Emergency medical services utilisation among febrile children attending emergency departments across Europe: an observational multicentre study
Authors: Tan Chantal D. , Vermont Clementien L. , Zachariasse Joany M. , von Both Ulrich , Eleftheriou Irini , Emonts Marieke , van der Flier Michiel , Herberg Jethro , Kohlmaier Benno , Levin Michael , Lim Emma , Maconochie Ian K. , Martinon-Torres Federico , Nijman Ruud G. , Pokorn Marko , Rivero-Calle Irene , Tsolia Maria , Zenz Werner , Zavadska Dace , Moll Henriëtte A. , Carrol Enitan D. ,   On behalf of PERFORM consortium (Personalised Risk assessment in febrile children to optimize Real-life Management across the European Union), Levin Michael , Cunnington Aubrey , De Tisham , Herberg Jethro , Kaforou Myrsini , Wright Victoria , Baumard Lucas , Bellos Evangelos , D’Souza Giselle , Galassini Rachel , Habgood-Coote Dominic , Hamilton Shea , Hoggart Clive , Hourmat Sara , Jackson Heather , Maconochie Ian , Menikou Stephanie , Lin Naomi , Nichols Samuel , Nijman Ruud , Paz Ivonne Pena , Shah Priyen , Shen Ching-Fen , Vito Ortensia , Wilson Clare , Abdulla Amina , Ali Ladan , Darnell Sarah , Jorgensen Rikke , Mustafa Sobia , Persand Salina , Stevens Molly , Kim Eunjung , Pierce Benjamin , Fidler Katy , Dudley Julia , Richmond Vivien , Tavliavini Emma , Liu Ching-Chuan , Wang Shih-Min , Martinón-Torres Federico , Salas Antonio , González Fernando Álvez , Farto Cristina Balo , Barral-Arca Ruth , Castro María Barreiro , Bello Xabier , García Mirian Ben , Carnota Sandra , Cebey-López Miriam , CurrasTuala María José , Suárez Carlos Durán , Vicente Luisa García , Gómez-Carballa Alberto , Rial Jose Gómez , Iglesias Pilar Leboráns , Martinón-Torres Federico , Martinón-Torres Nazareth , Martinón Sánchez José María , Pérez Belén Mosquera , Pardo-Seco Jacobo , Rodríguez Lidia Piñeiro , Pischedda Sara , Vázquez Sara Rey , Calle Irene Rivero , Rodríguez-Tenreiro Carmen , Redondo-Collazo Lorenzo , Ora Miguel Sadiki , Fernández Sonia Serén , Trasorras Cristina Serén , Iglesias Marisol Vilas , Zavadska Dace , Balode Anda , Bārzdiņa Arta , Deksne Dārta , Gardovska Dace , Grāvele Dagne , Grope Ilze , Meiere Anija , Nokalna Ieva , Pavāre Jana , Pučuka Zanda , Selecka Katrīna , Sidorova Aleksandra , Svile Dace , Urbāne Urzula Nora , Usuf Effua , Bojang Kalifa , Zaman Syed M. A. , Secka Fatou , Anderson Suzanne , Sarr Anna RocaIsatou , Saidykhan Momodou , Darboe Saffiatou , Ceesay Samba , D’alessandro Umberto , Moll Henriëtte A. , Borensztajn¹ Dorine M. , Hagedoorn Nienke N. , Tan Chantal , Vermont Clementien L. , Zachariasse Joany , Dik W , Agyeman Philipp , Schlapbach Luregn J , Aebi Christoph , Wyss Verena , Usman Mariama , Giannoni Eric , Stocker Martin , Posfay-Barbe Klara M , Heininger Ulrich , Bernhard-Stirnemann Sara , Niederer-Loher Anita , Kahlert Christian , Natalucci Giancarlo , Relly Christa , Riedel Thomas , Aebi Christoph , Berger Christoph , Carrol Enitan D , Paulus Stéphane , Cocklin Elizabeth , Jennings Rebecca , Johnston Joanne , Leigh Simon , Newall Karen , Romaine Sam , Tsolia Maria , Eleftheriou Irini , Tambouratzi Maria , Marmarinos Antonis , Xagorari Marietta , Syggelou Kelly , Fink Colin , Voice Marie , Calvo-Bado Leo , Zenz Werner , Kohlmaier Benno , Schweintzger Nina A. , Sagmeister Manfred G. , Kohlfürst Daniela S. , Zurl Christoph , Binder Alexander , Hösele Susanne , Leitner Manuel , Pölz Lena , Rajic Glorija , Bauchinger Sebastian , Baumgart Hinrich , Benesch Martin , Ceolotto Astrid , Eber Ernst , Gallistl Siegfried , Gores Gunther , Haidl Harald , Hauer Almuthe , Hude Christa , Keldorfer Markus , Krenn Larissa , Pilch Heidemarie , Pfleger Andreas , Pfurtscheller Klaus , Nordberg Gudrun , Niedrist Tobias , Rödl Siegfried , Skrabl-Baumgartner Andrea , Sperl Matthias , Stampfer Laura , Strenger Volker , Till Holger , Trobisch Andreas , Löffler Sabine , Yeung Shunmay , Dewez Juan Emmanuel , Hibberd Martin , Bath David , Miners Alec , Nijman Ruud , Wedderburn Catherine , Meierford Anne , Leurent Baptiste , Groot Ronald de , Flier Michiel van der , Jonge Marien I. de , Aerde Koen van , Alkema Wynand , Broek Bryan van den , Gloerich Jolein , Gool Alain J. van , Henriet Stefanie , Huijnen Martijn , Philipsen Ria , Willems Esther , Gerrits G.P.J.M. , Leur M. van , Heidema J. , Haan L. de , Miedema C.J. , Neeleman C. , Obihara C.C. , Tramper-Stranders G.A. , Pollard Andrew J. , Kandasamy Rama , Paulus Stéphane , Carter Michael J. , O’Connor Daniel , Bibi Sagida , Kelly Dominic F. , Gurung Meeru , Thorson Stephen , Ansari Imran , Murdoch David R. , Shrestha Shrijana , Oliver Zoe , Emonts Marieke , Lim Emma , Valentine Lucille , Allen Karen , Bell Kathryn , Chan Adora , Crulley Stephen , Devine Kirsty , Fabian Daniel , King Sharon , McAlinden Paul , McDonald Sam , McDonnell Anne , Pickering Ailsa , Thomson Evelyn , Wood Amanda , Wallia Diane , Woodsford Phil , Baxter Frances , Bell Ashley , Rhodes Mathew , Agbeko Rachel , Mackerness Christine , Baas Bryan , Kloosterhuis Lieke , Oosthoek Wilma , Arif Tasnim , Bennet Joshua , Collings Kalvin , Giessen Ilona van der , Martin Alex , Rashid Aqeela , Rowlands Emily , Vries Gabriella de , Velden Fabian van der , Valentine Lucille , Martin Mike , Mistry Ravi , Both Ulrich von , Kolberg Laura , Zwerenz Manuela , Buschbeck Judith , Bidlingmaier Christoph , Binder Vera , Danhauser Katharina , Haas Nikolaus , Griese Matthias , Feuchtinger Tobias , Keil Julia , Kappler Matthias , Lurz Eberhard , Muench Georg , Reiter Karl , Schoen Carola , Mallet François , Brengel-Pesce Karen , Pachot Alexandre , Mommert Marine , Pokorn Marko , Kolnik Mojca , Vincek Katarina , Srovin Tina Plankar , Bahovec Natalija , Prunk Petra , Osterman Veronika , Avramoska Tanja , Kuijpers Taco , Jongerius Ilse , Berg J.M. van den , Schonenberg D. , Barendregt A.M. , Pajkrt D. , Kuip M. van der , Furth A.M. van , Sprenkeler Evelien , Zandstra Judith , Mierlo G. van , Geissler J. 
Published: June 2023

Abstract
Children constitute 6–10% of all patients attending the emergency department (ED) by emergency medical services (EMS). However, discordant EMS use in children occurs in 37–61% with fever as an important risk factor. We aimed to describe EMS utilisation among febrile children attending European EDs. This study is part of an observational multicentre study assessing management and outcome in febrile children up to 18 years (MOFICHE) attending twelve EDs in eight European countries. Discordant EMS use was defined as the absence of markers of urgency including intermediate/high triage urgency, advanced diagnostics, treatment, and admission in children transferred by EMS. Multivariable logistic regression analyses were performed for the association between (1) EMS use and markers of urgency, and (2) patient characteristics and discordant EMS use after adjusting all analyses for the covariates age, gender, visiting hours, presenting symptoms, and ED setting. A total of 5464 (15%, range 0.1–42%) children attended the ED by EMS. Markers of urgency were more frequently present in the EMS group compared with the non-EMS group. Discordant EMS use occurred in 1601 children (29%, range 1–59%). Age and gender were not associated with discordant EMS use, whereas neurological symptoms were associated with less discordant EMS use (aOR 0.2, 95%CI 0.1–0.2), and attendance out of office hours was associated with more discordant EMS use (aOR 1.6, 95%CI 1.4–1.9). Settings with higher percentage of self-referrals to the ED had more discordant EMS use (p < 0.05). Conclusion: There is large practice variation in EMS use in febrile children attending European EDs. Markers of urgency were more frequently present in children in the EMS group. However, discordant EMS use occurred in 29%. Further research is needed on non-medical factors influencing discordant EMS use in febrile children across Europe, so that pre-emptive strategies can be implemented.

What is Known:

•Children constitute around 6–10% of all patients attending the emergency department by emergency medical services.

•Discordant EMS use occurs in 37–61% of all children, with fever as most common presenting symptom for discordant EMS use in children.

What is New:

•There is large practice variation in EMS use among febrile children across Europe with discordance EMS use occurring in 29% (range 1–59%), which was associated with attendance during out of office hours and with settings with higher percentage of self-referrals to the ED.

•Future research is needed focusing on non-medical factors (socioeconomic status, parental preferences and past experience, healthcare systems, referral pathways, out of hours services provision) that influence discordant EMS use in febrile children across Europe.