Roland Damian, Clarke Colin, Borland Meredith L, Pascoe Elaine M
Emergency Department, Leicester Royal Infirmary, Leicester, UK.
J Paediatr Child Health. 2010 Mar;46(3):103-7. doi: 10.1111/j.1440-1754.2009.01646.x. Epub 2010 Jan 26.
Clinical assessment of dehydration in children is often inaccurate. We aimed to determine if a scoring system based on standardised clinical signs would reduce the variability between doctors' assessment of dehydration.
A clinical scoring system was developed using seven physiological variables based on previously published research. Estimated percentage dehydration and severity scores were recorded for 100 children presenting to a Paediatric Emergency Department with symptoms of gastroenteritis and dehydration by three doctors of different seniority (resident medical officer, registrar and consultant). Agreement was measured using intra-class correlation coefficient (ICC) for percentage ratings and total clinical scores and kappa for individual characteristics.
Estimated percentage dehydration ranged from 0-9%, mean 2.96%, across the three groups. Total clinical scores from 0-10, mean 2.20. There was moderate agreement amongst clinicians for the percentage dehydration (ICC 0.40). The level of agreement on the clinical scoring system was identical (ICC 0.40). Consultants gave statistically lower scores than the other two groups (Consultant (Con) vs. Resident P = 0.001, Con vs. Registrar P = 0.013). There was a marked difference in agreement across characteristics comprising the scoring system, from kappa 0.02 for capillary refill time to 0.42 for neurological status.
The clinical scoring system used did not reduce the variability of assessment of dehydration compared to doctors' conventional methods. In order to reduce variability improving education may be more important than production of a scoring system as experience appears to be a key determinant in the assessment of a potentially dehydrated child.
对儿童脱水的临床评估常常不准确。我们旨在确定基于标准化临床体征的评分系统是否会减少医生对脱水评估之间的差异。
根据先前发表的研究，使用七个生理变量开发了一种临床评分系统。由三名不同资历的医生（住院医师、注册医师和顾问医师）对100名因肠胃炎和脱水症状就诊于儿科急诊科的儿童记录估计的脱水百分比和严重程度评分。使用组内相关系数（ICC）对百分比评级和总临床评分进行一致性测量，对个体特征使用kappa进行测量。
三组中估计的脱水百分比范围为0 - 9%，平均为2.96%。总临床评分为0 - 10分，平均为2.20分。临床医生对脱水百分比的一致性为中等（ICC 0.40）。对临床评分系统的一致性水平相同（ICC 0.40）。顾问医师给出的分数在统计学上低于其他两组（顾问医师（Con）与住院医师相比P = 0.001，Con与注册医师相比P = 0.013）。构成评分系统的各个特征的一致性存在显著差异，从毛细血管再充盈时间的kappa值0.02到神经状态的kappa值0.42。
与医生的传统方法相比，所使用的临床评分系统并未减少脱水评估的差异。为了减少差异，改善教育可能比制定评分系统更重要，因为经验似乎是评估潜在脱水儿童的关键决定因素。
