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.
On Wed, Dec 2, 2015 at 1:00 PM, Seiden, Jeffrey A <[log in to unmask]>
> 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.
> > On Dec 2, 2015, at 1:48 PM, Jay Fisher <[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.-
> > 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#> 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
> > <
> > 1, Fisher JD
> > <
> > Nelson DG
> > <
> > Khan S
> > <
> > .
> > Author information <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
> > ALTE, seizure, choking spell, or cyanosis were reviewed by 2 of 3
> > physicians. Level of agreement between reviewers was monitored.
> > 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
> > 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial
> > virus nasal washings were obtained in 32% of patients and were positive
> > 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
> > 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 <
> [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
> >> Do you perform any studies in the ED for the vast majority of infants
> >> are back to baseline by the time of their arrival to the ED and have
> >> vital signs and a normal exam?
> >> Thanks,James
> >> For more information, send mail to [log in to unmask] with the
> >> message: info PED-EM-L
> >> The URL for the PED-EM-L Web Page is:
> >> http://listserv.brown.edu/ped-em-l.html
> > For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> > http://listserv.brown.edu/ped-em-l.html
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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