were guided by the intervention to initiate additional tests for high-risk children. The clinical decision model was evaluated by 1) area-under-the-receiver-operating-characteristic-curve (AUC) to indicate discriminative ability and 2) feasibility, to measure nurses' compliance to model recommendations. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs.
  
  
  RESULTS
  The decision model had good discriminative ability for both pneumonia (n = 33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n = 22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination were observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value < 0.05) and more urine-dipstick testing (71% vs. 61%, p-value < 0.05).
  
  
  CONCLUSIONS
  In contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved, however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing.
  
  
  BACKGROUND
  Nederlands Trial Register NTR2381.
authors.affiliation: Department of general pediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, the Netherlands.
authors.forename: Evelien
authors.initials: E
authors.lastname: de Vos-Kerkhof
authors.affiliation: Department of general pediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, the Netherlands.
authors.forename: Ruud G
authors.initials: RG
authors.lastname: Nijman
authors.affiliation: Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Centre, Rotterdam, the Netherlands.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.affiliation: Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Polinder
authors.affiliation: Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Centre, Rotterdam, the Netherlands.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, the Netherlands.
authors.forename: Johan
authors.initials: J
authors.lastname: van der Lei
authors.affiliation: Department of general pediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, the Netherlands.
authors.forename: Henriëtte A
authors.initials: HA
authors.lastname: Moll
authors.affiliation: Department of general pediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, the Netherlands.
authors.forename: Rianne
authors.initials: R
authors.lastname: Oostenbrink
mesh_terms: D002675:Child, Preschool; D000066491:Clinical Decision-Making / Q000379:methods*; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008954:Models, Biological; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000628:therapy / Q000652:urine; D012307:Risk Factors