Background
Methods
Participants and methods
Activity | Mean duration (min) |
---|---|
Triage time (nurse)* | 4.5 |
Clinician consultation time (MTS green)* | 16.2 |
Clinician consultation time (MTS yellow)* | 19.4 |
Clinician consultation time (MTS orange)* | 21.1 |
Clinician consultation time (MTS red)* | 22.7 |
Clinician time—writing up patient notes# | 10 |
Order blood/urine culture (clinician)# | 10 |
Arrange X-ray (clinician)# | 6 |
Book patient into the ED (receptionist)# | 2 |
Refer patient to other specialties (clinician)# | 20 |
Insert cannula (clinician)* | 20 |
Provide antibiotics/other medicines (nurse)# | 5 |
Visual assessment triage (nurse)* | 2 |
Interpret results of ancillary investigations (clinician)# | 10 |
Unit costs
Item | Unit cost |
---|---|
Investigations (per test) | |
Amylase | £6.00 |
Bacterial PCR | £158.00 |
Bilirubin | £6.00 |
Biochemistry profile | £8.00 |
Blood albumin | £6.00 |
Blood glucose test | £6.00 |
Blood culture | £35.00 |
Blood gas# | £7.00 |
Blood taken | £3.00 |
Calcium profile | £7.00 |
Clotting screen | £5.00 |
Creatinine | £6.00 |
CRP | £6.00 |
CSF | £6.00 |
CT scan (head) | £201.00 |
ECG | £33.00 |
ENT swab | £19.00 |
ESR | £4.00 |
FBC | £3.00 |
Glandular fever screen | £4.00 |
Group and save | £12.00 |
LFTs | £7.00 |
Magnesium | £6.00 |
Malarial parasite test | £21.00 |
Measles PCR | £55.00 |
Meningo pneumo PCR | £25.00 |
Meningococci screen | £6.00 |
Mycoplasma SER | £23.00 |
Pertussis swab | £9.00 |
Phosphate | £6.00 |
Rapid Strep test | £9.00 |
Renal profile | £46.00 |
Respiratory PCR | £117.00 |
RSV screen | £12.00 |
Ultrasound | £55.00 |
Urinalysis# | £8.00 |
Urine albumin | £6.00 |
Urine culture# | £8.00 |
Urine dipstick# | £6.00 |
Urine sample | £8.53 |
Virus PCR | £56.00 |
X-ray | £46.00 |
Antibiotics (per dose/course) | |
Amoxicillin 125 mg (suspended)* | £1.16 |
Amoxicillin 125 mg (IV)* | £4.34 |
Amoxicillin 250 mg (susp.)* | £1.33 |
Cefotaxime 195 mg (IV)* | £0.48 |
Cefotaxime 575 mg (IV)* | £0.66 |
Nurse time (per hour) | |
Band 5 | £15.43 |
Band 6 | £18.95 |
Band 7 | £22.50 |
Band 8a | £27.39 |
Doctor time (per hour) | |
FY1/FY2 | £24.24 |
ST1-3 | £30.79 |
APNP | £27.39 |
Registrar | £39.02 |
Consultant | £76.11 |
Referral to other specialties | |
Surgery | £178.55 |
Medicine | £272.74 |
ENT | £146.92 |
Neuro | £411.78 |
Inpatient admission | |
Short stay (HRG PW20C, 3 days non-elective stay)# | £1712 |
Excess bed day charge# | £462 |
Outcomes and statistical analysis
Parameter | Distribution |
---|---|
Time (hours) | |
Nurse triage | Gamma (4.69, 0.01) |
Proportion performed by band 6 nurses | Beta (16, 55) |
Proportion performed by band 5 nurses | 1-Beta (16, 55) |
Clinical consultation | Gamma (3.9, 0.04) |
Clinician writing up patient notes | Uniform (1, 20) |
Arrange blood/urine culture | Uniform (1, 25) |
Arranging X-ray | Uniform (1, 30) |
Receptionist booking patient in | Uniform (1, 5) |
Clinician arranging referral | Uniform (1, 25) |
Clinician cannulating child | Uniform (5, 35) |
Nurse providing antibiotics to child | Uniform (1, 10) |
Visual assessment by nurse | Uniform (0.5,5) |
Days spent as inpatient (if admitted) | Gamma (3.72, 1.03) |
Salary (cost/hour) | |
Nurse (band 5) | Uniform (13.36, 17.5) |
Nurse (band 6) | Uniform (16.14, 21.77) |
Nurse (band 7) | Uniform (19.34, 25.67) |
Nurse (band 8a) | Uniform (24.8, 29.99) |
Foundation year doctor | Uniform (22.5,26) |
ST1-3 | Uniform (27, 30.8) |
APNP | Uniform (24.8, 29.99) |
Registrar | Uniform (36, 41) |
Consultant | Uniform (64.8, 87.4) |
Results
Descriptive statistics
Mean (SD) | Median (IQR) | Min | Max | |
---|---|---|---|---|
Age | 3.28 (3.09) | 2.17 (3.5) | 4 days | 15.98 years |
Gender male (freq) | 53.5% (3484) | – | – | – |
Temperature | 38.7 (1.07) | 38.6 (1.7) | 35 | 41.4 |
Respiratory rate (bpm) | 29.95 (9.23) | 28 (8) | 14 | 188 |
Pulse (bpm) | 138.7 (25.98) | 138 (37) | 22 | 250 |
Manchester Triage Scale (MTS) classification | ||||
MTS green (freq) | 47.52% (3097) | – | – | – |
MTS yellow (freq) | 8.88% (579) | – | – | – |
MTS yellow/red (freq) | 0.17% (11) | |||
MTS orange (freq) | 17.06% (1112) | – | – | – |
MTS orange/red (freq) | 23.03% (1501) | |||
MTS red (freq) | 0.39% (27) | – | – | – |
MTS not recorded (freq) | 2.9% (191) | – | – | – |
Timings | ||||
Time between booking and triage (min) | 15.3 (14.7) | 11 (18) | 0 | 71 |
< 10 | 47.8% | |||
11–20 | 24.1% | |||
21–40 | 20% | |||
41–60 | 5.6% | |||
> 61 | 2.5% | |||
Time between triage and consultation (min) | 67.9 (52) | 55 (65) | 0 | 609 |
< 30 | 26.9% | |||
31–60 | 27.7% | |||
61–120 | 30.8% | |||
121–180 | 11.4% | |||
181–240 | 2.6% | |||
> 240 | 0.6% | |||
Time in ED post consultation (min) | 68.4 (70.6) | 45 (72) | 0 | 630 |
< 30 | 43.5% | |||
30–60 | 15.1% | |||
61–120 | 24.8% | |||
121–180 | 9.7% | |||
> 181 | 7% | |||
Total time in ED (min) | 151.6 (81.3) | 135 (98) | 16 | 729 |
< 60 | 8.3% | |||
61–120 | 32.7% | |||
121–240 | 46.9% | |||
241–360 | 9.6% | |||
> 361 | 2.5% | |||
Inpatient length of stay (days) | ||||
Not hospitalised | 93.51% | |||
1–3 | 3.42% | |||
4–7 | 2.43% | |||
8+ | 0.63% | |||
Re-attendance (freq) | 3.43% (224) | – | – | – |
Afterhours (freq) | 88.9% (5798) | – | – | – |
Winter (freq) | 60.1% (3918) | – | – | – |
Reviewing clinician | ||||
APNP | 2.73% (178) | – | – | – |
Consultant | 7.99% (521) | – | – | – |
Foundation years 1 and 2 | 0.91% (59) | – | – | – |
Registrar | 22.05% (1437) | – | – | – |
ST1-3 | 66.32% (4323) |
Determinants of patient-level costs
Number | Mean | Std. dev | 95% CI | Median | IQR | p value* | |
---|---|---|---|---|---|---|---|
Age | |||||||
0–3 months | 129 | £1000.28 | £1469.98 | £82.39–£2993.37 | £76.65 | £1834.10 | |
3–6 months | 281 | £522.33 | £1737.66 | £122.08–£2123.51 | £53.63 | £55.70 | |
6–12 months | 1041 | £205.28 | £585.18 | £28.26–£734.39 | £51.29 | £21.50 | |
1–3 years | 2498 | £190.44 | £594.95 | £13.22–£643.89 | £51.64 | £21.60 | |
3–6 years | 1547 | £158.97 | £501.82 | £20.43–£1596.43 | £51.29 | £19.80 | p = 0.0001 |
6–10 years | 707 | £165.92 | £485.04 | £11.14–£843.02 | £52.98 | £20.70 | |
10–16 years | 315 | £408.32 | £1030.12 | £44.97–£2188.27 | £55.55 | £40.90 | |
Gender | |||||||
Male | 3482 | £210.17 | £600.23 | £38.45–£818.68 | £51.29 | £21.50 | |
Female | 3036 | £238.90 | £835.77 | £14.13–£924.63 | £53.16 | £23.10 | p = 0.0001 |
NICE NG51 heart rate red flag [27] | |||||||
Yes | 2797 | £259.40 | £848.10 | £21.76–£1015.89 | £54.03 | £24.60 | p = 0.0001 |
No | 3721 | £196.59 | £604.38 | £18.36–£699.74 | £50.87 | £20.30 | |
NICE NG51 respiratory rate red flag [27] | |||||||
Yes | 394 | £493.92 | £1035.52 | £89.16–£2011.32 | £66.67 | £70.45 | |
No | 6124 | £206.15 | £691.06 | £23.71–£737.44 | £51.29 | £21.50 | p = 0.0001 |
Clinical grade | |||||||
APNP | 178 | £109.52 | £312.67 | £12.74–£741,65 | £48.01 | £21.80 | |
Consultant | 521 | £315.13 | £1344.91 | £25.76–£1536.36 | £73.23 | £40.70 | p = 0.0001 |
FY 1 and 2 | 59 | £731.78 | £913.38 | £97.91–£1125.77 | £327.98 | £49.90 | |
Registrar | 1437 | £255.40 | £702.86 | £19.40–£1045.91 | £54.49 | £23.80 | |
ST1-3 | 4323 | £199.68 | £615.00 | £12.51–£721.02 | £49.77 | £28.05 | |
Afterhours | |||||||
Yes | 5798 | £222.22 | £726.36 | £14.77–£776.64 | £51.92 | £22.40 | |
No | 720 | £234.19 | £664.61 | £11.96–£913.33 | £51.65 | £22.00 | p = 0.0018 |
MTS classification | |||||||
Green | 3098 | £121.78 | £390.33 | £15.81 - £400.93 | £49.43 | £19.05 | |
Yellow | 579 | £424.43 | £1027.90 | £340.69–£508.17 | £63.10 | £557.35 | |
Yellow/red | 10 | £85.71 | £95.24 | £71.73–£99.42 | £52.33 | £16.50 | p = 0.0001 |
Orange | 1112 | £487.16 | £1209.15 | £416.08–£558.24 | £68.86 | £77.05 | |
Orange/red | 1502 | £152.13 | £491.60 | £123.44–£170.56 | £51.84 | £17.20 | |
Red | 26 | £549.42 | £813.99 | £236.47–£862.35 | £76.88 | £1165.85 | |
Not recorded | 191 | £292.01 | £966.43 | £154.93–£429.09 | £50.87 | £20.40 | |
Final diagnosis | |||||||
Bacterial infection/syndrome | 460 | £988.19 | £1781.97 | £86.89–£2971.08 | £77.95 | £1757.35 | |
Viral infection/syndrome | 1595 | £294.52 | £797.43 | £18.92–£1082.33 | £51.64 | £24.25 | |
Inflammatory infection/syndrome | 74 | £582.58 | £1302.26 | £37.60–£1516.05 | £63.44 | £1140.65 | p = 0.0001 |
Other or trivial infection | 130 | £390.06 | £786.27 | £22.34–£1243.30 | £64.04 | £187.15 | |
Unknown cause | 4259 | £103.06 | £286.52 | £12.40–633.87 | £51.29 | £18.60 |
Inpatient | Length of stay (days)# | Any test | Blood culture | X-ray | Urine sample | Review by consultant | |
---|---|---|---|---|---|---|---|
Age | |||||||
0–3 months | 34.11% | 5.67 | 51.16% | 28.70% | 9.30% | 39.53% | 10.07% |
3–6 months | 15.66% | 5.34 | 40.92% | 11.03% | 12.10% | 32.74% | 5.69% |
6–12 months | 6.34% | 3.83 | 31.98% | 2.01% | 9.12% | 23.24% | 8.64% |
1–3 years | 5.36% | 4.05 | 29.74% | 2.52% | 10.88% | 18.37% | 7.64% |
3–6 years | 4.01% | 4.02 | 28.70% | 3.03% | 9.43% | 13.70% | 8.14% |
6–10 years | 4.53% | 3.78 | 34.08% | 3.67% | 9.61% | 17.25% | 8.76% |
10–16 years | 7.96% | 4.73 | 42.22% | 8.88% | 10.15% | 15.87% | 7.3% |
p value | 0.0001§ | 0.0001* | 0.0001§ | 0.0001§ | 0.5370§ | 0.0001§ | 0.1342§ |
MTS classification | |||||||
Green | 2.61% | 3.88 | 24.59% | 1.51% | 5.68% | 16.17% | 8.06% |
Yellow | 13.64% | 4.64 | 43.52% | 7.42% | 11.91% | 23.48% | 9.32% |
Orange | 17.27% | 4.23 | 44.6% | 10.07% | 23.2% | 19.15% | 8.45% |
Red | 30.77% | 2.63 | 26.92% | 15.38% | 11.53% | 11.53% | 23.07% |
p value | 0.0001§ | 0.0001# | 0.0001§ | 0.0001§ | 0.0001§ | 0.0023§ |
Antibiotic prescribing patterns
Receiving antibiotics | |||||||||
---|---|---|---|---|---|---|---|---|---|
Total (%) | 0–3 months (%) | 3–6 months (%) | 6–12 months (%) | 1–3 years (%) | 3–6 years (%) | 6–10 years (%) | 10–16 years (%) | p value# | |
All | 32.4 | 27.9 | 24.2 | 24 | 31.9 | 37 | 34.5 | 40.3 | 0.0001 |
Bacterial | 89.6 | 85 | 96.8 | 84.3 | 93 | 89 | 87.7 | 91.9 | 0.3610 |
Viral | 6.6 | 20.8 | 10 | 3.2 | 9.4 | 4 | 2.60 | 5.7 | 0.0001 |
Inflammatory | 14.9 | 0 | 0 | 0 | 9.5 | 17.2 | 23.1 | 12.5 | 0.9330 |
Trivial | 10.8 | 0 | 50 | 0 | 9.7 | 8.1 | 20 | 5.3 | 0.0820 |
Unknown | 36.4 | 17.3 | 19.2 | 25.5 | 35.7 | 43.3 | 42.2 | 48.1 | 0.0001 |
Viral | Trivial | Inflammatory | Bacterial | |||||
---|---|---|---|---|---|---|---|---|
Antibiotics given? | Yes | No | Yes | No | Yes | No | Yes | No |
All* | £1392.30 | £140.10 | £324.49 | £224.54 | £185.08 | £669.86 | £755.03 | £747.43 |
0–3 months | £2842.60 | £479.65 | N/A | £113.81 | N/A | £50.87 | £2476.96 | £2419.07 |
3–6 months | £1969.38 | £142.81 | £50.39 | £334.50 | N/A | £65.92 | £1078.39 | £60.78 |
6–12 months | £2452.83 | £159.57 | N/A | £58.63 | N/A | N/A | £376.20 | £774.53 |
1–3 years | £687.02 | £151.09 | £2223.43 | £256.88 | £51.43 | £390.81 | £883.52 | £278.09 |
3–6 years | £1201.76 | £123.97 | £58.69 | £196.88 | £54.52 | £355.06 | £450.45 | £586.77 |
6–10 years | £1575.80 | £63.65 | £51.46 | £87.65 | £475.93 | £447.47 | £416.84 | £672.95 |
10–16 years | £2603.54 | £143.37 | N/A | £401.88 | £101.95 | £4842.32 | £1484.10 | £694.91 |
Determinants of increased healthcare expenditure during paediatric febrile episodes
Coefficient | Ln(β) | Exp (β) | 95% CI (β) low | 95% CI (β) high | p value |
---|---|---|---|---|---|
0–3 months | 1.265 | 3.543 | 2.589 | 4.85 | 0.001 |
3–6 months | 0.791 | 2.207 | 1.544 | 3.155 | 0.001 |
6–12 months | 0.171 | 1.186 | 0.924 | 1.524 | 0.180 |
3–6 years | − 0.164 | 0.848 | 0.705 | 1.021 | 0.082 |
6–10 years | − 0.046 | 0.954 | 0.738 | 1.235 | 0.724 |
10–16 years | 0.656 | 1.927 | 1.399 | 2.654 | 0.001 |
Gender (male) | − 0.163 | 0.849 | 0.736 | 0.978 | 0.024 |
Time from book-in to triage | − 0.005 | 0.994 | 0.990 | 0.999 | 0.013 |
NICE HR | 0.034 | 1.034 | 0.894 | 1.197 | 0.644 |
NICE RR | 0.543 | 1.721 | 1.289 | 2.299 | 0.001 |
Time from triage to call in | − 0.001 | 0.999 | 0.997 | 1.000 | 0.357 |
APNP | − 0.555 | 0.573 | 0.374 | 0.878 | 0.011 |
FY1/FY2 | 1.161 | 3.193 | 2.017 | 5.055 | 0.001 |
ST1-3 | − 0.161 | 0.851 | 0.670 | 1.081 | 0.187 |
Registrar | − 0.068 | 0.933 | 0.719 | 1.212 | 0.608 |
After hours** | 0.147 | 1.159 | 0.867 | 1.548 | 0.317 |
Winter | − 0.215 | 0.806 | 0.695 | 0.934 | 0.004 |
MTS yellow | 0.868 | 2.382 | 1.905 | 2.979 | 0.001 |
MTS orange | 1.049 | 2.857 | 2.397 | 3.405 | 0.001 |
MTS red | 1.096 | 2.992 | 1.762 | 5.081 | 0.001 |
Sensitivity analysis
β (base-case)# | β (bootstrapped) | Minimum β (% lower)# | Maximum β (% higher)# | Statistically significant* (%) | |
---|---|---|---|---|---|
0–3 months | 3.543 | 3.11 | 2.16 (39.02%) | 3.92 (10.69%) | 100 |
0–6 months | 2.207 | 2.08 | 1.45 (34.39%) | 2.68 (21.55%) | 100 |
6–12 months | 1.186 | 1.27 | 1.00 (15.75%) | 1.54 (29.84%) | 38.38 |
3–6 years | 0.848 | 0.88 | 0.68 (19.3%) | 0.98 (15.77%) | 19.19 |
6–10 years | 0.954 | 1.00 | 0.74 (22.39%) | 1.18 (23.63%) | 0 |
10–16 years | 1.927 | 1.81 | 1.25 (35.27%) | 2.10 (8.98%) | 100 |
Gender (male) | 0.849 | 0.90 | 0.78 (7.91%) | 0.99 (16.64%) | 8.08 |
Time (book-in to triage) | 0.994 | 1.00 | 0.99 (0.24%) | 1.00 (0.65%) | 16.16 |
NICE HR | 1.034 | 1.03 | 0.89 (14.04%) | 1.12 (8.75%) | 0 |
NICE RR | 1.721 | 1.65 | 1.19 (30.71%) | 1.99 (15.60%) | 100 |
Time (triage to call in) | 0.999 | 1.00 | 1.00 (0.14%) | 1.00 (0.13%) | 3.03 |
APNP | 0.573 | 0.69 | 0.37 (36.23%) | 0.99 (72.91%) | 28.28 |
FY1/FY2 | 3.193 | 3.29 | 1.98 (37.94%) | 4.06 (27.11%) | 100 |
ST1-3 | 0.851 | 0.90 | 0.72 (15.88%) | 1.01 (18.17%) | 0 |
REG | 0.933 | 1.00 | 0.76 (19.02%) | 1.12 (20.10%) | 0 |
After hours | 1.159 | 1.19 | 0.90 (21.98%) | 1.47 (26.54%) | 2.02 |
Winter | 0.806 | 0.79 | 0.68 (15.08%) | 0.89 (10.11%) | 98.99 |
MTS yellow | 2.382 | 2.27 | 1.77 (25.67%) | 2.61 (9.59%) | 100 |
MTS orange | 2.857 | 2.89 | 2.23 (22.08%) | 3.21 (12.43%) | 100 |
MTS red | 2.992 | 4.52 | 1.95 (34.80%) | 6.87 (129.76%) | 100 |
Constant | 164.8 | 143.50 | 90.33 (45.19%) | 179.37 (8.84%) | 100 |