Fever in the Returned Traveler — Disposition — Clinical Pathway: Emergency Department

Fever In the Returned Traveler — Emergency Department

Disposition

Discharge

Discharge Considerations for the Febrile Returned Traveler

  • No concern for highly communicable disease of public health importance (e.g. measles, Ebola)
  • Normal/reassuring VS and labs
  • Nontoxic appearing/able to self-hydrate
  • Low suspicion for falciparum malaria
  • Follow-up in 24 hours is possible
  • Reachable by telephone for results (e.g. malaria smear)
  • Non-falciparum malaria may be discharged if they demonstrate ability to take PO meds in ED, and have solid follow-up plan

Discharge Instructions

  1. PMD follow-up in 24 hrs
  2. Patients returning from dengue endemic areas and concern for dengue should have daily CBC until afebrile for > 48 hrs to assess for subtle signs of plasma leakage/developing dengue hemorrhagic fever (DHF), including:
    1. Hemoconcentration, defined by > 20% increase in hematocrit
      (above average for age or compared to the previous day)
      or
    2. > 20% post-volume drop in hematocrit if IVF received
    3. Thrombocytopenia (< 100 K)
    Note:
    CBC can be rechecked by PCP or via return ED visit.
    Contact PCP to ensure adequate follow-up is possible and type recommended labs in discharge instructions.
  3. Infectious Diseases outpatient follow-up as needed and per their recommendations

Admission Considerations

  • Any concerning lab value
  • Abnormal VS, concerning clinical exam
  • Inability to tolerate adequate PO
  • High Suspicion for or diagnosis of falciparum malaria of any severity
    • Admit for observation even if well appearing — at risk for clinical deterioration
  • Dengue hemorrhagic fever criteria met
  • Concern for highly communicable disease of public health importance
    • As per IP&C or Department of Public Health
  • Any concerns about ability to follow up/return to care
PICU
  • ICU level care required
  • Note: May need to await 1st parasitemia result in ED to determine if severe criteria are met
Inpatient General Peds
  • All patients with uncomplicated, non-severe falciparum to observe for clinical deterioration
    • Obtain a second parasitemia 4 hrs after the initial parasitemia
    • Obtain a follow-up (3rd) parasitemia the next day (~12-24 hrs) after the 2nd parasitemia
  • Non-falciparum malaria who do not meet discharge criteria