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Bacterial meningitis and meningococcal septicaemia Audit support (Clinical and organisational criteria) Implementing NICE guidance ( First issued 2010 Updated 2012 NICE clinical guideline 102 Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 1 of 19 This audit support accompanies the clinical guideline: ‘Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care’ (available online at www.nice.org.uk/guidance/CG102). Issue date: 2010 Updated 2012 to include reference to the NICE quality standard on bacterial meningitis and meningococcal septicaemia in children and young people. This is a support tool for clinical audit based on the NICE guidance. It is not NICE guidance. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. National Institute for Health and Clinical Excellence Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT;; www.nice.org.uk © National Institute for Health and Clinical Excellence, 2012. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE. Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 2 of 19 Using audit support The audit support document can be used to measure current practice in the management of children and young people under 16 with bacterial meningitis and meningococcal septicaemia against the recommendations in the NICE guideline. Use it for a local audit project, by either using the whole tool or cutting and pasting the relevant parts into a local audit template. Audit criteria and standards are based on the guideline’s recommendations. The audit standards given are typically 100% or 0%. If these are not achievable in the short term, set a more realistic standard based on discussions with local clinicians. However, the audit standards given remain the ultimate objective. The data collection tool can be used or adapted for the data collection part of the clinical audit cycle by the trust, service or practice. The tool is based on the recommendations relating to clinical activity and on organisational priorities. Data may be required from a range of sources, including policy documents and patient records. Suggestions for these are indicated on the tools, although this is not an exhaustive list and they may differ in your organisation. The sample for this audit should include children and young people under 16 with a suspected or actual diagnosis of bacterial meningitis or meningococcal septicaemia. Select an appropriate sample in line with your local clinical audit strategy. Whether or not the audit results meet the audit standards, re-auditing is a key part of the audit cycle. If your first data collection shows room for improvement, re-run it once changes to the service have had time to make an impact. Continue with this process until the results of the audit meet the standards. Links with other clinical audit priorities The audit based on this guideline should be considered in conjunction with other clinical audit priorities such as: Fever in children audit Child Health confidential enquiry that includes a themed confidential case review. Paediatric Intensive Care audit Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 3 of 19 Clinical criteria for ‘Bacterial meningitis and meningococcal septicaemia’ Symptoms, signs and initial assessment Children and young people with suspected bacterial meningitis should have the following monitored and recorded at least hourly: Criterion 1 Guideline reference physiological observations of heart rate respiratory rate oxygen saturations blood pressure temperature perfusion (capillary refill) neurological assessment 1.1.6 Associated quality standard: Bacterial meningitis and meningococcal septicaemia in children and young people statement 2. Exceptions None Audit standard 100% Definitions An example of neurological assessment would be the Alert, Voice, Pain, Unresponsive (AVPU) scale. Management in the pre-hospital setting Criterion 2 Children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia in pre-hospital settings should be transferred to secondary care as an emergency by telephoning 999 Guideline reference 1.2.1 (key priority) Exceptions None Audit standard 100% Definitions Healthcare professionals will occasionally encounter children and young people with signs and symptoms suggestive of bacterial meningitis or meningococcal disease. Any child or young person identified with suspected bacterial meningitis or meningococcal disease in a pre-hospital setting should be transferred to secondary care urgently. This will often involve contacting emergency ambulance services (calling 999) to arrange transport, and communicating essential clinical information (for example, relevant past medical history, medications, and drug allergies) to hospital-based medical teams, usually via telephone. Diagnosis in secondary care – polymerase chain reaction Criterion 3 EDTA (ethylenediaminetetraacetic acid) whole blood samples should be Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 4 of 19 submitted for real-time PCR testing to confirm the diagnosis of suspected meningococcal disease. Guideline reference 1.3.8 Associated quality standard: Bacterial meningitis and meningococcal septicaemia in children and young people statement 7. Exceptions None Audit standard 100% Definitions None Criterion 4 Children and young people with suspected meningococcal disease should have an EDTA whole blood sample taken as soon as possible after admission. Guideline reference 1.3.9 Exceptions None Audit standard 100% Definitions The guidance states that the blood sample should be taken as soon as possible after admission because early samples are more likely to be positive Criterion 5 CSF should be submitted to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but PCR testing should only be performed if the CSF culture is negative. Guideline reference 1.3.12 Exceptions None Audit standard 100% Definitions None The following diagnostic tools should not be used when investigating for possible meningococcal disease in children and young people: Criterion 6 skin scrapings skin biopsies aspirates Guideline reference 1.3.14 Exceptions None Audit standard 100% Definitions Aspirates are defined as samples aspirated with a needle and syringe form a petechial/purpuric skin lesion. Diagnosis in secondary care – lumbar puncture Criterion 7 Children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia should have a lumbar puncture Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 5 of 19 performed unless any of the following contraindications are present: Guideline reference signs suggesting raised intracranial pressure reduced or fluctuating level of consciousness relative bradycardia and hypertension focal neurological signs abnormal posture or posturing unequal, dilated or poorly responsive pupils papilloedema abnormal ‘doll’s eye’ movements shock (see Table 1) extensive or extending purpura after convulsions until stabilised coagulation abnormalities coagulation results (if obtained) outside the normal range platelet count below 100 x 109/litre receiving anticoagulant therapy local superficial infection at potential lumbar puncture site respiratory insufficiency 1.3.15, 1.3.18 Associated quality standard: Bacterial meningitis and meningococcal septicaemia in children and young people statement 5. Exceptions None Audit standard 100% Definitions If contraindications exist at presentation consider delaying lumbar puncture until there are no longer contraindications. Delayed lumber puncture is especially worthwhile if there is diagnostic uncertainty or unsatisfactory clinical progress. Lumbar puncture is considered to have a high risk or precipitating respiratory failure in the presence of respiratory insufficiency. Criterion 8 Guideline reference Lumbar puncture results should be made available within 4 hours. 1.3.20 Associated quality standard: Bacterial meningitis and meningococcal septicaemia in children and young people statement 6. Exceptions None Audit standard 100% Definitions Lumbar puncture results are defined as white blood cell count, protein and glucose. These results should be made available to support clinical decision making with regard to adjunctive steroid therapy. Criterion 9 In children and young people with suspected bacterial meningitis, a cranial computed tomography (CT) scan should not be used. Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 6 of 19 Guideline reference 1.3.27, 1.3.28 Exceptions A – Where a child or young person has a reduced or fluctuating level of consciousness (Glasgow Coma Score less than 9 or a drop of 3 or more) or has focal neurological signs, and a CT scan is performed to detect other possible intracranial pathologies. Audit standard 100% Definitions In children and young people with suspected bacterial meningitis, use clinical assessment and not a cranial CT scan to decide whether it is safe to perform a lumbar puncture. CT is unreliable for identifying raised intracranial pressure. In children and young people with suspected bacterial meningitis who have a reduced or fluctuating level of consciousness (Glasgow Coma Score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a CT scan to detect other possible intracranial pathologies. If performing a CT scan, consult an anaesthetist, paediatrician or intensivist. Management in secondary care – fluids for bacterial meningitis Criterion 10 Children and young people with suspected or confirmed bacterial meningitis should not have fluids restricted. Guideline reference 1.4.23 Exceptions B – Where there is evidence of raised intracranial pressure. C – Where there is evidence of increased antidiuretic hormone (ADH) secretion. Audit standard 100% Definitions Full-volume fluid maintenance fluids should be given to children and young people with suspected or confirmed bacterial meningitis to avoid hypoglycaemia and to maintain electrolyte balance. The National Patient Safety Agency (NPSA) has highlighted that some acutely ill children with increased ADH secretion may benefit from maintenance fluid being restricted (Please see ‘Reducing the risk of hyponatraemia when administering intravenous infusions to children’ [NPSA/2007/22] for more details; available at http://www.npsa.nhs.uk). Criterion 11 Children and young people with suspected or confirmed bacterial meningitis should have fluid administration and urine output monitored. Guideline reference 1.4.27 Exceptions None Audit standard 100% Definitions This is to ensure adequate hydration and avoid overhydration. Criterion 12 Children and young people with suspected or confirmed bacterial meningitis should have electrolytes and blood glucose monitored regularly. Guideline reference 1.4.28 Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 7 of 19 Exceptions None Audit standard 100% Definitions The guidance states that electrolytes and blood glucose should be monitored at least daily while the person is receiving intravenous fluids. Long-term management Criterion 13 Children and young people who have had bacterial meningitis or meningococcal septicaemia should be offered an audiological test as soon as possible. Guideline reference 1.5.3 Exceptions None Audit standard 100% Definitions The guidance states that the test should be performed as soon as possible, preferably before discharge, within 4 weeks of being fit to test. This is in line with recommendations in the National Deaf Children's Society (NDCS) (2009) Quality Standards in Paediatric Audiology, Vol IV. Criterion 14 Children and young people who are found to have severe or profound deafness should be offered an urgent assessment for cochlear implants as soon as they are fit to undergo testing. Guideline reference 1.5.4 Exceptions None Audit standard 100% Definitions Further guidance on the use of cochlear implants for severe to profound deafness can be found in ‘Cochlear implants for severe to profound deafness in children and adults’ [NICE technology appraisal 166]. Criterion 15 Children and young people who have had bacterial meningitis or meningococcal septicaemia should be reviewed by a paediatrician 4–6 weeks after discharge from hospital. Guideline reference 1.5.5 (key priority) Associated quality standard: Bacterial meningitis and meningococcal septicaemia in children and young people statement 14. Exceptions None Audit standard 100% Definitions The purpose of this review should be to discuss morbidities associated with the child’s condition and obtain referral to the appropriate services. The review should take place with the results of their hearing test. The following morbidities should be specifically considered: hearing loss (with the child or young person having undergone an urgent assessment for cochlear implants as soon as they are fit) orthopaedic complications (damage to bones and joints) skin complications (including scarring from necrosis) Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 8 of 19 psychosocial problems neurological and developmental problems renal failure. The following professionals should be informed of the child or young person’s bacterial meningitis or meningococcal septicaemia: Criterion 16 GP health visitor school nurse. Guideline reference 1.5.6 Exceptions D – Where the school nurse has not been notified because the child or young person is not of school age. Audit standard 100% Definitions None Criterion 17 Children and young people should be tested for complement deficiency if they have had more than one episode of meningococcal disease, or one episode of meningococcal disease caused by serogroups other than B, or meningococcal disease caused by any serogroup and a history of other recurrent or serious bacterial infections. Guideline reference 1.5.8 Exceptions None Audit standard 100% Definitions Serogroups listed in the full guidance include C, A, X, Y, W135, Z, 29E and non-groupable. Do not test children and young people for complement deficiency who have had either meningococcal disease caused by serogroup B meningococcus or unconfirmed meningococcal disease (1.5.10). Number of criterion replaced: Local alternatives to above criteria (to be used where other data addressing the same issue are more readily available). Exceptions Settings Audit standard Definitions Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 9 of 19 Organisational criteria for ‘Bacterial meningitis and meningococcal septicaemia’ Criterion 18 Table 1 in the NICE guideline should be used to identify children and young people who have bacterial meningitis or meningococcal septicaemia. Guideline reference 1.1.1 (key priority) Exceptions None Audit standard 100% Definitions None Criterion 19 Healthcare professionals should be trained in the recognition and management of meningococcal disease. Guideline reference 1.1.7 (key priority) Exceptions None Audit standard 100% Definitions None Criterion 20 National or local protocols should be used for the management of seizures in children and young people with suspected bacterial meningitis or meningococcal septicaemia. Guideline reference 1.4.19 Exceptions None Audit standard 100% Definitions None Criterion 21 National or local protocols should be used to treat raised intracranial pressure in children and young people with suspected bacterial meningitis. Guideline reference 1.4.20 Exceptions None Audit standard 100% Definitions None Criterion 22 National or local protocols should be used for the administration of vasoactive agents in children and young people with suspected or Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 10 of 19 confirmed bacterial meningitis or meningococcal septicaemia. Guideline reference 1.4.32 Exceptions None Audit standard 100% Definitions None Criterion 23 National or local protocols should be used for intubation in children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia. Guideline reference 1.4.38 Exceptions None Audit standard 100% Definitions None Criterion 24 Paediatric intensive care units (PICUs) should have paediatric intensive care retrieval teams to undertake the transfer of children and young people. Guideline reference 1.4.50 Associated quality standard: Bacterial meningitis and meningococcal septicaemia in children and young people statement 11. Exceptions None Audit standard 100% Definitions Retrieval teams should comprise of medical and nursing staff. Number of criterion replaced: Local alternatives to above criteria (to be used where other data addressing the same issue are more readily available). Exceptions Audit standard Definitions Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 11 of 19 Patient data collection tool for ‘bacterial meningitis and meningococcal septicaemia’ Complete one form for each patient or episode. Patient identifier: Sex: Age: Data item Criteria no. Symptoms, signs and initial assessment No. Ethnicity: Yes No NA/ Exceptionsa NICE guideline ref. Did the child or young person with suspected bacterial meningitis have the following monitored and recorded at least hourly? physiological observations of heart rate respiratory rate oxygen saturations 1.4 blood pressure temperature perfusion (capillary refill) 1.5 neurological assessment 1.1 1 1.2 1.3 1.1.6 Management in the pre-hospital setting 2 2.1 In a pre-hospital setting, was the child or young person with suspected bacterial meningitis or suspected meningococcal septicaemia transferred to secondary care as an emergency by phoning 999? 1.2.1 Diagnosis in secondary care – polymerase chain reaction 3 3.1 Was the EDTA whole blood sample submitted for realtime PCR testing to confirm the diagnosis of suspected meningococcal disease? 1.3.8 4 4.1 Did the child or young person with suspected meningococcal disease have an EDTA whole blood sample taken as soon as possible after admission? 1.3.9 5.1 Was the CSF submitted to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae? 5 1.3.12 5.2 Was the PCR test was only performed if the CSF culture was negative? Were the following diagnostic tools used for the diagnosis of meningococcal disease in the child or young person: 6 6.1 skin scrapings 6.2 skin biopsies 6.3 aspirates Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 12 of 19 1.3.4 No. Data item no. Criteria Yes No NA/ Exceptionsa NICE guideline ref. Diagnosis in secondary care – lumbar puncture 7.1 Did the child or young person with suspected bacterial meningitis or suspected meningococcal septicaemia have a lumbar puncture performed? If not, which of the following contraindications were given as reasons? reduced or fluctuating level of consciousness 7.3 relative bradycardia and hypertension 7.4 focal neurological signs 7.5 abnormal posture or posturing unequal, dilated or poorly responsive pupils 7.7 papilloedema 7.8 abnormal ‘doll’s eye’ movement 7.2 7.6 7 signs suggesting raised intracranial pressure 7.9 shock (see Table 1) 7.10 extensive or extending purpura 7.11 after convulsions until stabilised coagulation abnormalities coagulation results (if obtained) outside the normal range 7.13 platelet count below 100 x 109/litre 7.14 receiving anticoagulant therapy 7.12 7.15 7.16 1.3.15, 1.3.18 local superficial infection at potential lumbar puncture site respiratory insufficiency 7.17 Was a delayed lumbar puncture eventually carried out? 8 8.1 Were the lumbar puncture results available within 4 hours? 9 9.1 Was a cranial CT scan used in the child or young person with suspected bacterial meningitis? 1.3.20 A Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 13 of 19 1.3.27, 1.3.28 No. Data item no. Criteria Yes No NA/ Exceptionsa NICE guideline ref. Management in secondary care – fluids for bacterial meningitis 10 11 12 10.1 Did the child or young person with suspected or confirmed bacterial meningitis have fluids restricted? 11.1 Did the children or young person with suspected or confirmed bacterial meningitis have fluid administration and urine output monitored? 1.4.27 12.1 During the acute phase of their illness, did the child or young person with suspected or confirmed bacterial meningitis have electrolytes and blood glucose monitored daily? 1.4.28 B/C 1.4.23 Long-term management 13 13.1 Has the child or young person who has had bacterial meningitis or meningococcal septicaemia been offered an audiological test within 4 weeks? 1.5.3 14 14.1 Did the child or young person who was found to have severe or profound deafness offered an assessment for cochlear implants? 1.5.4 15.1 Has the child or young person who has had bacterial meningitis or meningococcal septicaemia been reviewed by a paediatrician 4–6 weeks after discharge from hospital? 1.5.5 15 Were the following professionals informed of the child or young person’s bacterial meningitis or meningococcal septicaemia? 16 16.1 GP 16.2 health visitor 16.3 school nurse 1.5.6 D Was the child or young person tested for complement deficiency if they had any of the following? 17 17.1 a Circle more than one episode of meningococcal disease an episode of meningococcal disease caused by serogroups other than B meningococcal disease caused by any serogroup and a history of other recurrent or serious bacterial infections 1.5.8 exception codes as appropriate. Details of exceptions are listed at the end of the patient data collection tool. Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 14 of 19 Exception codes A – Where a child or young person has a reduced or fluctuating level of consciousness (Glasgow Coma Score less than 9 or a drop of 3 or more) or focal neurological signs, and a CT scan is performed to detect other possible intracranial pathologies. B – Where there is evidence of raised intracranial pressure C – Where there is evidence of increased ADH secretion D – Where the school nurse has not been notified because the child or young person is not of school age) Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 15 of 19 Organisational data collection tool for ‘bacterial meningitis and meningococcal septicaemia’ Organisation/service: Data item Criteria 18.1 Do healthcare professionals in your organisation use table 1 in the NICE guidance to identify children and young people who have bacterial meningitis or meningococcal septicaemia (see Appendix A)? 1.1.1 19.1 Are the healthcare professionals in your organisation involved in the treatment of children and young people trained in the recognition and management of meningococcal disease? 1.1.7 20.1 Does your organisation have national or local protocols in use for the management of seizures in children and young people with suspected bacterial meningitis or meningococcal septicaemia? 1.4.19 21.1 Does your organisation have national or local protocols in use to treat raised intracranial pressure in children and young people with suspected bacterial meningitis? 1.4.20 22.1 Does your organisation have national or local protocols in use for the administration of vasoactive agents in children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia? 1.4.32 23 23.1 Does your organisation have national or local protocols in use for intubation in children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia? 1.4.38 24 24.1 Does your PICU have paediatric intensive care retrieval teams to undertake the transfer of children and young people? 1.4.50 No. 18 19 20 21 22 Yes No NA/ Exceptions a Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 16 of 19 NICE guideline ref. Further information For further information about clinical audit refer to a local clinical audit professional in your own organisation or the HQIP website. To ask a question about this audit support, or to provide feedback to help inform the development of future tools, please email [email protected] Supporting implementation NICE has developed tools to help organisations implement the clinical guideline on bacterial meningitis and meningococcal septicaemia (listed below). These are available on our website (www.nice.org.uk/CG102). Costing statement. Slides highlighting key messages for local discussion. Implementation advice on how to put the guidance into practice and national initiatives that support this locally. Audit support for monitoring local practice (this document). A series of practical guides to implementation are also available on our website (www.nice.org.uk/usingguidance/implementationtools). The guidance You can download the guidance documents from www.nice.org.uk/CG102. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email [email protected] and quote N2201 (quick reference guide) and/or N2202 (‘Understanding NICE guidance’). Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 17 of 19 Appendix A Table 1 Symptoms and signs of bacterial meningitis and meningococcal septicaemia Symptom/sign Fever Vomiting/nausea Lethargy Irritable/unsettled Ill appearance Refusing food/drink Headache Muscle ache/joint pain Respiratory symptoms/signs or breathing difficulty Chills/shivering Diarrhoea, abdominal pain/distension Sore throat/coryza or other ear, nose and throat symptoms/signs Bacterial Meningococcal Meningococcal Notes meningitis disease septicaemia (meningococcal (meningococcal meningitis and meningitis meningitis and/or caused by meningococcal other bacteria) septicaemia) Common non-specific symptoms/signs Not always present, especially in neonates Less common non-specific symptoms/signs NK Non-blanching rash Stiff neck Altered mental More specific symptoms/signs NK NK Be aware that a rash may be less visible in darker skin tones – check soles of feet, palms of hands and conjunctivae Includes Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 18 of 19 state Capillary refill time more than 2 seconds Unusual skin colour Shock Hypotension Leg pain Cold hands/feet Back rigidity Bulging fontanelle confusion, delirium and drowsiness, and impaired consciousness NK NK NK NK NK NK NK Photophobia Kernig’s sign Brudzinski’s sign Unconsciousness Toxic/moribund state Paresis Focal neurological deficit including cranial nerve involvement and abnormal pupils Seizures Signs of shock Capillary refill time more than 2 seconds Unusual skin colour Tachycardia and/or hypotension Respiratory symptoms or breathing difficulty Leg pain Cold hands/feet Toxic/moribund state Altered mental state/decreased conscious level Poor urine output Only relevant in children aged under 2 years X X X X X X symptom/sign present X symptom/sign not present NK not known if a symptom/sign is present (not reported in the evidence) Audit support: Bacterial meningitis and meningococcal septicaemia (2012) – clinical and organisational criteria Page 19 of 19
