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PED-EM-L  December 2015

PED-EM-L December 2015

Subject:

Re: ALTE

From:

"Linzer, Jeffrey F" <[log in to unmask]>

Reply-To:

Linzer, Jeffrey F

Date:

Thu, 3 Dec 2015 01:53:40 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (532 lines)

It's interesting to note that there wasn't a unique ICD code for ALTE until October 2009. All studies prior to that date had to use surrogate diagnoses terms in finding their patient populations.

Jeff


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mittal, Manoj K
Sent: Wednesday, December 02, 2015 7:11 PM
To: [log in to unmask]
Subject: Re: ALTE

Hi guys,

We followed the single-center prospective study referenced by Kevin with a multi-center prospective study. This study also had no mortality during admission or within 48 hrs of d/s. Together the 2 prospective studies had > 1100 infants.
 (Apparent Life-Threatening Event: Multicenter Prospective Cohort Study to Develop a Clinical Decision Rule for Admission to the Hospital.
Amy H. Kaji, MD, PhD; Ilene Claudius, MD; Genevieve Santillanes, MD; Manoj K. Mittal, MD; Katie Hayes, BS; Jumie Lee, CPNP, MSN; Marianne Gausche-Hill, MD Ann Emerg Med. 2013;61:379-387).

For the single center study, we followed the cohort for 6 months; 2 infants died (one by suffocation-father slept over the infant on a couch; 2nd from airway obstruction related to a mass in the pharynx that was identified during the original stay), resulting in a mortality rate of 0.67% (close to the overall infant mortality rate of about 0.5 in the USA).

These studies show that ALTE has a benign natural history with low morbidity and very low mortality.

We should target ED workup based on H&P.
There is no evidence to recommend routine:

CBC, blood glucose, electrolytes
Chest radiograph
ECG, Holter monitor
Testing for pertussis, viruses, blood, urine, CSF studies Toxicology; or Inborn errors of metabolism (Mittal MK. Shofer FS. Baren JM. Serious bacterial infections in infants who have experienced an apparent life-threatening event. Annals of Emergency Medicine. 54(4):523-7, 2009 Oct Tieder JS et al. Management of Apparent Life-Threatening Events in Infants: A Systematic Review. J Peds 2013 Claudius I, Mittal MK, Murray R, Condie T, Santillanes G. Should Infants Presenting with an Apparent Life Threatening Event Undergo Evaluation for Serious Bacterial Infections and Respiratory Pathogens? J Peds 2014.}


< 20% of infants hospitalized with ALTE have a significant intervention warranting hospital admission.
Indications for hospitalization:
Obvious need for admission / Abnormal exam in the ED
Prematurity/other sig. past medical history
>1 episode in last 24 hrs
Cyanosis as the color change
Lack of h/o choking/gagging

Thanks,
Manoj

Manoj Mittal, MD
CHOP






________________________________________
From: Pediatric Emergency Medicine Discussion List <[log in to unmask]> on behalf of Kevin Powell <[log in to unmask]>
Sent: Wednesday, December 2, 2015 5:42 PM
To: [log in to unmask]
Subject: Re: ALTE

I don't think either universal admission or universal discharge from ER are
ideal strategies. Consider the article appended below from CHOP which has
the opposite spin. I do not use the decision rule but it is an effort toward
consistency in care.

That study had 300 infants enrolled, 228 admitted, with no deaths in-house
or after discharge. So it was twice the size of Jay's article and if
combined in a meta-analysis, the risk is much lower than 1%.



The fact that deaths occurred in spite of admission is interesting. The
diagnosis of pneumonia severe enough to cause death in a well appearing
infant is suspect. Some sort of idiosyncratic event seems likely.

The negative blood cultures suggest it isn't sepsis. Perhaps the infants had
an inborn error of metabolism and were pushed over the edge by a mild
illness.



I use to ask residents whether a lab value would change what they would do.
If not, then don't order the lab. Nowadays I don't ask if it would change
what they would do, I ask if it will change outcomes.



ALTEs (aka BRUEs) are common admissions for pediatric hospitalists. There
are a few researchers studying the problem. I expect their new guidelines to
be enlightening.



 <http://www.ncbi.nlm.nih.gov/pubmed/22743742> Pediatr Emerg Care. 2012
Jul;28(7):599-605. doi: 10.1097/PEC.0b013e31825cf576.

A clinical decision rule to identify infants with apparent life-threatening
event who can be safely discharged from the emergency department.


<http://www.ncbi.nlm.nih.gov/pubmed/?term=Mittal%20MK%5BAuthor%5D&cauthor=tr
ue&cauthor_uid=22743742> Mittal MK1,
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Sun%20G%5BAuthor%5D&cauthor=true&c
author_uid=22743742> Sun G,
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Baren%20JM%5BAuthor%5D&cauthor=tru
e&cauthor_uid=22743742> Baren JM.

 <http://www.ncbi.nlm.nih.gov/pubmed/22743742> Author information

.         1Division of Emergency Medicine, The Children's Hospital of
Philadelphia, Philadelphia, PA 19104, USA. [log in to unmask]

Abstract

OBJECTIVE:

This study aimed to formulate a clinical decision rule (CDR) to identify
infants with apparent-life threatening event (ALTE) who are at low risk of
adverse outcome and can be discharged home safely from the emergency
department (ED).

METHODS:

This is a prospective cohort study of infants with an ED diagnosis of ALTE
at an urban children's hospital. Admission was considered warranted if the
infant required significant intervention during the hospital stay. Logistic
regression and recursive partitioning were used to develop a CDR identifying
patients at low risk of significant intervention and thus suitable for
discharge from the ED.

RESULTS:

A total of 300 infants were enrolled; 228 (76%) were admitted; 37 (12%)
required significant intervention. None died during hospital stay or within
72 hours of discharge or were diagnosed with serious bacterial infection.
Logistic regression identified prematurity, abnormal result in the physical
examination, color change to cyanosis, absence of symptoms of upper
respiratory tract infection, and absence of choking as predictors for
significant intervention. These variables were used to create a CDR, based
on which, 184 infants (64%) could be discharged home safely from the ED,
reducing the hospitalization rate to 102 (36%). The model has a negative
predictive value of 96.2% (92%-98.3%).

CONCLUSIONS:

Only 12% of infants presenting to the ED with ALTE had a significant
intervention warranting hospital admission. We created a CDR that would have
decreased the admission rate safely by 40%.

_________________



Kevin Powell MD PhD FAAP

Pediatric hospitalist

Saint Louis, MO









-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Seiden, Jeffrey A
Sent: Wednesday, December 02, 2015 3:52 PM
To: [log in to unmask]
Subject: Re: ALTE



Thanks, Jay.  I think your article serves to remind us that this is a
fragile population in whom bad outcomes can be very difficult to predict
from a single ED visit.  However, I still have a hard time with your
conclusions.  The first question (which I posed earlier) is whether a one
day hospital admission, which is probably the LOS for nearly all ALTE's that
don't have any concerning historical or PE features, can actually serve to
prevent the bad outcome.  The second question, which may be equally
important, is whether an inpatient hospitalization has any negative impact
on this vulnerable population.  Interesting that the two mortalities were
deemed infectious at autopsy...might one or both of them have been
hospital-acquired?



To be clear, I am not advocating for universal discharge of these patients.
However, if we are talking about any event that is frightening to the
observer and has a color change, choking, gagging, etc, etc, then we are
including a lot of patients who had an obvious gagging episode related to
feeding.  Exposing all of these patients to the inpatient hospital
environment is very likely to lead to unintended negative consequences.  I
am simply suggesting that having a thoughtful approach that weighs the pros
and cons of admission is sure to be more effective than universal admission.



As an aside, we don't admit neonates with a negative LP simply because of
the risk of bacterial meningitis.  We admit the youngest of neonates,
because we know that all of our available data (well appearance, normal UA,
CBC, and CSF studies) has been shown to miss a very significant portion of
serious bacterial infections in this age group, which can be cured by
intravenous antibiotics...a clear rationale for inpatient admission despite
the inherent risks of hospitalization.





Jeff







________________________________

From:  <mailto:[log in to unmask]> [log in to unmask] <
<mailto:[log in to unmask]> [log in to unmask]> on behalf of Jay Fisher
< <mailto:[log in to unmask]> [log in to unmask]>

Sent: Wednesday, December 2, 2015 4:35 PM

To: Seiden, Jeffrey A

Cc:  <mailto:[log in to unmask]> [log in to unmask]

Subject: Re: ALTE



Jeff- Thanks for your thoughts.



Agree that admission did not change the outcome of these kids, but the point
we were trying to make with this study is that the near-term mortality in
this population is quite high (at least in my population). Most of the the
literature, in my view, has been too dismissive of this presentation given
the small number of patients studied.



What other presentations that you could potentially discharge from the Peds
ED (we admitted virtually all during the study period) have a short term
mortality of 1 percent?



In fact, I think there are few Peds ED presentations that are managed as
outpatients with a 0.1% mortality.



In an era where the rule in rate for MI is 2-3%, and bacterial meningitis is
present in less than 1 in a 100 febrile newborns with a negative LP (and who
all get admitted), I don't see the logic in in discharging patients with an
ALTE that meets the NIH definition.



Thanks- Jay







On Wed, Dec 2, 2015 at 1:00 PM, Seiden, Jeffrey A <
<mailto:[log in to unmask]:[log in to unmask]>
[log in to unmask]<mailto:[log in to unmask]>> wrote:

While I certainly agree that these babies need to be evaluated carefully,
this article does not convince me that universal inpatient admission is
warranted. After all, every patient in this study WAS admitted! The real
question is whether the short-term mortality rate would be different in this
group compared with a cohort in which admission was considered more
selectively, based on age, other historical features (prematurity, relation
to gagging episode, etc), and exam findings.



Jeff



> On Dec 2, 2015, at 1:48 PM, Jay Fisher <
<mailto:[log in to unmask]:[log in to unmask]>
[log in to unmask]<mailto:[log in to unmask]>> wrote:

>

> I am in your camp James - I think this is a high risk group that

> decision algorithms will miss in a small but recurring percentage of

> patients.- see below

>

> Jay Fisher MD FAAP

> Medical Director of Pediatric EM

> Children's Hospital of Nevada

>

> Am J Emerg Med. < <http://www.ncbi.nlm.nih.gov/pubmed/23399327#>
http://www.ncbi.nlm.nih.gov/pubmed/23399327#> 2013

> Apr;31(4):730-3. doi: 10.1016/j.ajem.2013.01.002. Epub 2013 Feb 8

> Mortality after discharge in clinically stable infants admitted with a

> first-time apparent life-threatening event.

> Kant S

> <http://www.ncbi.nlm.nih.gov/pubmed/?term=Kant%20S%5BAuthor%5D&cauthor

> =true&cauthor_uid=23399327>

> 1, Fisher JD

> <http://www.ncbi.nlm.nih.gov/pubmed/?term=Fisher%20JD%5BAuthor%5D&caut

> hor=true&cauthor_uid=23399327>,

> Nelson DG

> <http://www.ncbi.nlm.nih.gov/pubmed/?term=Nelson%20DG%5BAuthor%5D&caut

> hor=true&cauthor_uid=23399327>,

> Khan S

> <http://www.ncbi.nlm.nih.gov/pubmed/?term=Khan%20S%5BAuthor%5D&cauthor

> =true&cauthor_uid=23399327>

> .

> Author information < <http://www.ncbi.nlm.nih.gov/pubmed/23399327#>
http://www.ncbi.nlm.nih.gov/pubmed/23399327#>

> AbstractOBJECTIVE:

>

> The objective of this study is to review the mortality after discharge

> in clinically stable infants admitted with a first apparent

> life-threatening event.

> METHODS: DESIGN:

>

> Retrospective chart review of all infants 0 to 6 months presenting

> with a first apparent life-threatening event (ALTE) over a 5-year

> period using explicit criteria. Patients with an emergency department

> (ED) diagnosis of ALTE, seizure, choking spell, or cyanosis were

> reviewed by 2 of 3 physicians. Level of agreement between reviewers

> was monitored. Mortalities were identified by a review of the county

> death record database and hospital records.

> RESULTS:

>

> Three hundred sixty-six charts were reviewed; 176 cases met inclusion

> criteria. All apparent life-threatening event (ALTE) cases were

> admitted; 1 signed out against medical advice. Blood cultures were

> obtained in 111 patients (63%)-no pathogens were identified.

> Cerebrospinal fluid analysis and culture was performed in 65 patients

> (37%)-no pathogens were identified. One patient had pleocytosis. Chest

> radiographs were obtained in

> 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial

> virus nasal washings were obtained in 32% of patients and were

> positive in

> 9 patients. The average length of follow-up was 34 months; 2 patients

> (1.1%) had died at the time of follow-up. Both deaths occurred after

> hospital discharge and within 2 weeks of the ED visit. Neither of the

> fatalities had a positive diagnostic evaluation in the ED. The cause

> of death by coroner report was pneumonia in both instances.

> CONCLUSIONS:

>

> The risk of subsequent mortality in infants admitted from our

> pediatric ED with an ALTE is substantial. Emergency physicians should

> consider routine admission for patients with ALTE.

>

>

> On Wed, Dec 2, 2015 at 9:09 AM, james reingold

> < <mailto:[log in to unmask]:[log in to unmask]>
[log in to unmask]<mailto:[log in to unmask]>>

> wrote:

>

>> Hello Colleagues,

>> I find I am getting increased resistance to admitting infants with

>> ALTE diagnosis, likely as administration gets more concerned about

>> poor reimbursement for observation status admissions.

>> I have two questions.

>> 1.  How do you decide which infants who have had a spell require admit?2.

>> Do you perform any studies in the ED for the vast majority of infants

>> who are back to baseline by the time of their arrival to the ED and

>> have normal vital signs and a normal exam?

>>

>> Thanks,James

>>

>>

>> For more information, send mail to

>>
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>> the

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>

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