Can I Discharge a Pediatric Patient with Abnormal Vital Signs?

Written by Aaron Lacy

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18% of children in this cohort were discharged from a pediatric ED with at least one abnormal vital sign. In all-comers, there was no significant difference in return rate between those discharged with or without abnormal vital signs. Those who, at time of discharge, had two or more abnormal vital signs or were less than 3 years of age were more likely to return.

Why does this matter?
Vital signs are….well, vital. We have heard that before, which is why we check discharge vital signs before patient leave the ED. We know that discharging patients over 65 with abnormal vital signs predict bouncebacks, but what about vital signs on babies, not just the boomers?

Would have been able to discharge them too, if it weren’t for those meddling vital signs!
This retrospective cohort study reviewed 83,092 pediatric patients (0-18 years) who were discharged from two tertiary academic pediatric emergency departments. Vital signs were deemed abnormal if flagged in the EHR, indicating a value outside of the 5th and 95th percentiles based on age-adjusted appropriate norms. 17,661 (18.1%) of discharged patients were discharged with an abnormal vital sign.

Of patients discharged with at least one abnormal vital sign, 404 (2.28%) returned to the ED for a related condition, with 95 (0.5%) being admitted. The rate of return in 48 hours for patients discharged with normal vital signs was similar at 2.45% (p=0.219). Patients were more likely to return if they had two or more abnormal vital signs (OR 1.6, 95% CI 1.23-2.07), were less than 3 years old (OR 1.69, 95% CI 1.39-2.06), or had a high acuity at their initial visit (OR 1.34, 95% CI 1.1-1.63). No child who returned died, required CPR, or intubation. Four were admitted to the PICU.

Data and the heart are often at war. Children are resilient, and often bounce back well from illness and injury. Discharging a child with abnormal vital signs may make us feel uneasy, but if based on your evaluation and gestalt you think they can go, you are probably right. The practice of requiring normal vital signs prior to discharging a pediatric patient may not be necessary based on these results, especially if you think they otherwise can go. While you should never ignore abnormal vital signs, requiring the child with an elevated heart rate to remain in the ED and drink fluids until it drops below the “it’s no longer red in EPIC” threshold may not be necessary. Here is where I insert the generic line about having a risk-benefit and shared decision-making conversation with the patient (if they can talk) and their family. It’s cliché, but if we can keep kids at home (safely) and out of the hospital, it’s a win-win for everyone.

Source
Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs. Am J Emerg Med. 2022 Apr 26;57:76-80. Doi: 10.1016/j.ajem.2022.04.021.

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