The role of nurses' clinical impression in the first assessment of children at the emergency department

Objective: To assess the diagnostic value and determinants of nurses' clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED).

Design: Secondary analysis of a prospective cohort.

Setting and patients: 6390 consecutive children <16 years of age presenting to a paediatric ED with a non-surgical chief complaint and complete data available.

Main outcome measures: Diagnostic accuracy of nurses' clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses' impression that a child appeared ill.

Results: Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses' clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses' impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

Conclusion: The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.