More than a Spot Check?
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.
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.
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…
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.
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.
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.
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.