More than a Spot Check?: Meningococcal Septicaemia at St.Emlyn’s

More than a Spot Check – What does the NICE Quality Standard for bacterial meningitis and meningococcal septicemia in children and young people mean for the Emergency Dept?

Who’s that now?

If you work in the UK, I’m sure you’ve heard of NICE – the National Institute for Clinical Excellence. In their own words;

“We provide independent, authoritative and evidence-based guidance on the most effective ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation. We develop our guidance and other products by working with experts from the NHS, local authorities, and others in the public, private and voluntary sectors – including patients and the public.”

And what are these Quality Standards about?

NICE quality standards are “a concise set of statements designed to drive and measure priority quality improvements within a particular area of care.” They are considered to be the “Gold standard” of care delivered within the NHS.

The quality standard for bacterial meningitis and meningococcal septicaemia in children and young people was published by NICE in June 2012, and has been endorsed by the Meningitis Research Foundation, the Meningitis Trust and (rather morbidly) the Royal College of Pathologists.

Why?

NICE is central to clinical governance in the NHS, ensuring that the right care is given by the right people at the right time. Clinical governance itself has been defined as;

“A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”

If you want to learn more about clinical governance, see this online resource.

Bacterial meningitis and meningococcal disease are reasonably rare (660 cases of invasive meningococcal disease in the UK in under-19s in 2010) but carry high mortality (10% quoted by NICE) and morbidity. Getting good quality care for these patients is in everyone’s best interests.

How?

The quality standard covers 14 quality statements, 10 of which are directly related to or raise issues relevant to ED care. Each statement sets a standard of care with the aim of assessing local practice and expressing results as a proportion receiving care to the suggested standard. I haven’t gone mad: the numbering corresponds with the numbering in the NICE document (so number 6 is missing).

Let’s have a little look then!

1. Parents and carers of children and young people presenting with non-specific symptoms and signs are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.

This is, on the surface, common sense. NICE recognises that not all children with a temperature and in a bad mood have invasive meningococcal disease, and conversely not all children who are diagnosed with invasive meningococcal disease present with fever, vomiting and a purpuric rash. They may not look particularly unwell to begin with; in fact, back in late 2011 I saw an alarming case where a child with a temp had been admitted to the observation ward, had some vomiting and diarrhoea, normal WCC and CRP of 4. At the time her purpura appeared (approx 11h after her attendance at PED), her EWS had been “green” for more than four hours and it was Mum’s assertion that she “just wasn’t right” combined with a blood glucose of 2.9 that had made me hang on to her a little longer. She grew Neisseria meningiditis from the blood culture taken at the same time as her baseline bloods.

Let’s not beat about the bush; this is a nasty, aggressive disease, and for all we let the media malign our colleagues for missing it, sometimes the diagnosis just isn’t obvious until it’s barn-door.

So, this quality statement is about communicating the paragraph above to the child’s parents without scaring the life out of them (not all that easy, actually!).
NICE wants us to communicate, specifically, where and when parents should access further care. Their “must include list” comprises:

  • The child develops a non-blanching rash.
  • The parent or carer feels that the child is less well than when they previously sought advice.
  • The parent or carer is more worried than when they previously sought advice.
  • The fever lasts longer than 5 days.
  • The parent or carer is distressed, or concerned that they are unable to look after the child.
  • The child is lethargic or irritable.
  • The child stops feeding (infants only).
  • The child has a fit.


How can you communicate this without the parents point-blank refusing to leave the department even though their snotty two-year-old is running around, cackling and breaking everything in sight? Well, NICE is happy with oral and/or written information – so make the most of your department’s “Feverish child” patient information leaflets which should contain this information (and if they don’t, take charge and sort it out!), document in the notes that you’ve given written advice and top it up with a stock paediatric patient disclaimer (feel free to use mine, I say the following to 99.9% of parents):

“We know that when it comes to children, things can change very quickly. If you are worried, at all, about anything – even if you just get to your car and think “he’s not right” – come back and see us. We won’t tell you off. We’d rather check him over and make sure everything is ok.”

2. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.

This is more likely to be delivered by nursing staff, but it’s important to be aware of this standard. Having done an audit of triage observations for children presenting with temperature (as in the NICE Feverish Illness guideline), I can tell you that this is something we do badly. Why? Because EDs are busy, and ED nurses (despite being the best nursing staff in the hospital – I genuinely believe this!) are busy and often stretched beyond the capacity of mere humans. It makes sense, of course – we know that these children can deteriorate quickly, so we need to keep a close eye on them. Another exercise in communication then; asking the super-stretched nurses to perform hourly observations without annoying them too much – or maybe doing them yourself?? The risk of not doing so is unwanted press attention

3. Children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance.

This statement references the bacterial meninigitis and meningococcal septicaemia clinical guideline. Below is the flow diagram for investigating petechial rash in children.

I’ve read around this quite a bit for my MSc in Emergency Medicine, and I think it’s probably worth drawing your attention to the work of Downes who found that 27.6% of babies at a “well baby” clinic had petechiae. I don’t know how sensitive or specific the NICE flow-diagram is; but I can’t help but think you’d be brave not to give antibiotics to a child with petechiae, fever and abnormal WCC/CRP. Do learn from others’ mistakes

As a result of this, a lot of kids get admitted for 48h antibiotics pending blood culture and PCR results (see statement 7); but remember my personal horror story and don’t be dissuaded by pushy specialty doctors. If you were concerned enough to start antibiotics, stand by your decision and get the child admitted. If they have a purpuric rash with fever, get the antibiotics in and think of ITP/HSP later. And, just to make sure I sound like a broken record, remember NAI.

4. Children and young people with suspected bacterial meningitis or meningococcal septicaemia receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.

This statement is useful for two reasons; firstly, advocating IO administration (great advice here although please don’t give children 2mls of 1% lidocaine down the IO! Jury’s out on how much/if you can give IO local anaesthesia in kids – more on this at a later date maybe). IO access is brilliant, the EZIO (the “baby drill”, as I like to call it) makes it ridiculously easy, and you honestly do look even cooler drilling into a baby’s leg than you do getting the cannula no-one else could manage. And this comes from someone who lists IV cannulation as one of her two skills (the other is ABGs – thanks for asking). If the kid is sick/purpuric enough that you want to give antibiotics asap, get the IO in, give a fluid bolus (slowly, it hurts) and then you might be lucky enough to find your IV access not so hard. If not, call ICU and keep giving the fluid.

Secondly, the target of administration within an hour; with time-related targets in every ED in the UK, wouldn’t it be nice to get your blood results back within 60mins for the well-looking feverish children with petechiae, so you can give them antibiotics? Helpfully, the Royal College of Pathologists has endorsed the standards, so it should be easier to get bloods processed. Although in reality if you call the lab, ask nicely and explain why you need the results, it will probably work better than taking the “because NICE says so” route.

5. Children and young people with suspected bacterial meningitis have a lumbar puncture.

All you really need to know about this standard is that there are enough exclusion criteria that unless you are skilled enough and particularly want to do so, this probably doesn’t need to be done by the ED doc. Notably, you need to have normal coagulation; so in children with a petechial or purpuric rash, LP shouldn’t be carried out until platelet and coag results are available and confirmed normal.

7. Children and young people with suspected bacterial meningitis or meningococcal septicaemia have whole blood meningococcal polymerase chain reaction (PCR) testing.

Really important; especially for the kids who are “well” but with petechiae. Please, please, think about this when you do your initial blood tests. My top tip; take a blood culture and PCR sample at the same time as your FBC and CRP, and put them to one side (labelled, of course). No-one likes stabbing a child repeatedly, so if your results or a change in clinical condition necessitates antibiotics, you can send the culture and PCR; if not, and you are discharging the child, you can discard them. Simple!

8. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia, who have signs of shock or raised intracranial pressure, are assessed by a consultant paediatrician.

This is a slightly odd statement, as it has no rationale attached to it and no specified timeframe, but in essence it’s a reminder that sick kids should be seen by consultants.  I would suggest (and I’m sure Simon will chip in on this one), that if a kid has signs of shock or raised ICP in the ED, the ED consultant will probably want to know about it too. I am certain that (unpleasant exam willing) when I am a consultant, this is definitely the sort of patient I want to know about.

9. Children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation have the procedure undertaken by an anaesthetist experienced in paediatric airway management.

There’s quite a long statement of indications for intubation and ventilation attached to this. The situation you are most likely to encounter is the child requiring more than 40ml/kg fluid resuscitation (i.e. boluses, not maintenance). And who are these anaesthetists, “experienced in paediatric airway management”? Well, they are anaesthetists who are current APLS providers (or equivalent) – or other clinicians experienced in paediatric airway management (which presumably means the same APLS standard). There’s a little reminder to let your local PICU’s consultant oncall know if you are intubating; the child is going to end up there and we do like to know about these things in advance (as sometimes we need to discharge other patients).

10. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals are escorted by a healthcare professional trained in advanced paediatric life support.

Again, common sense; don’t transfer kids unless you are trained to deal with the potential consequences of their illness, including intubation, ventilation, seizure management, cardiac arrest and a whole host of other unpleasant situations. It is scary, and not nearly as much fun as it sounds.

11. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital are transferred by a specialist paediatric retrieval team.

Lastly, the gold standard for transfer for PICU/PHDU is by retrieval team, unless the transfer is time-critical (associated intracerebral bleed requiring urgent neurosurgery, for example). This is either available to you or it isn’t – so I’m going to take the opportunity to big-up the fabulous NEWTS team. Having spent the last three months working (and training) alongside these guys, I can see why this standard exists; not only are they highly skilled in looking after sick kids, they also set up infusions etc. in the way they will run in PICU, making transfer of care much smoother. They are brilliant; but don’t call NEWTS (unless you are working in the North West/North Wales); find out about your local service and use them.

OK, got it! So what now?

Well, you’ve got the basics of “gold standard care”. But what is your department actually doing? How are your ED team performing? It’s a perfect time to get out there and audit; identify the weaknesses and take steps to fortify them.

And from NICE? Look out for more quality standards coming your way; of interest to the ED: upper GI bleeding, asthma, and just for Dan – thromboembolic disease. I can hardly wait!

Best Wishes

Natalie May

 

Before you go don’t forget

Posted by Natalie May

Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM is section lead for paediatrics and medical education. She is an Editorial Board Member of the St Emlyn’s blog and podcast. She is a specialist in Emergency Medicine (Australia) and a Specialist in Emergency Medicine with Paediatric Emergency Medicine (UK). She works as Staff Specialist in Prehospital and Retrieval Medicine with the Ambulance Service of New South Wales (aka Sydney HEMS). She also works as aStaff Specialist, Emergency Medicine, St George Hospital (South Eastern Sydney Local Health District). Her research interests include medical education, particularly feedback; gender inequity in healthcare; paediatric emergency medicine. You can find her on twitter as @_NMay

  1. This is great as it is accessible by anyone from EM/Paediatrics and can engage those normally put off by all things NICE and guideline related.

    Few comments:

    Precisely for the reason you mention in your physiologically well child who ended up with meningococcal disease we have developed POPS (Paediatric Observation Priority Score) which includes behavioural and observational features (and is also a free app – http://bit.ly/Ne2P81)

    The consultant paediatrician statement does seem odd without a time frame and it would be scary, if this day and age, at some point in the admission of a really sick child with meningococcal disease they weren’t assessed by a consultant. How will this standard improve quality?

    EDs need to start thinking about who normally transfers the physiologically well child with a fever and non-blanching rash (_+/- antibiotics in the ED) to the childrens or observations ward. Do they always have APLS….

    Great work with this!

    Damian

    Reply

  2. Prof Simon Carley August 3, 2012 at 9:18 am

    Hi Nat – absolutely I want to know about any sick kids in the dept.

    A little thought for you about the mentality of the use of ABs in kids with petechial rashes in the ED.

    There seems to be a feeling that if you give one dose of IV ABs for a kid who might have septicaemia then you HAVE to keep the child on IVs, in hospital (usually) for 48 hours.

    I have a problem with this as it can induce a mindset that in the equivocal case where suspicion is low, but not zero, clinicians might delay ABs until the bloods are back, the child has been observed, reviewed etc.

    I believe when we are talking about ABs in suspected septicaemia we should shoot first and ask questions later. So, we encourage the early use of ABs even if suspicion is low. We can always review later, with bloods, a more senior doc, a better history and more time….and sure if everything turns out to be fine we CAN change our minds and do something different to an automatic admission.

    It’s important that we put no real, or imagined barriers in place to encouraging all our clinicians to give antibiotics early if we suspect this devastating and humbling disease.

    vb

    S

    Reply

  3. I agree with Simon I think there is a tendency with some (usually more junior staff but not exclusively so) to not use antiobiotics in the well petechial patient incase it mandates 48hours of antibiotics. I think this is particularly so when the petechiae are in an SVC distribution ( and I’m sure we all know that it svc distribution alone doesnt exclude meningococcaemia).
    Get the antibiotics in then we can review our diagnosis at a later time…afterall you wouldnt continue the fragmin and antiplatelets whose chest pain turned out to reflux because you started them

    Gareth

    Reply

  4. Thanks for your thoughts, gentlemen.
    I guess what we are missing is a validated petechial rash decision rule. I like the idea of starting antibiotics with a view to stopping them sooner than 48h; the problems with this are;
    1. Lack of data regarding the post-test probability of meningococcal disease in event of normal blood tests
    Should we send PCR samples on these kids straight away? At RMCH they take 48h to give a result, but they don’t usually get processed immediately if out of hours. Is negative PCR the gold standard? Negative blood culture? Normal WCC and CRP (clearly not for my patient!)?
    2. Some studies suggest that being well and having petechiae i.e. using clinical assessment, is reasonably sensitive – in particular, see Mandl et al’s paper in the Journal of Pediatrics (http://www.jpeds.com/article/S0022-3476(97)80065-0/abstract)
    Their study of 411 children with petechiae found bacteraemia/sepsis in only 8, with none of the 357 “well-looking” children having bacteraemia.
    Drugs aren’t without side effects; risk/benefit ratio? Should we have treated all 411 with antibiotics in the first instance? And if not, does the NICE flow chart actually give us a pretty reasonable (if not validated) clinical decision rule?

    Nat
    *Edited for grammar (tut tut!) and when I realised I was talking nonsense… Note to self, don’t post before nights. Am much more coherent at 6am.

    Reply

  5. Hi Nat,

    What would link the posts and the comments is indeed a clinical decision rule that takes into account pre-test probabability together with tests….and one of those test will be observation over time. As you know we have a PED short stay unit so we have the option to keep kids for up to 24 hours under the care of the ED.

    Time and observation are a powerful diagnostic tools….., but you rarely see them in clinical decision rules.

    S

    Reply

  6. A clinical problem that just won’t go away…vaccination improves, rates of serious bacterial illness [SBI] fall, presentations of children continue to increase, perception of risk of SBI rightly remains high and diagnostic conundrum remains unchanged!

    My personal belief, not backed up be evidence (yet..) is that there is no clinical prediction rule that can control for instinct or gestalt. An experienced clinician in (paediatric) emergency medicine will have a different set of alarm bells than someone less experienced. A shoot first ask questions later policy in respect of SBI in children is clearly safe but when I will shoot will be different from the juniors I work with. If ALL children who were perceived at any risk had admission and antibiotics (even if only for short duration and one dose) then systems would struggle.

    The reason that ‘seniors’ exist is to provide the finesse to a clinical pathway to a clinical decision rule can never do. And I hope that never changes.

    Simon’s point regarding observation is also extremely valid – RCT of a clinical pathway with mandatory observation versus not anyone 🙂

    Reply

Thanks so much for following. Viva la #FOAMed

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