title: Clinicians' overestimation of febrile child risk assessment.
abstract: We aimed to estimate clinicians' based risk thresholds at which febrile children would be managed as serious bacterial infections (SBI) to determine influencing characteristics and to compare thresholds with prediction model (Feverkidstool) risk estimates. Twenty-one video vignettes of febrile children visiting the emergency department (ED) were assessed by 42 (40.4 %) international paediatricians/paediatric emergency clinicians. Questions were related to clinical risk scores of the child having SBI and SBI management decisions on visual analogue scales. Feverkidstool risk scores were based on clinical signs/symptoms and C-reactive protein. Amongst vignettes assigned to SBI management, the median risk was 60 % (interquartile range (IQR) 30.0-80.5) and 16.0 % (IQR 5.0-32.0) when vignettes were not managed as SBI. Ill appearance and aberrant circulatory signs were the most influencing factors, as age and duration of fever were the least influencing factors on SBI management decisions. Feverkidstool risk scores varied from 13 % (IQR 7.7-28.1) for SBI management to 7.3 % (IQR 5.7-16.3) for no SBI management.
  
  
  CONCLUSIONS
  Clinicians assigned high risk scores to children who they would have managed as SBI, mostly influenced by ill appearance and aberrant circulation. In contrast to SBI risk assessment of the Feverkidstool, clinicians' appeared to apply a more stepwise assessment of the risk of presence/absence of SBI at different steps in the diagnostic and therapeutic process. Uniform risk thresholds at which one should start SBI management in febrile children remains unclear; risk thresholds at which we refrained from SBI management were more consistent.
  
  
  BACKGROUND
  •Only a small proportion of febrile children presenting to the emergency department will have serious bacterial infections (SBI) and uniform risk thresholds to start or withhold SBI treatment are not known. •The low prevalence of SBI and consequently the low exposure of clinicians to these infections make them rely more on alarming signs or clinical decision rules. What is New: •Previously identified model predictors for SBI appeared to be significantly influencing factors in clinicians' febrile child management in emergency care. •Clinicians' wielded higher risk thresholds regarding SBI febrile child management than reflected by the clinical prediction model while smaller differences in risk thresholds between clinical and model prediction were observed when clinicians refrained from SBI management.
authors.affiliation: Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80 room Sp-1541, 3015 CN, Rotterdam, The Netherlands.
authors.forename: Evelien
authors.initials: E
authors.lastname: deVos-Kerkhof
authors.affiliation: Department of Health Sciences, SAPPHIRE Group, Leicester University and Leicester Hospitals, Leicester, UK.
authors.forename: Damian
authors.initials: D
authors.lastname: Roland
authors.affiliation: Department of Public Health, Centre for Medical Decision Making, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands.
authors.forename: Esther
authors.initials: E
authors.lastname: de Bekker-Grob
authors.affiliation: Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80 room Sp-1541, 3015 CN, Rotterdam, The Netherlands.
authors.forename: Rianne
authors.initials: R
authors.lastname: Oostenbrink
authors.affiliation: Department of General and Adolescent Paediatrics, UCL Institute of Child Health, Great Ormond Street, London, UK.
authors.forename: Monica
authors.initials: M
authors.lastname: Lakhanpaul
authors.affiliation: Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80 room Sp-1541, 3015 CN, Rotterdam, The Netherlands. h.a.moll@erasmusmc.nl.
authors.forename: Henriëtte A
authors.initials: HA
authors.lastname: Moll
mesh_terms: D001291:Attitude of Health Personnel; D001424:Bacterial Infections / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D005334:Fever; D006801:Humans; D007223:Infant; D008297:Male; D000069342:Medical Overuse; D010820:Physicians; D010818:Practice Patterns, Physicians'; D018570:Risk Assessment / Q000379:methods
keywords: Children; Clinical prediction model; Emergency department; Fever; Serious bacterial infections