Use of alarm features in referral of febrile children to the emergency department: an observational study

Background The diagnostic value of alarm features of serious infections in low prevalence settings is unclear. Aim To explore to what extent alarm features play a role in referral to the emergency department (ED) by GPs who face a febrile child during out-of-hours care. Design and setting Observational study using semi-structured, routine clinical practice data of febrile children (< 16 years) presenting to GP out-of-hours care. Method Logistic regression analyses were performed to assess the association between alarm features of serious infections (selected from two guidelines and one systematic review) and referral to the ED. Adherence to the guideline was explored by a 2x2 contingency table. Results In total 794 (8.1%) of 9794 eligible patients were referred to the ED. Alarm signs most strongly associated with referral were 'age < 1 month', 'decreased consciousness', 'meningeal irritation', and 'signs of dehydration'. Nineteen percent of 3424 children with a positive referral indication according to the guideline were referred to the ED. The majority of those not referred had only one or two alarm features present. A negative referral indication was adhered to for the majority of children. Still, in 20% of referred children, alarm features were absent. Conclusion In contrast to guidance, GPs working in primary out-of-hours care seem more conservative in referring febrile children to the ED, especially if only one or two alarm features of serious infection are present. In addition, in 20% of referred children, alarm features were absent, which suggests that other factors may be important in decisions about referral of febrile children to the hospital ED.