The National Institute for Health and Clinical Excellence (NICE) 2012 “Quality Standard for Bacterial Meningitis and Meningococcal Septicaemia in Children and Young People” is outstanding and worth the brief time it takes to review it.
And also visit and go through the NICE pathways “Prehospital management for bacterial meningitis and meningococcal disease“, “Management of meningococcal disease“, “Management of bacterial meningitis“, “Feverish illness in children overview“, “Symptoms and signs of specific illnesses in children with fever“, “Bacterial meningitis and meningococcal septicaemia overview“,and “Management of petechial rash“. They are all outstanding clinical pathways that are related to the NICE 2012 Quality Standard (QS).
Now I’ll list each of the fourteen quality statements from the (NICE) 2012 “Quality Standard for Bacterial Meningitis and Meningococcal Septicaemia in Children and Young People“. All that follows are direct quotes for the QS. Any comments I make will be bracketed [like this].
Introduction
Bacterial meningitis is an inflammation of the meninges, which are the membranes that cover the brain. In children and young people aged 3 months or older, bacterial meningitis is most commonly caused by Neisseria meningitidis (meningococcus). Meningococcal septicaemia is a severe systemic infection in which there is multiplication of infective organisms in the blood stream.
Meningococcal meningitis and meningococcal septicaemia are sometimes referred to as invasive meningococcal disease. Meningococcal disease most commonly presents as meningitis (15% of cases) or septicaemia (25% of cases), or as a combination of the two (60% of cases).
Meningococcal disease occurs primarily in children aged under 5 years, with a peak incidence in those aged under 1 year. There is a smaller, secondary peak in incidence in young people between 15 and 19 years. Most cases of meningococcal disease occur sporadically, with less than 5% occurring in clusters. Outbreaks are most common among young people, occurring for example in schools or universities. In 2010 there were 660 laboratory confirmed cases of invasive meningococcal disease in children and young people aged under 19 years in England and Wales.
Meningococcal disease causes death in around 1 in 10 cases, and is the leading cause of death from infection in early childhood in the UK, making its control a priority for clinical management. The identification and treatment of meningococcal disease is time-critical; emergency admission to hospital and treatment with antibiotics should be sought without delay, as the disease can be fatal within hours of the first symptoms appearing. Prompt recognition of the symptoms and signs is key to preventing death or disability.
List of quality statements [Just Click on each of the statement numbers to be taken to that page and the reasoning and details behind each statement]
Statement 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.
Statement 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.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia have the physiological observations described in the statement assessed regularly throughout their care pathway, whether presenting in primary care or after they have been admitted to hospital.
Neurological condition is assessed using observations that include pupillary reactions, motor function and levels of consciousness (Glasgow Coma Scale or AVPU [Alert, Voice, Pain, Unresponsive]).
Statement 3. Children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance.
Children and young people with a rash of small red or purple spots that doesn’t fade when a glass is pressed firmly against the skin (a non-blanching rash) have appropriate investigations and receive antibiotics if their healthcare professional considers them at risk of bacterial meningitis or meningococcal septicaemia (blood poisoning).
Statement 4. Children and young people with suspected bacterial meningitis or meningococcal septicaemia receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Antibiotics should be administered for children and young people with suspected bacterial meningitis or meningococcal septicaemia as soon as possible in order to optimise chances of recovery, and within an hour of arrival in secondary care.
While antibiotics should be given at the earliest opportunity, either in primary or secondary care (without delaying urgent transfer to hospital to do so), this statement concerns children and young people with suspected bacterial meningitis or meningococcal septicaemia for whom there has been no delay in their transfer to hospital, either from their GP or through attendance at an accident and emergency department.
For children and young people for whom urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), antibiotics may be given in primary or community care (see NICE clinical guideline 102 recommendations 1.2.3 and 1.2.4).
Statement 5. Children and young people with suspected bacterial meningitis have a lumbar puncture.
It is important that children and young people with suspected bacterial meningitis have a lumbar puncture as soon as possible, but only when it is safe to do so. Contraindications to lumbar puncture include:
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signs suggesting raised intracranial pressure
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reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
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age-relative bradycardia and hypertension
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focal neurological signs
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abnormal posture or posturing
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unequal, dilated or poorly responsive pupils
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papilloedema
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abnormal ‘doll’s eye’ movements
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tense, bulging fontanelle
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shock
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extensive or spreading purpura
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convulsions until stabilised
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coagulation abnormalities:
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coagulation results (if obtained) outside the normal range
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platelet count below 100 x 109/litre
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receiving anticoagulant therapy
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superficial infection at the lumbar puncture site
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respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency).
Statement 6. Children and young people with suspected bacterial meningitis have their cerebrospinal fluid (CSF) microscopy result available within 4 hours of lumbar puncture.
CSF microscopy provides the CSF white blood cell count, which is the most important investigation for a diagnosis of meningitis. Samples should also be routinely processed for total protein and glucose concentrations.
It is important that samples are processed rapidly given that white cell counts decrease significantly with time.
Statement 7. Children and young people with suspected bacterial meningitis or meningococcal septicaemia have whole blood meningococcal polymerase chain reaction (PCR) testing.
PCR is a DNA-based diagnostic test.
PCR testing may not always be appropriate (for example, if the diagnosis has been confirmed by positive blood or cerebrospinal fluid cultures).
Statement 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.
Tracheal intubation with mechanical ventilation is required for the following indications.
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Threatened (for example, loss of gag reflex) or actual loss of airway patency.
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The need for any form of assisted ventilation, for example bag–mask ventilation.
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Clinical observation of increasingly laboured breathing.
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Hypoventilation or apnoea.
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Features of respiratory failure, including:
− irregular respiration (for example, Cheyne–Stokes breathing)
− hypoxia (PaO2 less than 13 kPa or 97.5 mmHg) or decreased oxygen saturations in air
− hypercapnia (PaCO2 greater than 6 kPa or 45 mmHg).
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Continuing shock following infusion of a total of 40 ml/kg of resuscitation fluid.
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Signs of raised intracranial pressure.
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Impaired mental status, including:
− reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
− moribund state.
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Control of intractable seizures.
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Need for stabilisation and management to allow brain imaging or transfer to the paediatric intensive care unit or another hospital.
An anaesthetist experienced in paediatric airway management is an anaesthetist who has maintained their skills in paediatric resuscitation to the level of advanced paediatric life support or equivalent (for example by undertaking regular supernumerary attachments to paediatric lists or secondments to specialist centres/paediatric simulator work).
In the absence of an anaesthetist, another clinician experienced in paediatric airway management may undertake tracheal intubation and mechanical ventilation for children and young people with meningococcal septicaemia.
A paediatric intensivist should be consulted by the clinician undertaking tracheal intubation and mechanical ventilation.
Statement 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.
A specialist paediatric retrieval team comprises medical and nursing staff with specialist training in the transfer of sick children and young people from hospitals to paediatric intensive care or high dependency units.
Statement 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.
Statement 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.
Statement 12. Children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, are given information before discharge about the disease, its potential long-term effects and how to access further support.
Statement 13. Children and young people who have had bacterial meningitis or meningococcal septicaemia have an audiological assessment before discharge.
Statement 14. Children and young people who have had bacterial meningitis or meningococcal septicaemia have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
