Joseph Britto

Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery

BACKGROUND AND AIMS The case fatality rate from meningococcal disease (MD) has remained relatively unchanged in the post antibiotic era, with 20–50% of patients who develop shock still dying. In 1992 a new paediatric intensive care unit (PICU) specialising in MD was opened. Educational information was disseminated to local hospitals, and a specialist transport service was established which delivered mobile intensive care. The influence of these changes on mortality of children with MD was investigated. METHODS A total of 331 consecutive children with meningococcal disease admitted to the PICU between 1992 and 1997 were studied. Severity of the disease on admission was assessed using the paediatric risk of mortality (PRISM) score. Logistic regression analysis was used to correct for clinical severity, age, and sex; death was the outcome, and year of admission, a temporal trend variable, was the primary exposure. RESULTS The case fatality rate fell year on year (from 23% in 1992/93 to 2% in 1997) despite disease severity remaining largely unchanged. After adjustment for age, sex, and disease severity, the overall estimate for improvement in the odds of death was 59% per year (odds ratio for the yearly trend 0.41). CONCLUSIONS A significant improvement in outcome for children admitted with MD to a PICU has occurred in association with improvements in initial management of patients with MD at referring hospitals, use of a mobile intensive care service, and centralisation of care in a specialist unit.

Emergency management of meningococcal disease

Meningococcal disease remains a major cause of mortality in children in the UK. Aggressive early volume resuscitation, meticulous attention to the normalisation of all physiological and laboratory parameters, and prompt referral to specialist paediatric intensive care may lead to a sharp reduction in mortality. Application of the management algorithm described in this article may be helpful to those involved in the early part of management of critically ill patients with meningococcal disease.

The role of healthcare delivery in the outcome of meningococcal disease in children: case-control study of fatal and non-fatal cases

Abstract Objective To determine whether suboptimal management in hospital could contribute to poor outcome in children admitted with meningococcal disease. Design Case-control study of childhood deaths from meningococcal disease, comparing hospital care in fatal and non-fatal cases. Setting National statistics and hospital records. Subjects All children under 17 years who died from meningococcal disease (cases) matched by age with three survivors (controls) from the same region of the country. Main outcome measures Predefined criteria defined optimal management. A panel of paediatricians blinded to the outcome assessed case records using a standardised form and scored patients for suboptimal management. Results We identified 143 cases and 355 controls. Departures from optimal (per protocol) management occurred more frequently in the fatal cases than in the survivors. Multivariate analysis identified three factors independently associated with an increased risk of death: failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes. Failure to recognise complications of the disease was a significant risk factor for death, although not independently of absence of paediatric care (P = 0.002). The odds ratio for death was 8.7 (95% confidence interval 2.3 to 33) with two failures, increasing with multiple failures. Conclusions Suboptimal healthcare delivery significantly reduces the likelihood of survival in children with meningococcal disease. Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses.

Avoidable deficiencies in the delivery of health care to children with meningococcal disease.

OBJECTIVES: It is apparent that delays and inadequate or inappropriate management occur frequently and may contribute to the continued high mortality seen in meningococcal disease. An attempt has been made to define the major sources of delay or inappropriate treatment. METHODS: A prospective, descriptive study of children with meningococcal disease referred to a tertiary centre paediatric intensive care and infectious disease unit. Definitions of optimal care were established at three stages: parental; general practitioner (GP)/accident and emergency (A&E) department; and hospital. Duration of symptoms and management were recorded from direct questioning of parents and carers, and from hospital records. RESULTS: 54 consecutive children with meningococcal disease were recruited to the study. Delayed parental recognition occurred in 16 children. GPs correctly diagnosed 19 of 35 children. Delay of 2.5-21 hours occurred in those who were incorrectly diagnosed. Two of 15 children who presented to the A&E department with specific features were incorrectly diagnosed. Hospital treatment was suboptimal in 71%. Shock was not recognised or treated in 50%, 20% of children had unnecessary lumbar punctures. Time from illness onset to treatment was longer in fatal disease (median 18.3, range 8-24 hours), compared with survivors (median 12, range 2-48 hours; p < 0.01, Mann-Whitney U test). CONCLUSION: Suboptimal treatment in meningococcal disease is due to failure of parents, GPs, and hospital doctors to recognise specific features of the illness. Improvement by public education and better training of clinicians in recognition, resuscitation, and stabilisation of seriously ill children.

Whooping cough—a continuing problem

News media announced a global resurgence of whooping cough in April this year following a session on pertussis at the 12th European Congress of Clinical Microbiology and Infectious Diseases in Milan, Italy. Subsequently the European Union sent an alert to member states. Pertussis is one of the top causes of vaccine preventable deaths, with nearly 300 000 deaths in children worldwide in 2000.1 However, reports of a global resurgence originated in countries with low mortality and high vaccination coverage. For such countries the issue is how to fine tune effective immunisation programmes. In the rest of the world, priorities are to decrease infant mortality by improving coverage and timeliness of vaccination and implementing pertussis surveillance.2 Pertussis has re-emerged in low mortality countries in the past because of low coverage after a vaccine scare in the 1980s (in the United Kingdom) or the use of vaccines with poor efficacy (Canada, Sweden).3 Sweden and Germany stopped their vaccination programmes completely and only reinstituted vaccination for pertussis after years of recurrent epidemics of whooping cough. More recently …

ISABEL: a web-based differential diagnostic aid for paediatrics: results from an initial performance evaluation

Aims: To test the clinical accuracy of a web based differential diagnostic tool (ISABEL) for a set of case histories collected during a two stage evaluation. Methods: Setting: acute paediatric units in two teaching and two district general hospitals in the southeast of England. Materials: sets of summary clinical features from both stages, and the diagnoses expected for these features from stage I (hypothetical cases provided by participating clinicians in August 2000) and final diagnoses for cases in stage II (children presenting to participating acute paediatric units between October and December 2000). Main outcome measure: presence of the expected or final diagnosis in the ISABEL output list. Results: A total of 99 hypothetical cases from stage I and 100 real life cases from stage II were included in the study. Cases from stage II covered a range of paediatric specialties (n = 14) and final diagnoses (n = 55). ISABEL displayed the diagnosis expected by the clinician in 90/99 hypothetical cases (91%). In stage II evaluation, ISABEL displayed the final diagnosis in 83/87 real cases (95%). Conclusion: ISABEL showed acceptable clinical accuracy in producing the final diagnosis for a variety of real as well as hypothetical case scenarios.

Pertussis is increasing in unimmunised infants: is a change in policy needed?

The proportion and trend in absolute number of pertussis notifications in young infants has increased each year in England and Wales since the accelerated immunisation schedule was introduced. We report five infants all less than 3 months of age admitted with life threatening pertussis infection to two paediatric intensive care units. Despite aggressive cardiorespiratory support measures, three of the infants died. Pertussis remains a significant cause of morbidity and mortality in unimmunised infants. In this age group presentation is likely to be atypical and infection more severe. Public health measures to prevent the disease could be strengthened. Chemoprophylaxis should be offered to susceptible contacts and booster vaccinations against pertussis considered.

Systemic complications associated with bacterial tracheitis.

The toxic shock syndrome, septic shock, pulmonary oedema, and the acute respiratory distress syndrome (ARDS) were recognised in four children with bacterial tracheitis. ARDS has not previously been reported in association with bacterial tracheitis. Prompt recognition of the severe systemic complications of bacterial tracheitis could lead to a decrease in the morbidity and mortality of this condition.

Validation of a diagnostic reminder system in emergency medicine: a multi‐centre study

Background: Diagnostic error is a significant problem in emergency medicine, where initial clinical assessment and decision making is often based on incomplete clinical information. Traditional computerised diagnostic systems have been of limited use in the acute setting, mainly due to the need for lengthy system consultation. We evaluated a novel web-based reminder system, which provides rapid diagnostic advice to users based on free text search terms. Methods: Clinical data collected from patients presenting to three emergency departments with acute medical problems were entered into the diagnostic system. The displayed results were assessed against the final discharge diagnoses for patients who were admitted to hospital (diagnostic accuracy) and against a set of “appropriate” diagnoses for each case provided by an expert panel (potential utility). Results: Data were collected from 594 patients (53.4% of screened attendances). Mean age was 49.4 years (95% CI 47.7 to 51.1) and the majority had significant past illnesses. Most were assessed first by junior doctors (70%) and 266/594 (44.6%) were admitted to hospital. Overall, the diagnostic system displayed the final discharge diagnosis in 95% of inpatients and 90% of “must-not-miss” diagnoses suggested by the expert panel. The discharge diagnosis appeared within the first 10 suggestions in 78% of cases. Conclusions: The Isabel diagnostic aid has been shown to be of potential use in reminding junior doctors of key diagnoses in the emergency department. The effects of its widespread use on decision making and diagnostic error can be clarified by evaluating its impact on routine clinical decision making.

Noninvasive Measurement of Cardiac Output in Critically Ill Children

This study was performed to evaluate the hemodynamic status of children admitted to the intensive care unit, using suprasternal and transesophageal Doppler ultrasound, and to establish a suitable noninvasive technique to monitor trends in cardiac output in critically ill children. Twenty children were studied over a period of 6 months. The median age was 32.5 months and weight 14.5 kg. Minute distance (MD), which is a linear cardiac output parameter, was assessed. Seven simultaneous pairs of measurements of MD were made using transesophageal Doppler (TED) and suprasternal Doppler (SSD) by the same operator. Following a fluid challenge, seven repeat pairs of measurements were made. The mean percentage changes for MD by TED and SSD were 21.84 (SD 9.97) and 5.75 (SD 7.32). The average coefficients of variation for measurements of MD by TED and SSD were 2.34% and 15.98%, respectively. The mean difference in percentage change between MD, measured by TED and SSD, was 27.59 with a 95% confidence interval and wide limits of agreement. The repeatability of TED measurements was good, but the measurements by SSD were wide and erratic with poor reproducibility. Our study shows that TED is easy to use, reliable, and very useful for monitoring hemodynamic changes in critically ill children.