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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? If you work in the UK, I’m sure you’ve heard of NICE – the National Institute for Clinical Excellence. 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. 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. The quality standard covers 14 quality statements, 10 of which are directly related to or raise issues relevant to ED care.
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.
The parent or carer feels that the child is less well than when they previously sought advice. The parent or carer is distressed, or concerned that they are unable to look after the child.
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? This is more likely to be delivered by nursing staff, but it’s important to be aware of this standard. This statement references the bacterial meninigitis and meningococcal septicaemia clinical guideline. 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. 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. 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! 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? 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. 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. There’s quite a long statement of indications for intubation and ventilation attached to this. 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. 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. 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. 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.
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. 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! Los accidentes cerebrovasculares o ACV son una de las afecciones que mas estan creciendo en la actualidad. Los calambres musculares son contracciones o espasmos musculares involuntarios  que genera dolor y se produce en forma esporadica.
Muchas personas cuando van en automovil, barco, tren u otros transportes sufren de vertigos y mareos.
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. 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. 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. 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. Children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance. If you were concerned enough to start antibiotics, stand by your decision and get the child admitted. Children and young people with suspected bacterial meningitis or meningococcal septicaemia receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Helpfully, the Royal College of Pathologists has endorsed the standards, so it should be easier to get bloods processed. 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.
Children and young people with suspected bacterial meningitis or meningococcal septicaemia have whole blood meningococcal polymerase chain reaction (PCR) testing. 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. 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. 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. 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. 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. 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).

At RMCH they take 48h to give a result, but they don’t usually get processed immediately if out of hours. 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. An experienced clinician in (paediatric) emergency medicine will have a different set of alarm bells than someone less experienced.
El calcio D-glucarico a menudo se promociona como una solucion natural para la prevencion de ciertos tipos de cancer. 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. 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. 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. 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). I am certain that (unpleasant exam willing) when I am a consultant, this is definitely the sort of patient I want to know about. 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. And if not, does the NICE flow chart actually give us a pretty reasonable (if not validated) clinical decision rule? 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. 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. 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. And this comes from someone who lists IV cannulation as one of her two skills (the other is ABGs – thanks for asking).
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.
It’s a perfect time to get out there and audit; identify the weaknesses and take steps to fortify them. 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.
She grew Neisseria meningiditis from the blood culture taken at the same time as her baseline bloods. It makes sense, of course – we know that these children can deteriorate quickly, so we need to keep a close eye on them. 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). Another exercise in communication then; asking the super-stretched nurses to perform hourly observations without annoying them too much – or maybe doing them yourself?? 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).

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