Clinical decision rule associated with 40% decrease in ALTE-related hospital admissions [Classics Series]

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1. Abnormal physical exam findings, prematurity, cyanosis, absence of upper respiratory infection (URI), and absence of choking were significant predictors of the need for significant intervention among study participants admitted for hospitalization following apparent life-threatening events (ALTEs). 

2. A clinical decision rule (CDR) was designed and validated that would have reduced ALTE-related hospital admission in this sample by 40%. 

Original Date of Publication: July 2012   

Study Rundown: ALTEs include varying episodes characterized by an alarming change in an infant’s appearance including cyanosis, limpness, and/or gagging. Multiple studies have indicated that ALTE episodes may be benign; however, many infants presenting to the emergency department (ED) for ALTE are hospitalized without requiring intervention during the stay. This study aimed to establish a CDR for ED providers to determine which ALTE-presenting infants could be discharged home safely. A validated CDR was created that would have reduced hospital admissions by 40%. In this CDR, infants presenting with ALTE born at term without cyanosis, those with cyanosis in the context of a choking history, and those born preterm with a history of URI symptoms were identified as safe to discharge home. While this study was limited by its use of patients from one hospital, the study sample is similar demographically and in discharge diagnoses to those in other ALTE studies. A high 76% admission rate of ALTE-presenting infants in this study is consistent with those in other studies; however, data from this investigation further strengthens claims that hospitalization is often unnecessary among ALTE patients.

Click to read the study in Pediatric Emergency Care

In-Depth [prospective cohort study]: 300 infants under 12 months of age presenting to a tertiary children’s hospital following an episode consistent with ALTE were recruited during the June 2006 to January 2008 study period. Patients’ parents were interviewed, the infant was evaluated by a clinician, and patients’ clinical courses were followed throughout their hospital admission or, if discharged home, through phone interview four weeks after discharge. Primary study outcomes for admitted patients included significant interventions such as parental antibiotics, supplemental oxygen, or intubation. For those discharged, recurrence of ALTE symptoms, death, or other major events were considered primary outcomes. 228 participants (76%) were admitted with 37 requiring significant intervention. Of the 72 discharged home, no deaths or major events occurred. Analysis of patient and ALTE characteristics revealed that prematurity (<37 weeks gestation) (OR = 4.5), abnormal physical exam (OR = 3.4), cyanosis (OR = 3.2), absence of URI symptoms (OR = 2.9), and absence of choking (OR = 2.3) were predictors of intervention need. A CDR was then designed identifying infants presenting with ALTE born at term without cyanosis, those with cyanosis in the context of a choking history, and those born preterm with a history of URI symptoms as safe to discharge home. This CDR would reduce hospitalizations in this study sample by 40% with a negative predictive value of 96.2% and specificity of 70.5%. 7 infants were misclassified by CDR, though none had significant problems following hospital discharge.

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