Pre- and postpaediatric emergency care: Where do we go from here?

The decision to come to an emergency department (ED) is often difficult for a parent. In addition to concerns about the immediate symptoms of their children, parents are often anxious about perceived deterioration and significant illness. This is likely to occur to a greater degree in paediatric patients than in adult patients. Also, younger paediatric patients are often developmentally unable to communicate their symptoms. Finally, paediatric patients may present with common benign symptoms such as fever, and subsequently have serious illnesses such as bacteremia and meningitis, but will often initially look quite well.

Some common conditions in paediatric patients that need ED care include difficulty breathing, head trauma, seizures, loss of consciousness, severe abdominal pain or concerns of abuse. Many injuries such as broken bones, major sprains, and injuries to the eyes and hands require ED care. Fever greater than 38ºC (rectal) in infants younger than three months of age, and fever in older infants and children if clinically unwell-appearing, require evaluation in the ED. Also, children with vomiting and/or diarrhea, if dehydrated or lethargic, should be evaluated acutely. Although rare in paediatrics, any suicidal child or adolescent warrants immediate assessment (1).

Although not inclusive, this list serves as a guideline for any paediatric patient. Additionally, many paediatric patients with complex underlying medical or surgical problems may initially present with minor complaints and may subsequently deteriorate. A lower threshold for ED evaluation of these patients is often warranted. For those parents who are unsure about their decision, there exists many options including telephone advice from their primary care physician, after-hour clinics and, in some cases, provincial telephone advice centres.

At the completion of assessment and for those deemed stable enough for ongoing outpatient care and follow-up, discharge instructions (DIs) provide an opportunity to clarify the working diagnosis, describe treatments given and, finally, educate parents when to follow up with their physician and when to return to the ED. It is important to distinguish the latter to avoid unnecessary ED revisits, while at the same time to ensure that patients who do deteriorate will come back quickly for appropriate assessment and care.

To that end, given the patient's presumptive diagnosis, instructions to return should include specific information relevant to that condition and some general systemic symptoms. For example, a patient with pneumonia who is stable enough for outpatient therapy may worsen despite appropriate care, and should return if increased respiratory rate and work of breathing such as indrawing (specific) develop. Additionally, if patients are septic or hypoxic, they would look lethargic or ‘very ill appearing’ and this should also be described (general). For other symptoms, returning to their primary care physician is more appropriate.

Finally, there is some literature on how to give DIs that merits mention. First, instructions should be given out – it is remarkable that many EDs still do not give out formal DIs (2). These instructions are best understood and result in increased compliance when they are standardized (3), simplified and written at a grade 4 to 5 reading level (4); used with illustrations (5) and written in several languages. Although this has become the standard of care at most paediatric institutions, many centres would do well to adopt similar strategies. Interestingly, one study (6) found that the biggest contribution to misunderstanding was the use of medical terminology.

The decision to come to the ED and the immediate period after being given DIs is often a stressful time for parents. Access to community resources is fundamental to help guide parents in the decision to come, while clear and simplified instructions in a language that they can understand is crucial to their compliance and follow-up. Future research is needed to better delineate whether our interventions are improving care and patient satisfaction.

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