viral illness, acute, pediatric

Care Planning - Inpatient Admission and AlternativesClinical Indications for Admission to Inpatient CareAlternatives to AdmissionAlternative Care Planning

HospitalizationOptimal Recovery CourseGoal Length of Stay - 2 daysExtended StayHospital Care Planning

DischargeDischarge PlanningDischarge Destination

Evidence SummaryBackgroundCriteriaAlternativesHospitalizationLength of Stay

ReferencesFootnotesDefinitionsCodes

Viral Illness, Acute, PediatricORG: P-280 (ISC)Link to Codes

Care Planning - Inpatient Admission and AlternativesClinical Indications for Admission to Inpatient Care

Note: Some patients may be appropriate for observation care. For consideration of observation care, see ViralIllness, Acute: Observation Care ISC.

Admission is indicated for 1 or more of the following[A][B](1)(2)(3)(4)(5)(6)(7): Pulmonary manifestation, as indicated by 1 or more of the following:

HypoxemiaVentilatory assistance needed (eg, mechanical ventilation, noninvasive ventilation)Accessory muscle useRespiratory retractions (eg, suprasternal, intercostal, or subcostal)CyanosisGrunting or nasal flaringTachypnea that persists despite observation careAirway obstruction (eg, due to airway edema from infectious mononucleosis)

Systemic[A] manifestation, as indicated by 1 or more of the following:Hemodynamic instabilityDehydration that is severe or persistentInability to maintain oral hydration (eg, needs IV fluid support) that persists despite observation careAltered mental status that is severe or persistentNew coagulopathy (eg, disseminated intravascular coagulation, liver failure, acute thrombosis)Acute kidney injury (stage 2)Acute renal failure (stage 3 acute kidney injury)Cardiac arrhythmias of immediate concernHypothermiaAcute or progressive neuromuscular impairment (eg, Guillain-Barre syndrome)

Disseminated herpes varicella zoster infectionSuspected or diagnosed viral hemorrhagic fever(14)Isolation indicated that cannot be performed outside hospital setting[C][D]

MCG Health - Inpatient & Surgical Care (26th Edition)Copyright © 2021 MCG Health, LLC. All Rights Reserved.

Alternatives to AdmissionAlternatives include(1)(2)(4)(6)(7)(15)(16)(17)(18):

Outpatient care in emergency department, rapid treatment site, urgent care center, or medical officeHistory, physical examination, and assessment of risk factorsChest x-ray and laboratory testingOral antiviral agent(20)(21)

Observation. See Viral Illness, Acute: Observation Care ISC guideline as appropriate.Home care(16)

Nursing visits for assessment and laboratory workMedication administration, respiratory therapy, oxygen

Isolation facility (eg, when needed during pandemic outbreak)[C][D]

Alternative Care PlanningCare planning needs for patient not requiring admission may include(1)(2)(3)(4)(5)(15)(17)(22)(23)(24):

Diagnostic tests, including(25)(26):CBC, chemistries, renal and hepatic function testingNasopharyngeal specimen (deep) or nasal swab for viral pathogens(1)(2)(20)(27)Nucleic acid amplification test (eg, PCR) for viral pathogens(1)(2)(20)(27)(28)Viral serologiesC-reactive proteinChest x-ray[E]Blood cultureProcalcitonin (eg, if bacterial infection suspected or as marker for COVID-19 severity)(25)Urinary antigen tests (eg, for Streptococcus pneumoniae and Legionella species, if bacterial infection suspected)Pulse oximetryABG

Treatments and procedures, including(26)(29):Infection prevention and control measures[C][D]AntipyreticsAntiviral medication(20)(21)Respiratory therapy

Discharge Planning as appropriatePatient, family, and caregiver education as appropriate. See Viral Illness, Acute, Pediatric: Patient Education for CliniciansSR.

HospitalizationOptimal Recovery Course

Day Level of Care Clinical Status Activity Routes Interventions Medications

1 ICU[F] or floorSocialDeterminants ofHealthAssessmentDischargeplanning

ClinicalIndicationsmet[G]Possible FeverPossibleTachypneaPossibleHypoxemiaPossible Alteredmental status

Activity astolerated

Oral or IVfluidsParenteral ororalmedicationsLiquid orusual diet

Possibleisolation[C][D]CBC withdifferential,chemistries, renaland hepatic functiontesting, C-reactiveprotein, coagulationpanelPCR for viralpathogensPossible viralserologiesABG or oximetryPossible oxygenPossible chest x-ray

Possible antiviralmedicationPossible antibiotic(eg, for bacterialcoinfection orsuperinfection)PossibleantipyreticmedicationPossiblecorticosteroid[H][I]Possible DVTprophylaxis

2 FloorSocialDeterminants ofHealthAssessment

HypotensionabsentNo requirementfor mechanicalventilation

Advanceactivity astolerated

OralhydrationOral or IVmedicationsUsual diet

Possible isolationPulse oximetryPossible oxygen

Possible antiviralmedicationPossible antibiotic(eg, for bacterial


Oxygenation atbaseline orimprovedMental status atbaseline

coinfection orsuperinfection)PossiblecorticosteroidPossibleantipyreticmedicationPossible DVTprophylaxis

3 SocialDeterminants ofHealthAssessmentFloor todischargeCompletedischargeplanning

HemodynamicstabilityAfebrile ortemperatureacceptable fornext level ofcareTachypneaabsentHypoxemiaabsentMental status atbaselineRenal functionat baseline, orstable andacceptable fornext level ofcareDischarge plansand educationunderstood

Ambulatoryoracceptablefor nextlevel ofcare[J]

Oralhydration[K]Oralmedicationsor regimenacceptablefor nextlevel of careOral diet oracceptablefor nextlevel of care

Isolation notindicated, or isperformable atnext level ofcare[C][D]Pulse oximetry

PossiblecorticosteroidPossible DVTprophylaxisAntimicrobialmedicationabsent orregimenestablished fornext level ofcare

(2)(4)(5)(6)(8)(9)(10)(11)(12)(13)(34)

Recovery Milestones are indicated in bold.

Goal Length of Stay: 2 days

Note: Goal Length of Stay assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care(either later than or sooner than the goal) when it is appropriate for their clinical status and care needs.

Extended StayMinimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days).

Extended stay beyond goal length of stay may be needed for(2)(3)(4)(5)(9)(10)(11)(12)(13):Respiratory insufficiency or failure (eg, severe influenza or coronavirus disease 2019 (COVID-19) pneumonia)(8)(15)(34)

Anticipate invasive or noninvasive ventilatory support, or high-flow oxygen.Patient with acute respiratory distress syndrome may require high levels of positive end-expiratory pressure (PEEP),prone ventilation, pulmonary vasodilator therapy, paralytic agent, or extracorporeal membrane oxygenation.Expect brief to moderate stay extension.See Respiratory Insufficiency: Common Complications and Conditions ISC.

Multisystem inflammatory syndrome in children (MIS-C) in setting of COVID-19 infection[L](11)(29)(33)Anticipate multiorgan involvement (eg, cardiac dysfunction, shock, myocarditis, rash).Anticipate cardiac monitoring, echocardiogram, and serial monitoring of inflammatory and cardiac biomarkers.Anticipate treatment with corticosteroids, immunoglobulin, anticoagulants, low-dose aspirin, interleukin-1 receptorantagonist (anakinra), vasopressors.Expect moderate to prolonged stay extension.

Worsening of renal function (eg, Acute renal failure (stage 3 acute kidney injury) or Acute kidney injury (stage 2))Anticipate close monitoring of fluid status, renal ultrasound, urine chemistries and analysis.Renal replacement therapy may be required.Anticipate brief to moderate stay extension.See Renal Failure: Common Complications and Conditions ISC.


Persistence or worsening of signs and symptoms (eg, Fever, Altered mental status, Hypotension)Patient may be coinfected or secondarily infected.Expect brief stay extension.See Fever: Common Complications and Conditions ISC, Mental Status Change: Common Complications andConditions ISC, or Hemodynamic Instability: Common Complications and Conditions ISC.

Significant comorbid illness (eg, cystic fibrosis, severe asthma, congenital heart disease, immunocompromise, neuromuscularcondition, sickle cell anemia, Down syndrome)(6)(20)(35)

Patient with underlying comorbidity may be at risk for more severe infection and slower recovery.Anticipate evaluation and treatment of specific comorbidity.Expect brief stay extension.

Clinically significant metabolic or electrolyte abnormality that is severe or persistent (eg, hypoosmolality-hyponatremia,hypokalemia, metabolic acidosis)

Anticipate repeat testing, and treatment (eg, supplementation, fluid restriction) as indicated.Expect brief stay extension.

Thromboembolic complications(5)(7)(25)Patients with COVID-19 infection are at higher risk for thrombosis.Anticipate anticoagulation, imaging studies, and possible thrombolysis or other revascularization procedure.Expect brief to moderate stay extension.See Venous Thrombosis and Pulmonary Embolism: Common Complications and Conditions ISC.

See Common Complications and Conditions ISC for further information.

Hospital Care PlanningHospital evaluation and care needs may include(1)(2)(3)(4)(5)(6)(7)(17)(22):

Diagnostic test scheduling and completion, including(25)(29)(33):CBC with differential, chemistries, renal and hepatic function testingPT, PTT, fibrinogen, D-dimerCardiac biomarkers (eg, troponin, BNP, if cardiac involvement suspected)Nasopharyngeal specimen (deep) or nasal swab for viral pathogens(2)(27)Nucleic acid amplification test (eg, PCR) for viral pathogens(27)Viral serologies(2)C-reactive proteinErythrocyte sedimentation rateSerum ferritinPulse oximetryABGBlood and respiratory tract cultures as indicated (eg, for sepsis or suspected bacterial coinfection)Procalcitonin (eg, if bacterial infection suspected or as marker for coronavirus disease 2019 (COVID-19) severity)(25)Urinary antigen tests (eg, for Streptococcus pneumoniae and Legionella species, if bacterial infection suspected)Chest x-ray(36)CT chest(36)Thoracic ultrasound(36)ElectrocardiogramEchocardiogramBronchoscopy

Treatment and procedure scheduling and completion, including(26)(29):Infection protection and control measures as indicated[C][D]Antiviral medication(20)(21)(37)Coronavirus disease 2019 (COVID-19) specific therapy (eg, remdesivir)(26)Systemic corticosteroids[H][I](26)(32)(33)Antibiotics as indicated (eg, if bacterial infection suspected)(4)(5)(17)Antipyretic medicationPossible DVT prophylaxisOxygenVentilatory assistance (mechanical, noninvasive, high-flow nasal canula)Vasopressors

Consultation, assessment, and other services scheduling and completion, including:Pulmonary consultationCritical care consultationInfectious diseases consultationOther subspecialty consultations as indicated by organ involvement (eg, nephrology, hepatology, gastroenterology)

Monitoring patient's status for deterioration and comorbid conditions (see Inpatient Monitoring and Assessment Tool SR); keyitems include(38)(39):


FeverHemodynamic statusRespiratory statusSigns of dehydrationLevel of activityMental statusSigns and symptoms of sepsisEmergence of secondary infectionsNutritional status

DischargeDischarge Planning

Discharge planning includes[M]:Assessment of needs and planning for care, including(41):

Develop treatment plan (involving multiple providers as needed).Evaluate and address preadmission functioning as needed.Evaluate and address social determinants of health (eg, housing, food).Evaluate and address patient or caregiver preferences as indicated.Identify skilled services needed at next level of care, with specific attention to(16):

Home safety assessment(16)(42)(43)Medication management, adherence instruction, and side effects assessmentOngoing education required(16)Oxygen or other respiratory equipment managementRespiratory status assessment

Evaluate and address psychosocial status issues as indicated. See Psychosocial Assessment SR for furtherinformation.

Early identification of anticipated discharge destination; options include(44)(45):Home, considerations include[N][O](16)(47):

Access to follow-up careHome safety assessment. See Home Safety Assessment SR for further information.Self-management ability if appropriate. See Activities of Daily Living (ADL) and Instrumental Activities of Daily Living(IADL) Assessment SR for further information.Caregiver need, ability, and availability

Post-acute skilled care or custodial care as indicated. See Discharge Planning Tool SR for further information.Transitions of care plan complete, including(45):

Patient, family, and caregiver education complete. See Viral Illness, Acute, Pediatric: Patient Education for CliniciansSR for further information.

See Teach Back Tool SR for further information. Medication reconciliation completion includes(48)(49):

Compare patient's discharge list of medications (prescribed and over-the-counter) against provider's admission ortransfer orders.Assess each medication for correlation to disease state or medical condition.Report medication discrepancies to prescribing provider, attending physician, and primary care provider, and ensureaccurate medication order is identified.Provide reconciled medication list to all treating providers.Confirm that patient, family, or caregiver can acquire medication.Educate patient, family, and caregiver.

Provide complete medication list to patient, family, and caregiver.Importance of presenting personal medication list to all providers at each care transition, including allprovider appointmentsReason, dosage, and timing of medication (eg, use "teach-back" techniques)(50)

Encourage communication between patient, family, caregiver, and pharmacy for obtaining prescriptions, setting uphome medication delivery, and reviewing for drug-drug interactions.See Medication Reconciliation Tool SR for further information.

Plan communicated to patient, family, caregiver, and all members of care team, including(51)(52):Inpatient care and service providersPrimary care providerAll post-discharge care and service providers

Appointments planned or scheduled, which may include:Primary care provider


Follow-up evaluation call. See Post-Acute Care Follow-Up Call Tool SR for more information.[P]Infectious disease specialistPulmonologistSpecialists for management of comorbidities as neededOther

Outpatient testing and procedure plans made, which may include:Laboratory testingRadiologyOther

Referrals made for assistance or support, which may include:Community servicesFinancial, for follow-up care, medication, and transportationTobacco use treatmentOther

Medical equipment and supplies coordinated (ie, delivered or delivery confirmed), which may include:Incentive spirometerOxygen and suppliesPulse oximeterOther

Discharge DestinationPost-hospital levels of admission may include:

Home.Home healthcare. See Home Care Indications for Admission Section HC in Viral Illness, Acute, Pediatric guideline in HomeCare.

Evidence SummaryBackgroundThe acute viral illness guideline applies to known or suspected viral illnesses other than those that are primarily gastrointestinal (eg,gastroenteritis, hepatitis), primarily neurologic (eg, meningitis, encephalitis), or primarily dermatologic (signs and symptoms are notsystemic in nature, such as nondisseminated herpes zoster). Diagnoses that are appropriate for this guideline (list not exhaustive) areinfluenza, coronavirus disease 2019 (COVID-19), other coronavirus infections (eg, severe acute respiratory syndrome (SARS), MiddleEast respiratory syndrome (MERS)), upper respiratory infections, acute bronchitis or pneumonia suspected or known to be viral inetiology, and generalized or systemic viral infections (eg, mononucleosis). For pediatric patients with pneumonia of unknown etiology(eg, treating with antibiotics empirically), the Pneumonia, Pediatric guideline (P-330) is appropriate. Likewise, for pediatric patients witha generalized febrile illness without focal infection or source (eg, not pneumonia, UTI, cellulitis) of unknown etiology (ie, may be viral,bacterial, or fungal), the Sepsis and Other Febrile Illness, without Focal Infection, Pediatric guideline (P-410) is appropriate.

Due to the rapidly growing clinical experience with COVID-19, recommendations and information may change. Therefore, pleaseconsult the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/ or the World Health Organization (WHO) athttps://www.who.int/ for the most up-to-date guidance on the details of clinical care of patients with COVID-19 (eg, medications shownto be of benefit and for whom, when to discontinue isolation). At the time of this writing, the CDC launch page can be found athttps://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html and contains clinical information, withclear links to other relevant pages. The analogous page for the WHO is https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management and can provide further information. The CDC page athttps://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html can provide specific infection control and preventionrecommendations (eg, isolation recommendations).

CriteriaCoronavirus Disease 2019 (COVID-19) Inpatient Demographics: Analysis of data from hospitals in 14 US states identified 204adolescents (median age 14.8 years) hospitalized due to COVID-19 between January 1, 2021 and March 31, 2021, and found that 31%required ICU admission and 5% required mechanical ventilation.(8) (EG 2) Analysis of a multicenter database including 874 children(median age 8 years (interquartile range (IQR) 1.25 to 14 years)) hospitalized for COVID-19 between February 2020 and January 2021found that 46% of patients were admitted to an ICU and 9% required mechanical ventilation.(9) (EG 2) In the same analysis, themedian ICU length of stay was 3.9 days (IQR 2.0 to 7.7 days).(9) (EG 2) Analysis of a cohort of 1695 pediatric patients (median age 9.1years, IQR 2.4 to 15.3 years) hospitalized across 61 centers between March 15, 2020 and December 15, 2020 found that 49% ofpatients were admitted to an ICU with 13% requiring mechanical ventilation.(10) (EG 2) In the same analysis, the median ICU length ofstay was 4 days (IQR 2 to 7 days).(10) (EG 2) Analysis of a subset of the same cohort (pediatric patients admitted for COVID-19 March15, 2020 to October 31, 2020) identified 539 patients (median age 8.9 years, IQR 4.7 to 13.2 years) with multisystem inflammatorysyndrome in children (MIS-C) and found that 74% were admitted to an ICU with noninvasive positive pressure ventilation, invasive


mechanical ventilation, and extracorporeal membrane oxygenation required in 36%, 18%, and 3% of patients, respectively.(11) (EG 2)In the same analysis, the median ICU length of stay was 4 days (IQR 2 to 7 days).(11) (EG 2)

Coronavirus Disease 2019 (COVID-19) Admission Rates from the Emergency Department Commercially Insured PediatricPatients: Analysis of national hospital discharge data for the period January 1, 2020 to March 31, 2021 shows 3.9% of commerciallyinsured pediatric emergency department patients with the principal diagnosis of COVID-19 were admitted to inpatient care.(12) (EG 3)The same analysis limited to the time period January 1, 2021 to March 31, 2021 shows an admission rate of 4.1%.(13) (EG 3)

Coronavirus Disease 2019 (COVID-19) Admission Rates from the Emergency Department Traditional and Managed MedicaidInsured Pediatric Patients: Analysis of national hospital discharge data for the period January 1, 2020 to March 31, 2021 shows 3%of Medicaid (traditional and managed) insured pediatric emergency department patients with the principal diagnosis of COVID-19 wereadmitted to inpatient care.(12) (EG 3) The same analysis limited to the time period January 1, 2021 to March 31, 2021 shows anadmission rate of 4.1%.(13) (EG 3)

Influenza Admission Rates from the Emergency Department Commercially Insured Pediatric Patients: Analysis of nationalhospital discharge data for the period January 1, 2020 to March 31, 2021 shows 2.7% of commercially insured pediatric emergencydepartment patients with the principal diagnosis of influenza were admitted to inpatient care.(12) (EG 3)

AlternativesAnalysis of a national database found that over 10 seasonal flu seasons (2006-2007 to 2015-2016) and across all age groups, 17.8%of patients seen in the emergency department with flu were admitted to inpatient care (10-year range, 12.1% to 22.8%). The sameanalysis when limited to the 4 busiest flu seasons (highest rate of flu patients presenting to the emergency department) found that the4-year mean admission rate for patients up to 4 years of age was 10.3%, and that the 4-year mean for patients 5 to 17 years of agewas 5.2%.(19) (EG 2)

HospitalizationCoronavirus Disease 2019 (COVID-19): A National Institutes of Health (NIH) guideline notes the lack of high-quality evidenceregarding the treatment of hospitalized pediatric COVID-19 patients and thus recommendations are made based largely upon expertopinion.(26) (EG 2) Remdesivir is recommended for hospitalized children 12 years of age or older who have risk factors for severedisease (eg, obesity, chronic medical illness, congenital heart disease, neurodevelopmental disorder, technological dependence) andhave an emergent or increasing need for supplemental oxygen.(26) (EG 2) Remdesivir is also recommended for patients 16 years ofage or older who have an emergent or increasing need for supplemental oxygen.(26) (EG 2) Dexamethasone is recommended forpatients who require high-flow oxygen, noninvasive ventilation, invasive mechanical ventilation, or extracorporeal membraneoxygenation.(26) (EG 2)

Length of StayIn a study of 1391 children admitted with laboratory-proven acute respiratory viral infection, the median length of stay was 1.9 days.(34)(EG 2) Analysis of national hospital discharge data for a pediatric population shows 65% of hospitalized patients with the principaldiagnosis of an acute viral illness (coronavirus disease 2019 (COVID-19) not included) discharged in 2 days or less.(12) (EG 3)

Coronavirus Disease 2019 (COVID-19) Length of Stay: Analysis of a database of pediatric hospitalizations for COVID-19 thatoccurred across 14 US states identified 204 adolescents (median age 14.8 years) hospitalized due to COVID-19 between January 1,2021 and March 31, 2021 and reported a median length of stay of 2.4 days.(8) (EG 2) Analysis of a cohort of 470 pediatric COVID-19patients (median age 5.7 years) hospitalized between February 2020 and January 2021 found a median length of stay of 2.2 days.(9)(EG 2) A case series of 1695 hospitalized pediatric COVID-19 patients (median age 9.1 years) hospitalized between March 15, 2020and December 15, 2020 found that 25% of patients had a length of stay of 2 days or less.(10) (EG 2) Examination of a cohort of 560pediatric patients (median age 11.7 years) hospitalized with severe COVID-19 (severe complications involving one or more organsystems) showed a median length of stay of 3 days, with 25% of patients discharged in 2 days or less.(11) (EG 2)

Analysis of national hospital discharge data covering the time period January 1, 2020 to March 31, 2021 shows 52% of hospitalizedpediatric patients with a principal diagnosis of COVID-19 discharged in 2 days or less, 66% discharged within 3 days, and 75%discharged in 4 days or less.(12) (EG 3) The same analysis limited to the time period January 1, 2021 to March 31, 2021 shows 57%discharged in 2 days or less, 67% discharged within 3 days, and 75% discharged in 4 days or less.(13) (EG 3)

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33. Henderson LA, et al. American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated withSARS-CoV-2 and hyperinflammation in pediatric COVID-19: version 2. Arthritis & Rheumatology (Hoboken, N.J.) 2021;73(4):e13-e29. DOI:10.1002/art.41616. (Reaffirmed 2021 Apr) [ Context Link 1, 2, 3, 4, 5 ] View abstract...

34. Fine J, Bray-Aschenbrenner A, Williams H, Buchanan P, Werner J. The resource burden of infections with rhinovirus/enterovirus, influenza, andrespiratory syncytial virus in children. Clinical Pediatrics 2019;58(2):177-184. DOI: 10.1177/0009922818809483. [ Context Link 1, 2, 3 ] Viewabstract...

35. Tuckerman J, Misan S, Crawford NW, Marshall HS. Influenza in children with special risk medical conditions: a systematic review and meta-analysis. Pediatric Infectious Disease Journal 2019;38(9):912-919. DOI: 10.1097/INF.0000000000002405. [ Context Link 1 ] View abstract...

36. Islam N, et al. Thoracic imaging tests for the diagnosis of COVID-19. Cochrane Database of Systematic Reviews 2021, Issue 3. Art. No.:CD013639. DOI: 10.1002/14651858.CD013639.pub4. [ Context Link 1, 2, 3 ] View abstract...

37. Walsh EE, Englund JA. Respiratory syncytial virus. In: Bennett JE, Dolin R, Blaser MJ, editors. Mandell, Douglas, and Bennett's Principles andPractice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier; 2020:2093-2103.e5. [ Context Link 1 ]

38. Conlon P. The child with respiratory dysfunction. In: Hockenberry MJ, Wilson D, Rodgers CC, editors. Wong's Nursing Care of Infants andChildren. 11th ed. St. Louis, MO: Elsevier; 2019:883-957. [ Context Link 1 ]

39. Respiratory disorders. In: Nettina SM, editor. Lippincott Manual of Nursing Practice. 11th ed. Philadelphia: Wolters Kluwer Health | LippincottWilliams & Wilkins; 2019:191-231. [ Context Link 1 ]

40. Adams-Leander S. Transcultural nursing in the community. In: Rector C, editor. Community and Public Health Nursing Promoting the Public'sHealth. 9th ed. Philadelphia, PA: Wolters Kluwer; 2018:128-164. [ Context Link 1 ]

41. Mayer RS, Noles A, Vinh D. Determination of postacute hospitalization level of care. Medical Clinics of North America 2020;44(2):128-130.[ Context Link 1 ] View abstract...

42. Infection Prevention And Control During Health Care When COVID-19 Is Suspected. Interim Guidance WHO Reference Number WHO/2019-nCoV/IPC/2020.3 [Internet] World Health Organization. 2020 Mar Accessed at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. [accessed 2021 Jun 01] [ Context Link 1, 2 ]

43. Prevent Getting Sick. CDC Coronavirus Disease 2019 (COVID-19) [Internet] Centers for Disease Control and Prevention. Accessed at:https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/index.html. Updated 2021 Jan [accessed 2021 Mar 11] [ Context Link 1 ]

44. Roles, functions, and preparation of case management team members. In: Powell SK, Tahan H, editors. Case Management a Practical Guide forEducation and Practice. 4th ed. Philadelphia, PA: Wolters Kluwer, Lippincott, Williams & Wilkins; 2019:35-60. [ Context Link 1 ]

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46. Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19). [Internet]Centers for Disease Control and Prevention. Accessed at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html. Updated2020 Oct [accessed 2021 May 26] [ Context Link 1 ]

47. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). [Internet] Centers for Disease Controland Prevention. Accessed at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. Updated 2020 Jun[accessed 2021 Mar 12] [ Context Link 1 ]

48. National Patient Safety Goals. 2021 National Patient Safety Goals [Internet] Joint Commission on Accreditation of Healthcare Organizations.Accessed at: https://www.jointcommission.org/standards_information/npsgs.aspx. Updated 2020 [accessed 2021 Apr 29] [ Context Link 1 ]

49. Adverse drug reactions and medication errors. In: Burchum JR, Rosenthal LD, editors. Lehne's Pharmacology for Nursing Care. 10th ed. St.Louis, MO: Elsevier; 2019:63-73. [ Context Link 1 ]

50. Ostendorf WR. Preparation for safe medication administration. In: Perry AG, Potter PA, Ostendorf WR, editors. Nursing Interventions and ClinicalSkills. 7th ed. Elsevier; 2020:551-567. [ Context Link 1 ]

51. Transitional planning: understanding levels and transitions of care. In: Powell SK, Tahan H, editors. Case Management a Practical Guide forEducation and Practice. 4th ed. Philadelphia, PA: Wolters Kluwer, Lippincott, Williams & Wilkins; 2019:156-211. [ Context Link 1 ]

52. Case management standards and professional organizations. In: Powell SK, Tahan H, editors. Case Management a Practical Guide for Educationand Practice. 4th ed. Philadelphia, PA: Wolters Kluwer, Lippincott, Williams & Wilkins; 2019:314-354. [ Context Link 1 ]

Footnotes[A] The acute viral illness guideline applies to known or suspected viral illnesses other than those that are primarily gastrointestinal (eg,gastroenteritis, hepatitis), primarily neurologic (eg, meningitis, encephalitis), or primarily dermatologic (signs and symptoms are notsystemic in nature, such as nondisseminated herpes zoster). Diagnoses that are appropriate for this guideline (list not exhaustive) areinfluenza, coronavirus disease 2019 (COVID-19), other coronavirus infections (eg, severe acute respiratory syndrome (SARS), Middle


East respiratory syndrome (MERS)), upper respiratory infections, acute bronchitis or pneumonia suspected or known to be viral inetiology, and generalized or systemic viral infections (eg, mononucleosis). For pediatric patients with pneumonia of unknown etiology(eg, treating with antibiotics empirically), the Pneumonia, Pediatric guideline (P-330) is appropriate. Likewise, for pediatric patients witha generalized febrile illness without focal infection or source (eg, not pneumonia, UTI, cellulitis) of unknown etiology (ie, may be viral,bacterial, or fungal), the Sepsis and Other Febrile Illness, without Focal Infection, Pediatric guideline (P-410) is appropriate. [ A inContext Link 1, 2, 3 ]

[B] Due to this being a novel virus in humans, and the rapidly growing clinical experience with coronavirus disease 2019 (COVID-19),recommendations and information may change. For example, the details on recommended isolation and infection control practiceshave changed over the first few months of the pandemic. Therefore, please consult the Centers for Disease Control and Prevention(CDC) at https://www.cdc.gov/ or the World Health Organization (WHO) at https://www.who.int/ for the most up-to-date guidance on thedetails of clinical care of patients with COVID-19 (eg, medications shown to be of benefit and for whom, when to discontinue isolation).At the time of this writing, the CDC launch page can be found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html and contains clinical information, with clear links to other relevant pages. The analogous page for the WHOis https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management and can provide furtherinformation. The CDC launch page at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html can provide specificinfection control and prevention recommendations. [ B in Context Link 1 ]

[C] The indications and specifics for various infection control measures vary by diagnosis and can change over time. The Centers forDisease Control and Prevention can provide detailed and up-to-date recommendations. See https://www.cdc.gov/coronavirus/2019-ncov/infection-control.html and https://www.cdc.gov/infectioncontrol/guidelines/isolation/updates.html for more information. [ C inContext Link 1, 2, 3, 4, 5, 6 ]

[D] Most patients who do not have clinical indications for inpatient care can continue their appropriate level of isolation at other levels ofcare (eg, home, recovery facility).(6) [ D in Context Link 1, 2, 3, 4, 5, 6 ]

[E] Chest x-rays may not be necessary for pediatric patients with suspected pneumonia who can be treated on an outpatient basis.(22)[ E in Context Link 1 ]

[F] ICU is indicated for impending respiratory failure, need for invasive or noninvasive ventilation, Hemodynamic instability, need forintravenous vasopressor or inotrope infusion, pulse oximetry less than 92% on more than 50% inspired oxygen, respiratory acidosiswith pH less than 7.20, recurrent apnea, or altered mental status or end organ dysfunction.(22)(30)(31) [ F in Context Link 1 ]

[G] See Clinical Indications for Admission to Inpatient Care in this guideline. [ G in Context Link 1 ]

[H] Specialty guidelines recommend use of corticosteroids for patients in septic shock with hypotension refractory to fluid resuscitation,and vasopressors and for patients with concomitant conditions requiring their use (eg, asthma, adrenal insufficiency).(32) [ H in ContextLink 1, 2 ]

[I] Dexamethasone is recommended for pediatric coronavirus disease 2019 (COVID-19) patients who require high-flow oxygen,noninvasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation.(26) A specialty guidelinerecommends corticosteroid therapy for children with Multisystem Inflammatory Syndrome in Children (MIS-C).(33) [ I in Context Link 1,2 ]

[J] Patient is ambulatory or near baseline activity for age and development. [ J in Context Link 1 ]

[K] Some patients may have their hydration needs met via alternative means (eg, percutaneous endoscopic gastrostomy tube). [ K inContext Link 1 ]

[L] The Centers for Disease Control and Prevention (CDC) defines multisystem inflammatory syndrome in children (MIS-C) as currentor recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a patient younger than 21 years with fevergreater than 100.4 degrees F (38 degrees C) for at least 24 hours, laboratory evidence of inflammation (eg, elevated C-reactive protein,erythrocyte sedimentation rate, fibrinogen, procalcitonin, D-dimer), and evidence of clinically severe illness requiring hospitalization withmultiorgan system involvement (eg, cardiovascular, respiratory, renal, gastrointestinal, hematologic) without identified alternative cause.(29)(33) [ L in Context Link 1 ]

[M] Discharge instructions should be given in the patient's and caregiver's native language using trained language interpreterswhenever possible.(40) [ M in Context Link 1 ]

[N] Specialty society: The World Health Organization (WHO) recommends that coronavirus disease 2019 (COVID-19) patients beingcared for at home have a home assessment to evaluate if the setting is suitable for care and the patient and caregivers are able toadhere to the isolation and care.(42) [ N in Context Link 1 ]

[O] National guidelines: The Centers for Disease Control and Prevention (CDC) recommends the following considerations for care athome of coronavirus disease 2019 (COVID-19) patients: clinical stability, available separate bedroom for patient recovery, resources


available (eg, caregivers, food), personal protective equipment available and likely to be used, and if there are at-risk householdmembers also living in the home.(46) [ O in Context Link 1 ]

[P] Specialty society: The World Health Organization (WHO) recommends that patients with coronavirus disease 2019 (COVID-19) bemonitored by healthcare professionals for the duration of home isolation.(16) [ P in Context Link 1 ]

DefinitionsAcute kidney injury (stage 2)

Acute kidney injury (stage 2) with significant clinical findings, as indicated by ALL of the following(1)(2):Acute[A] kidney injury (stage 2),[B] as indicated by 1 or more of the following:

Two-fold or more rise in serum creatinine from baselineReduction of more than 50% in estimated glomerular filtration rate from baseline eGFR - Adult Calculator eGFR - Pediatric CalculatorUrine output less than 0.5 mL/kg/hr for 12 hours despite adequate volume status

Significant clinical findings, as indicated by 1 or more of the following:Hemodynamic instabilityWorsening clinical status (eg, rising creatinine) despite appropriate treatment (eg, hydration)Altered mental statusCardiac arrhythmias of immediate concernSevere hypertension (SBP greater than 180 mm Hg or DBP greater than 120 mm Hg in adults or greater than the 95th

percentile for age, gender, and height plus 30 mm Hg in pediatric patients)(3)(4)Significant respiratory findings (eg, pulmonary edema) that are severe (eg, Hypoxemia) or persist despite appropriate

treatmentClinically significant electrolyte abnormality that is severe (eg, hyperkalemia with severe ECG findings)[C] or persists

despite appropriate treatmentClinically significant metabolic abnormality (eg, metabolic acidosis) that is severe or persists despite appropriate

treatmentDialysis needed and is not feasible or appropriate in alternative setting (eg, no previous vascular access, new to dialysis)

References1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute

kidney injury. Kidney International. Supplement 2012;2(1):1-138. (Reaffirmed 2021 Mar)2. Devarajan P. Renal failure. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson Textbook of

Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:2769-2779.e1.3. Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection,

evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American HeartAssociation Task Force on Clinical Practice Guidelines. Circulation 2018;138(17):e484-e594. DOI:10.1161/CIR.0000000000000596. (Reaffirmed 2021 Oct)

4. Flynn JT, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents.Pediatrics 2017;140(3):e20171904. DOI: 10.1542/peds.2017-1904. (Reaffirmed 2021 Jul)

5. Mirvis DM, Goldberger AL. Electrocardiography. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, editors.Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:117-153.

FootnotesA. A specialty society practice guideline defines acute kidney injury as a change in renal function that is known or presumed to have

occurred over the previous 7 days.(1)B. Various criteria that identify acute renal failure and classify kidney injury into severity grades (RIFLE, pediatric RIFLE, and KDIGO

criteria) on the basis of change in serum creatinine and urine output have been defined. Of note, in the ICD-10 diagnostic codingsystem (main coding scheme used in labeling diagnoses), the relevant codes covering the clinical entity of significant acute renalinjury use the label acute kidney failure (eg, code N17.9).(1)(2)

C. Severe ECG findings include arrhythmias, PR interval greater than 0.20 seconds, and QRS interval greater than 0.12 seconds.Isolated peaked T-waves do not constitute a severe ECG finding.(5)

Acute renal failure (stage 3 acute kidney injury)Acute[A] kidney injury (stage 3),[B] as indicated by 1 or more of the following(1)(2):

3-fold rise in serum creatinine from baselineSerum creatinine greater than 4 mg/dL (354 micromoles/L) with acute rise greater than 0.5 mg/dL (44.2 micromoles/L)Reduction of more than 75% in estimated glomerular filtration rate from baseline eGFR - Adult CalculatorEstimated glomerular filtration rate less than 35 mL/min/1.73m2 (0.59 mL/sec/1.73m2) in child younger than 18 years eGFR - Pediatric Calculator


Anuria, as indicated by ALL of the following:Adequate volume statusOligoanuria, as indicated by 1 or more of the following:

Urine output less than 0.3 mL/kg/hour for 24 hoursAnuria (urine output less than 0.1 mL/kg/hour) for 12 hours

References1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute

kidney injury. Kidney International. Supplement 2012;2(1):1-138. (Reaffirmed 2021 Mar)2. Devarajan P. Renal failure. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson Textbook of

Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:2769-2779.e1.

FootnotesA. A specialty society practice guideline defines acute kidney injury as a change in renal function that is known or presumed to have

occurred over the previous 7 days.(1)B. Various criteria that identify acute renal failure and classify kidney injury into severity grades (RIFLE, pediatric RIFLE, and KDIGO

criteria) on the basis of change in serum creatinine and urine output have been defined. For purposes of this guideline, acute renalfailure can be viewed as stage 3 acute kidney injury in the KDIGO classification system. The term acute kidney injury is preferred bysome, but the central issue remains the severity of the findings such that inpatient care is warranted. In the RIFLE classificationsystem, this degree of severity is deemed failure. For purposes of consistency in nomenclature, the title of this guideline has notchanged. Of note, in the ICD-10 diagnostic coding system (main coding scheme used in labeling diagnoses), the relevant codescovering the clinical entity of significant acute renal injury use the label acute kidney failure (eg, code N17.9).(1)(2)

Altered mental statusAltered mental status (ie, different from baseline), as indicated by 1 or more of the following(1)(2)(3)(4):

Confusional state (eg, disorientation, difficulty following commands, deficit in attention)Lethargy (awake or arousable, but with drowsiness; reduced awareness of self and environment)Obtundation (ie, arousable only with strong stimuli, lessened interest in environment, slowed responses to stimulation)Stupor (may be arousable but patient does not return to normal baseline level of awareness)Coma (not arousable)

References1. Huff JS. Confusion. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA: Elsevier; 2018:132-137.2. Lei C, Smith C. Depressed consciousness and coma. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed.

Philadelphia, PA: Elsevier; 2018:123-131.3. Abraham G, Zun LS. Delirium and dementia. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA:

Elsevier; 2018:1278-1288.4. MacNeill EC, Vashist S. Approach to syncope and altered mental status. Pediatric Clinics of North America 2013;60(5):1083-1106.

DOI: 10.1016/j.pcl.2013.06.013.

Altered mental status that is severe or persistentAltered mental status (ie, different from baseline) that is severe or persistent, as indicated by 1 or more of the following(1)(2)(3)(4):

Confusional state (eg, disorientation, difficulty following commands, deficit in attention) that persists (eg, for more than fewhours) despite appropriate treatment (eg, of underlying cause)

Lethargy (awake or arousable, but with drowsiness; reduced awareness of self and environment) that persists (eg, for morethan few hours) despite appropriate treatment (eg, of underlying cause)

Obtundation (ie, arousable only with strong stimuli, lessened interest in environment, slowed responses to stimulation)Stupor (may be arousable but patient does not return to normal baseline level of awareness)Coma (not arousable)

References1. Huff JS. Confusion. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA: Elsevier; 2018:132-137.2. Lei C, Smith C. Depressed consciousness and coma. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed.

Philadelphia, PA: Elsevier; 2018:123-131.3. Abraham G, Zun LS. Delirium and dementia. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA:

Elsevier; 2018:1278-1288.4. MacNeill EC, Vashist S. Approach to syncope and altered mental status. Pediatric Clinics of North America 2013;60(5):1083-1106.

DOI: 10.1016/j.pcl.2013.06.013.


BradycardiaBradycardia, as indicated by 1 or more of the following(1)(2)(3):

Heart rate less than 50 beats per minute in adult (age 18 years or older)[A]Heart rate less than 60 beats per minute in child or adolescent 6 to 17 years of ageHeart rate less than 70 beats per minute in child 3 to 5 years of ageHeart rate less than 80 beats per minute in child 1 to 2 years of ageHeart rate less than 90 beats per minute in infant 6 to 11 months of ageHeart rate less than 100 beats per minute in infant 3 to 5 months of age

References1. Kusumoto FM, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac

conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical PracticeGuidelines and the Heart Rhythm Society. Circulation 2019;140(8):e382-e482. DOI: 10.1161/CIR.0000000000000628. (Reaffirmed2021 Aug)

2. Yealy DM, Kosowsky JM. Dysrhythmias. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA:Elsevier; 2018:929-958.

3. Pediatric parameters and equipment. In: Kleinman K, McDaniel L, Molloy M, editors. The Harriet Lane Handbook: A Manual forPediatric House Officers. 22nd ed. 202: Elsevier; 2021:frontpiece tables.

FootnotesA. An evidence-based specialty society guideline has defined bradycardia in adults as less than 50 beats per minute.(1)

Cardiac arrhythmias of immediate concernCardiac arrhythmias or findings of immediate concern, as indicated by 1 or more of the following(1)(2):

Heart rhythms that are inherently dangerous or unstable, as indicated by 1 or more of the following(3)(4)(5):Resuscitated ventricular fibrillation or cardiac arrestVentricular escape rhythmSustained ventricular tachycardia (30 seconds or more of ventricular rhythm at greater than 100 beats per minute)Nonsustained ventricular tachycardia and 1 or more of the following:

Suspected cardiac ischemia as cause or consequence of ventricular tachycardiaAcute myocarditis

Unstable cardiac conduction defects, as indicated by 1 or more of the following(5)(6)(7):Type II second-degree atrioventricular blockThird-degree atrioventricular blockNew-onset left bundle branch block with suspected myocardial ischemia

Any heart rhythm and 1 or more of the following(3)(4)(8)(9)(10):Continuous long-term ECG monitoring needed (eg, initiation of drug requiring monitoring for more than 24 hours)Patient has automatic implanted cardioverter-defibrillator that is repeatedly firing, malfunctioning, or in need of immediate

adjustment of settings beyond scope of observation care.Heart rhythms of concern due to 1 or more of the following:

HypotensionRespiratory distressAssociation with other significant symptoms (eg, Bradycardia with syncope or ongoing dizziness, supraventricular

tachycardia with chest pain)(8)(9)(11)

References1. Miller JM, Tomaselli GF, Zipes DP. Diagnosis of cardiac arrhythmias. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF,

Braunwald E, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier;2019:648-669.

2. Dalal AS, Van Hare GF. Disturbances of rate and rhythm of the heart. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, TaskerRC, Wilson KM, editors. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:2436-2447.e1.

3. El-Chami M, Fernando L. Ventricular arrhythmias. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles andPractice of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:1003-1014.

4. Al-Khatib SM, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention ofsudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical PracticeGuidelines and the Heart Rhythm Society. Circulation 2018;138(13):e272-e391. DOI: 10.1161/CIR.0000000000000549. (Reaffirmed2021 Aug)

5. Epstein AE, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-basedtherapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart AssociationTask Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2013;127(3):e283-e352. DOI:10.1161/CIR.0b013e318276ce9b. (Reaffirmed 2021 Sep)


6. Miller JM, Tomaselli GF, Zipes DP. Therapy for cardiac arrhythmias. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF,Braunwald E, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier;2019:670-705.

7. Park DS, Fishman GI. The cardiac conduction system. Circulation 2011;123(8):904-15. DOI:10.1161/CIRCULATIONAHA.110.942284.

8. January CT, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the AmericanCollege of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. Circulation2014;130(23):e199-e267. DOI: 10.1161/CIR.0000000000000041. (Reaffirmed 2021 Oct)

9. Chun EB, McGorisk GM. Supraventricular tachyarrhythmias. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors.Principles and Practice of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:980-995.

10. Hoskins MH, De Lurgio DB. Pacemakers, defibrillators, and cardiac resynchronization devices in hospital medicine. In: McKean SC,Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of Hospital Medicine. 2nd ed. New York, NY: McGraw-HillEducation; 2017:1025-34.

11. Westerman S, Manogue M, Hoskins MH. Bradycardia. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles andPractice of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:996-1002.

Dehydration that is severe or persistentDehydration that is severe or persistent, as indicated by 1 or more of the following(1)(2)(3)(4):

Clinical findings of severe dehydration, as indicated by 1 or more of the following:Acute loss of weight from baseline (5% of body weight in adults, 9% in pediatric patients)Hemodynamic instabilityAcute renal failure (stage 3 acute kidney injury)Acute kidney injury (stage 2)Serum sodium greater than 150 mEq/L (mmol/L)

Dehydration that is persistent, as indicated by ALL of the following:Oral rehydration therapy not tolerated or insufficient to adequately correct dehydrationAppropriate intravenous treatment (eg, fluids) does not readily correct dehydration.

References1. Padlipsky P, McCormick T. Infectious diarrheal disease and dehydration. In: Walls RM, et al., editors. Rosen's Emergency Medicine.

9th ed. Philadelphia, PA: Elsevier; 2018:2145-2162.2. Mount DB. Fluid and electrolyte disturbances. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J, editors.

Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill Education; 2018:295-312.3. Greenbaum LA. Deficit therapy. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson

Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:429-432.e1.4. Greenbaum LA. Maintenance and replacement therapy. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM,

editors. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:425-428.e1.

FeverFever is defined as a core[A] temperature greater than or equal to 100.4 degrees F (38 degrees C).[B](2)(3)

References1. Niven DJ, Gaudet JE, Laupland KB, Mrklas KJ, Roberts DJ, Stelfox HT. Accuracy of peripheral thermometers for estimating

temperature: a systematic review and meta-analysis. Annals of Internal Medicine 2015;163(10):768-77. DOI: 10.7326/M15-1150.2. Nield LS, Kamat D. Fever. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson Textbook of

Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:1386-1388.e1.3. Miller CS, Wiese JG. Hyperthermia and fever. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice

of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:647-656.

FootnotesA. While a rectal temperature can be considered a core reading, it is not always practical. Tympanic membrane temperature is not

usually considered a core reading; however, the devices that measure this temperature often are (or can be) programmed such thatthey automatically adjust readings to reflect a core temperature equivalent.(1)

B. There is not a universally accepted definition of fever, as various temperatures are proposed as the cut-off that constitutes a fever.

Hemodynamic instabilityHemodynamic instability, as indicated by 1 or more of the following(1)(2)(3)(4)(5):

Vital sign abnormality not readily corrected by appropriate treatment, as indicated by 1 or more of the following[A]:


Tachycardia that persists despite appropriate treatment (eg, volume repletion, treatment of pain, treatment of underlyingcause)

Hypotension that persists despite appropriate treatment (eg, volume repletion, treatment of underlying cause)Orthostatic hypotension that persists despite appropriate treatment (eg, volume repletion)

Vital sign abnormality that is severe, as indicated by 1 or more of the following:Vital sign abnormality leading to inadequate systemic perfusion, as indicated by 1 or more of the following:

Lactate of 22.5 mg/dL (2.5 mmol/L) or more[B](6)(7)(8)(9)Metabolic acidosis (arterial or venous[C] pH less than 7.35) not otherwise explainedAltered mental status that is severe or persistentMyocardial ischemia

Mean arterial pressure[A][D] less than 65 mm HgIV inotropic or vasopressor medication required to maintain adequate blood pressure or perfusion

References1. Puskarich MA, Jones AE. Shock. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA: Elsevier;

2018:68-76.2. Lewis J, Patel B. Shock. In: Gershel JC, Rauch DA, editors. Caring for the Hospitalized Child: A Handbook of Inpatient Pediatrics.

2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2018:69-78.3. Singer M, et al. The Third International Consensus definitions for sepsis and septic shock (Sepsis-3). Journal of the American

Medical Association 2016;315(8):801-810. DOI: 10.1001/jama.2016.0287.4. Turner DA, Cheifetz IM. Shock. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson

Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:572-583.e1.5. Nyhan A. Cardiology. In: Kleinman K, McDaniel L, Molloy M, editors. The Harriet Lane Handbook: A Manual for Pediatric House

Officers. 22nd ed. 202: Elsevier; 2021:145-188.e4.6. Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying lactate in the emergency department. Annals of Emergency

Medicine 2020;75(2):287-298. DOI: 10.1016/j.annemergmed.2019.06.027.7. Levitt DG, Levitt JE, Levitt MD. Quantitative assessment of blood lactate in shock: measure of hypoxia or beneficial energy source.

BioMed Research International 2020;2020:Online. DOI: 10.1155/2020/2608318.8. Bakker J, Postelnicu R, Mukherjee V. Lactate: where are we now? Critical Care Clinics 2020;36(1):115-124. DOI:

10.1016/j.ccc.2019.08.009.9. Kraut JA, Madias NE. Lactic acidosis. New England Journal of Medicine 2014;371(24):2309-2319. DOI: 10.1056/NEJMra1309483.

10. Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emergency Medicine Clinics of North America2013;31(3):755-773. DOI: 10.1016/j.emc.2013.05.004.

11. Maloney GE Jr, Glauser JM. Diabetes mellitus and disorders of glucose homeostasis. In: Walls RM, et al., editors. Rosen'sEmergency Medicine. 9th ed. Philadelphia, PA: Elsevier; 2018:1533-1547.

12. Arnold TD, Miller M, van Wessem KP, Evans JA, Balogh ZJ. Base deficit from the first peripheral venous sample: a surrogate forarterial base deficit in the trauma bay. Journal of Trauma 2011;71(4):793-7; discussion 797. DOI: 10.1097/TA.0b013e31822ad694.

13. Malinoski DJ, Todd SR, Slone S, Mullins RJ, Schreiber MA. Correlation of central venous and arterial blood gas measurements inmechanically ventilated trauma patients. Archives of Surgery 2005;140(11):1122-5. DOI: 10.1001/archsurg.140.11.1122.

14. Zakrison T, McFarlan A, Wu YY, Keshet I, Nathens A. Venous and arterial base deficits: do these agree in occult shock and in theelderly? A Bland-Altman analysis. Journal of Trauma and Acute Care Surgery 2013;74(3):936-9. DOI:10.1097/TA.0b013e318282747a.

FootnotesA. Criteria based upon clinician-acquired numeric values (eg, vital signs, oxygen saturation) should be used if they are accurate

reflections of the patient's condition. Transitory findings (eg, abnormal only upon initial emergency department intake or only onetime out of multiple readings) that rapidly improve with no or minimal treatment usually do not reflect disease severity or risk fordeterioration. This does not imply that an initial or one-time reading cannot ever be applicable. The goal is to separate erroneous orincidental findings from those that truly represent the patient's clinical picture.

B. There are numerous causes of an elevated lactate level. The most common are cardiogenic or hypovolemic shock, severe heartfailure, severe trauma, or sepsis. However, there are also other etiologies to consider such as vigorous exercise, seizures, liverdisease, or medication use (eg, metformin, beta2-agonists); therefore, interpretation of elevated lactate levels requires considerationof the clinical context (eg, well-appearing post exercise vs hypotensive). The severity and persistence of the elevation cansometimes be helpful in this differentiation. In most instances of lactic acidosis, blood pH is less than 7.35, with a serum bicarbonatelevel 20 mEq/L (mmol/L) or lower. However, a coexisting respiratory or metabolic alkalosis can mask these findings.(6)(7)(8)(9)

C. Analyses have concluded that venous and arterial pH measurements are highly correlated, with small differences between themthat are usually not clinically significant.(10)(11)(12)(13)(14) If a mixed acid-base disorder is suspected, an arterial blood gas isindicated.(11)

D. The mean arterial pressure takes into account both systolic and diastolic blood pressure readings and is calculated as mean arterialpressure (MAP) equals 1/3 SBP + 2/3 DBP.(1)(4)

Hemodynamic stabilityMCG Health - Inpatient & Surgical Care (26th Edition)

Copyright © 2021 MCG Health, LLC. All Rights Reserved.

Hemodynamic stability, as indicated by 1 or more of the following:Hemodynamic abnormalities at baseline or acceptable for next level of carePatient hemodynamically stable, as indicated by ALL of the following(1)(2)(3)(4)(5):

Tachycardia absentHypotension absentNo evidence of inadequate perfusion (eg, no myocardial ischemia)No other hemodynamic abnormalities (eg, no Orthostatic hypotension)

References1. Puskarich MA, Jones AE. Shock. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA: Elsevier;

2018:68-76.2. Lewis J, Patel B. Shock. In: Gershel JC, Rauch DA, editors. Caring for the Hospitalized Child: A Handbook of Inpatient Pediatrics.

2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2018:69-78.3. Ingbar DH, Thiele H. Cardiogenic shock and pulmonary edema. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL,

Loscalzo J, editors. Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill Education; 2018:2052-2059.4. Seymour CW, Angus DC. Sepsis and septic shock. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J,

editors. Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill Education; 2018:2044-2052.5. Singer M, et al. The Third International Consensus definitions for sepsis and septic shock (Sepsis-3). Journal of the American

Medical Association 2016;315(8):801-810. DOI: 10.1001/jama.2016.0287.

HypotensionHypotension, as indicated by ALL of the following(1)(2)(3)(4):

Not patient baseline (eg, healthy adult with low SBP) or intentional therapeutic goal (eg, low SBP as treatment goal in heartfailure)

Low blood pressure, as indicated by 1 or more of the following:SBP less than 90 mm Hg in adult or child 10 years or older[A]Decrease in baseline SBP greater than 40 mm Hg in adult or child 10 years or olderMean arterial pressure[A][B] less than 70 mm Hg in adult or child 10 years or olderDecrease in baseline mean arterial pressure[A][B] by 25% or moreSBP less than sum of 70 mm Hg plus twice patient's age in years in child 1 to 9 years of age[A]

SBP less than 70 mm Hg in infant 1 to 11 months of age[A]

References1. Jones D, Di Francesco L. Hypotension. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of

Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:657-64.2. Massaro AF. Approach to the patient with shock. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J, editors.

Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill Education; 2018:2039-2044.3. Horeczko T, Inaba AS. Cardiac disorders. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA:

Elsevier; 2018:2099-2125.4. Huang MG, Santillanes G. General approach to the pediatric patient. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th

ed. Philadelphia, PA: Elsevier; 2018:1985-93.

FootnotesA. Criteria based upon clinician acquired numeric values (eg, vital signs, oxygen saturation) should be used if they are accurate


B. The mean arterial pressure takes into account both systolic and diastolic blood pressure readings and is calculated as Mean ArterialPressure (MAP) = 1/3 SBP + 2/3 DBP.

Hypotension absentHypotension absent, as indicated by 1 or more of the following(1)(2)(3)(4):

SBP greater than or equal to 90 mm Hg and without recent decrease greater than 40 mm Hg from baseline in adult or child 10years or older

Mean arterial pressure[A] greater than or equal to 70 mm Hg in adult or child 10 years or olderMean arterial pressure[A] at patient's baseline (eg, healthy adult with low SBP), or at intentional therapeutic goal (eg, patient

with heart failure)SBP greater than or equal to sum of 70 mm Hg plus twice patient's age in years in child 1 to 9 years of ageSBP greater than or equal to 70 mm Hg in infant 1 to 11 months of age


References1. Jones D, Di Francesco L. Hypotension. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of

Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:657-64.2. Massaro AF. Approach to the patient with shock. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J, editors.

Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill Education; 2018:2039-2044.3. Horeczko T, Inaba AS. Cardiac disorders. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA:

Elsevier; 2018:2099-2125.4. Huang MG, Santillanes G. General approach to the pediatric patient. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th

ed. Philadelphia, PA: Elsevier; 2018:1985-93.

FootnotesA. The mean arterial pressure takes into account both systolic and diastolic blood pressure readings and is calculated as Mean Arterial

Pressure (MAP) = 1/3 SBP + 2/3 DBP.

HypothermiaHypothermia indicated by core (eg, rectal) body temperature less than or equal to 95 degrees F (35 degrees C)(1)

References1. Zafren K, Danzl DF. Accidental hypothermia. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA:

Elsevier; 2018:1743-1754.

HypoxemiaHypoxemia, as indicated by 1 or more of the following(1):

Patient without baseline need for supplemental oxygen with oxygen saturation (SaO2) of less than 90% or arterial blood gaspartial pressure of oxygen (PO2) of less than 60 mm Hg (8.0 kPa) on room air[A][B]

Patient without baseline need for supplemental oxygen who now requires supplemental oxygen to keep SaO2 greater than90% or PO2 greater than 60 mm Hg (8.0 kPa)[A]

Patient with baseline need for supplemental oxygen who now requires increased supplemental oxygen to maintainoxygenation at baseline or acceptable level

References1. Dezube R, Lechtzin N. Hypoxia. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of Hospital

Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:669-75.

FootnotesA. Specific target values (ie, 90% or 60 mm Hg (8.0 kPa)) may require adjustment when care is delivered at high altitude.(1)B. Criteria based upon clinician-acquired numeric values (eg, vital signs, oxygen saturation) should be used if they are accurate


Hypoxemia absentHypoxemia absent, as indicated by 1 or more of the following(1):

Arterial oxygen saturation (SaO2) of 90% or greater or arterial partial pressure of oxygen (PO2) of 60 mm Hg (8.0 kPa) orgreater on room air[A]

Oxygen requirements are stable and arranged for at next level of care.

References1. Dezube R, Lechtzin N. Hypoxia. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of Hospital

Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:669-75.

FootnotesA. Specific target values (ie, 90% or 60 mm Hg (8.0 kPa)) may require adjustment when care is delivered at high altitude.(1)


Orthostatic hypotensionOrthostatic hypotension,[A][B] as indicated by 1 or more of the following(1)(2)(3):

Fall in SBP of 20 mm Hg or more 1 to 3 minutes after patient sits or stands from recumbent positionFall in DBP of 10 mm Hg or more 1 to 3 minutes after patient sits or stands from recumbent position

References1. Shibao C, Lipsitz LA, Biaggioni I, American Society of Hypertension Writing Group. Evaluation and treatment of orthostatic

hypotension. Journal of the American Society of Hypertension 2013 Jul-Aug;7(4):317-324. DOI: 10.1016/j.jash.2013.04.006.2. Dalal AS, Van Hare GF. Syncope. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson

Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:566-571.e1.3. Fang JC, O'Gara PT. History and physical examination: an evidence-based approach. In: Zipes DP, Libby P, Bonow RO, Mann DL,

Tomaselli GF, Braunwald E, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA:Elsevier; 2019:83-101.e1.

FootnotesA. Concomitant measurements of the heart rate are important to measure to help diagnose subtypes of orthostatic hypotension (eg,

the lack of a compensatory increase in heart rate is typical of autonomic failure and an exaggerated tachycardia may be reflective ofvolume depletion). However, the heart rate is not a component of the definition of orthostatic hypotension which relies upon bloodpressure alone.(1)(2)(3)

B. Criteria based upon clinician acquired numeric values (eg, vital signs, oxygen saturation) should be used if they are accuratereflections of the patient's condition. Transitory findings (eg, abnormal only upon initial emergency department intake or only onetime out of multiple readings) that rapidly improve with no or minimal treatment usually do not reflect disease severity or risk fordeterioration. This does not imply that an initial or one-time reading cannot ever be applicable. The goal is to separate erroneous orincidental findings from those that truly represent the patient's clinical picture.

Respiratory distressRespiratory distress, as indicated by ALL of the following(1)(2):

Patient with 1 or more of the following:Dyspnea (difficulty breathing)TachypneaAbnormal breathing pattern (eg, chest retractions)Other evidence of difficulty breathing

Evidence of respiratory compromise, as indicated by 1 or more of the following:HypoxemiaAltered mental statusOther evidence of respiratory compromise (eg, respiratory acidosis)

References1. Braithwaite SA, Perina D. Dyspnea. In: Walls RM, et al., editors. Rosen's Emergency Medicine. 9th ed. Philadelphia, PA: Elsevier;

2018:195-203.2. Naureckas ET, Solway J. Disturbances of respiratory function. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL,

Loscalzo J, editors. Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill Education; 2018:1945-1951.

Social Determinants of Health AssessmentRisk of poor health outcomes may be increased by the presence of 1 or more of the following social determinants of health(1)(2)(3)

(4):Housing insecurity, as indicated by 1 or more of the following:

Individual or caregiver's current living situation is 1 or more of the following(5):Does not have own housing (eg, staying in a hotel, shelter, or with others)Has own housing (eg, house, apartment), but at risk of losing it in the future (ie, behind on rent or mortgage)Has own housing (eg, house, apartment), but has lived in 3 or more places in past year

Current housing has 1 or more of the following:Electrical appliances (eg, stove, refrigerator) not working or unavailableInsufficient heating or coolingInsufficient ventilationLead paint or pipesMoldPests (eg, bugs) or rodentsSmoke detectors not working or unavailable

Food insecurity, as indicated by 1 or more of the following(6):


In the past year, individual or caregiver ran out of food and did not have money to buy more food.In the past year, individual or caregiver worried that they would run out of food before they received money to buy more

food.Insufficient transportation, as indicated by 1 or more of the following:

In the past year, individual or caregiver missed medical appointments or could not get medications due to lack oftransportation.

In the past year, individual or caregiver missed nonmedical activities, work, or could not get things needed for daily livingdue to lack of transportation.

Insufficient utilities, as indicated by 1 or more of the following:Utilities (eg, electricity, water, gas, or oil) are currently shut off or unavailable.In the past year, electric, water, gas, or oil company threatened to shut off services.

Personal safety risk, as indicated by 2 or more of the following(6):Individual is sometimes or frequently physically hurt by another person (including family member).Individual is sometimes or frequently insulted or talked down to by another person (including family member).Individual is sometimes or frequently threatened with physical harm by another person (including family member).Individual is sometimes or frequently screamed or cursed at by another person (including family member).

Insufficient dependent care, as indicated by 1 or more of the following:In the past year, individual or caregiver was unable to work due to lack of dependent care.In the past year, individual or caregiver was unable to work more (additional) hours due to lack of dependent care.In the past year, individual or caregiver missed medical appointments or could not get medications due to lack of

dependent care.In the past year, individual or caregiver missed nonmedical activities (eg, school, church, social activity) due to lack of

dependent care.Depression risk, as indicated by ALL of the following:

In the past 2 weeks, individual had little interest or pleasure in normal activities on at least several days.In the past 2 weeks, individual felt down, depressed, or hopeless on at least several days.

References1. Social Determinants of Health. [Internet] World Health Organization. Accessed at:

https://www.who.int/social_determinants/sdh_definition/en/. Updated 2021 [accessed 2021 Jun 01]2. Moen M, Storr C, German D, Friedmann E, Johantgen M. A review of tools to screen for social determinants of health in the United

States: a practice brief. Population Health Management 2020;23(6):422-429. DOI: 10.1089/pop.2019.0158.3. Daniel-Robinson L, Moore JE. Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care.

[Internet] Institute for Medicaid Innovation. 2019 Jan Accessed at: https://www.medicaidinnovation.org/. [accessed 2021 Apr 30]4. Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: the

Accountable Health Communities Screening Tool. [Internet] National Academy of Sciences. 2017 May Accessed at:https://nam.edu/. [accessed 2021 Mar 11]

5. Sandel M, et al. Unstable housing and caregiver and child health in renter families. Pediatrics 2018;14(2):e20172199. DOI:10.1542/peds.2017-2199.

6. 2018 Children's HealthWatch Survey. Screening Instrument [Internet] Children's HealthWatch. 2018 Accessed at:https://childrenshealthwatch.org/. [accessed 2021 Mar 08]

TachycardiaTachycardia,[A] as indicated by 1 or more of the following(1)(2):

Heart rate greater than 100 beats per minute in adult or child age 6 years or older[A]

Heart rate greater than 115 beats per minute in child 3 to 5 years of age[A]

Heart rate greater than 125 beats per minute in child 1 or 2 years of age[A]

Heart rate greater than 130 beats per minute in infant 6 to 11 months of age[A]Heart rate greater than 150 beats per minute in infant 3 to 5 months of ageHeart rate greater than 160 beats per minute in infant 1 or 2 months of age

References1. Southmayd GL. Tachycardia. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of Hospital

Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:729-39.2. Pediatric parameters and equipment. In: Kleinman K, McDaniel L, Molloy M, editors. The Harriet Lane Handbook: A Manual for

Pediatric House Officers. 22nd ed. 202: Elsevier; 2021:frontpiece tables.


reflections of the patient's condition. Transitory findings (eg, abnormal only upon initial emergency department intake or only onetime out of multiple readings) that rapidly improve with no or minimal treatment usually do not reflect disease severity or risk for


deterioration. This does not imply that an initial or one-time reading cannot ever be applicable. The goal is to separate erroneous orincidental findings from those that truly represent the patient's clinical picture.

Tachycardia absentTachycardia absent, as indicated by 1 or more of the following(1)(2):

Heart rate less than or equal to 100 beats per minute in adult or child 6 years or olderHeart rate less than or equal to 115 beats per minute in child 3 to 5 years of ageHeart rate less than or equal to 125 beats per minute in child 1 or 2 years of ageHeart rate less than or equal to 130 beats per minute in infant 6 to 11 months of ageHeart rate less than or equal to 150 beats per minute in infant 3 to 5 months of ageHeart rate less than or equal to 160 beats per minute in infant 1 or 2 months of age

References1. Southmayd GL. Tachycardia. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, editors. Principles and Practice of Hospital

Medicine. 2nd ed. New York, NY: McGraw-Hill Education; 2017:729-39.2. Pediatric parameters and equipment. In: Kleinman K, McDaniel L, Molloy M, editors. The Harriet Lane Handbook: A Manual for


TachypneaTachypnea,[A] as indicated by respiratory rate of 1 or more of the following(1)(2):

Greater than 18 breaths per minute in adult or child 13 years of age or older[A]

Greater than 22 breaths per minute in child 6 to 12 years of age[A]

Greater than 25 breaths per minute in child 3 to 5 years of age[A]

Greater than 30 breaths per minute in child 1 or 2 years of age[A]

Greater than 40 breaths per minute in infant 6 to 11 months of age[A]

Greater than 45 breaths per minute in infant 3 to 5 months of age[A]

Greater than 60 breaths per minute in infant 1 or 2 months of age[A]


2018:195-203.2. Pediatric parameters and equipment. In: Kleinman K, McDaniel L, Molloy M, editors. The Harriet Lane Handbook: A Manual for




Tachypnea absentTachypnea absent, as indicated by respiratory rate of 1 or more of the following(1)(2):

Less than or equal to 18 breaths per minute in adult or child 13 years of age or olderLess than or equal to 22 breaths per minute in child 6 to 12 years of ageLess than or equal to 25 breaths per minute in child 3 to 5 years of ageLess than or equal to 30 breaths per minute in child 1 or 2 years of ageLess than or equal to 40 breaths per minute in infant 6 to 11 months of ageLess than or equal to 45 breaths per minute in infant 3 to 5 months of ageLess than or equal to 60 breaths per minute in infant 1 or 2 months of age


2018:195-203.2. Pediatric parameters and equipment. In: Kleinman K, McDaniel L, Molloy M, editors. The Harriet Lane Handbook: A Manual for



Vital sign abnormalityVital sign abnormality, as indicated by ALL of the following:

Vital sign findings not as expected for chronic patient condition or baseline (eg, intentionally low blood pressure in heart failure)Vital sign abnormality, as indicated by 1 or more of the following:

TachycardiaHypotensionOrthostatic hypotension

CodesICD-10 Diagnosis: A90, A91, A92.0, A92.1, A92.30, A92.39, A92.5, A92.8, A92.9, A93.0, A93.1, A93.2, A93.8, A94, A95.0, A95.1, A95.9, A96.0,A96.1, A96.2, A96.8, A96.9, A98.0, A98.1, A98.2, A98.3, A98.4, A98.5, A98.8, A99, B01.2, B01.89, B01.9, B03, B04, B05.2, B05.89, B05.9, B06.81,B06.89, B06.9, B08.20, B08.21, B08.22, B08.3, B08.4, B08.60, B08.62, B08.69, B08.70, B08.71, B08.72, B08.79, B10.81, B10.82, B10.89, B25.0,B25.8, B25.9, B26.89, B26.9, B27.00, B27.09, B27.10, B27.19, B27.80, B27.89, B27.90, B27.99, B33.1, B33.3, B33.4, B34.0, B34.1, B34.2, B34.3,B34.4, B34.8, B34.9, B97.0, B97.10, B97.11, B97.12, B97.19, B97.21, B97.29, B97.30, B97.31, B97.32, B97.33, B97.34, B97.35, B97.39, B97.4,B97.5, B97.6, B97.7, B97.81, B97.89, J00, J06.9, J09.X1, J09.X2, J09.X9, J10.00, J10.01, J10.08, J10.1, J10.89, J11.00, J11.08, J11.1, J11.89,J12.0, J12.1, J12.2, J12.3, J12.81, J12.82, J12.89, J12.9, J20.3, J20.4, J20.5, J20.6, J20.7, U07.1 [Hide]


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