Fran Lowry
October 7, 2009 (Boston, Massachusetts) — Emergency department physicians had difficulty identifying influenza victims after a mass outbreak in a simulated pandemic influenza drill in a study presented here at the American College of Emergency Physicians 2009 Scientific Assembly.
Using a screening algorithm called the Mass Screening, Triage and Isolation (MSTI) tool, the doctors failed to recognize influenza in 46% of children aged 5 years and younger. They also separated children from their parents for treatment when their symptoms differed, despite existing recommendations to the contrary, announced Baruch S. Fertel, MD, from the University of Cincinnati in Ohio.
"The most important thing we learned from this simulation exercise was that it is easy to miss the diagnosis in children," said Dr. Fertel in an interview with Medscape Emergency Medicine. The study was conducted when he was at SUNY Downstate Medical Center in Brooklyn, New York. "Even experienced clinicians who see a lot of patients often have trouble identifying children with influenza-like illnesses."
Dr. Fertel and his colleagues assessed 171 adult and 113 child "actors" or simulated patients who presented with flu-like symptoms for treatment at 3 hospital emergency departments. The cohort consisted of 45 families that contained at least 1 adult and 1 child and, of these, 26 (58%) had a child with symptoms differing from the parents. The patients were screened and triaged according to the MSTI.
The investigators found a significant correlation between decreasing age and difficulty recognizing influenza symptoms. In addition to missing the diagnosis in almost half of the youngest children, they misdiagnosed 23% of the children aged 13 to 17 years and 33% of the children aged 6 to 12 years, saying they did not meet the criteria for influenza. They also found that of the 26 families who had a child with differing symptoms, 14 (54%) received a discordant disposition that resulted in the separation of children from their parents for treatment.
"Not only did this cause additional trauma to the children, it was also labor-intensive, as additional staff were needed to chaperone unaccompanied minors," Dr. Fertel said.
"Part of pandemic and disaster preparedness is getting ready for the unknown," he pointed out. "The best way we can prepare for an unknown, especially in disaster medicine, is by conducting drills and exercises. We believe that our drill was unique because it is hard to get kids [to act as patients], but we got a lot of kids to participate in our study. That is what gave it a more realistic scenario."
With an H1N1 pandemic waiting in the wings, "we’ve got to figure out how to treat families as a unit," Dr. Fertel said. "We did this study at Downstate, and we treated everybody in the same building. I’m in Cincinnati now and we have the University hospital and we have the Children’s Hospital. You get someone with a sniffle who doesn’t meet the age group and they will send that person across the street. But what do you do when Mom comes in with her 2 kids? This is something I’m seeing almost daily."
Gregory Moran, MD, from Olive-View University of California at Los Angeles Medical Center in Sylmar, who moderated the session, told Medscape Emergency Medicine that such studies are useful. "The main thing we have to deal with in the emergency department is screening people quickly to identify those who are contagious so we can limit exposure as much as possible. With H1N1, we know we are going to have to deal with this issue. It’s likely that a lot of emergency departments have not drilled on this specifically, and I think this study is a good model to use for these types of practice processes."
Dr. Fertel and Dr. Moran have disclosed no relevant financial relationships.
American College of Emergency Physicians (ACEP) 2009 Scientific Assembly: Abstract 5. Presented October 6, 2009.
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