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

Development of a standardised assessment tool

To provide an objective assessment of the promptness and quality of emergency medical care provided, we developed a standardised assessment tool using published and widely accepted criteria for diagnosis and management of meningococcal disease and its complications (table 1).9 Following guidelines in the UK advanced paediatric life support manual,10 we defined the following disease complications (organ failures) namely: cardiovascular failure (shock), respiratory failure, neurological failure, raised intracranial pressure, and haemorrhagic rash. When patients were admitted with tachycardia or tachypnoea but, because of inadequate documentation in the notes, we could not diagnose or rule out a specific organ failure, we categorised the patient as having “abnormal signs only.”

Panel

An assessment panel—comprising a consultant in paediatric emergency medicine, a consultant in paediatric infectious diseases, and two consultants in paediatric intensive care—reviewed data on all cases.

Blinded evaluation of patient records using the standardised assessment tool

Vital signs and laboratory results recorded in each patient's notes in the first 24 hours after admission were transcribed on to flow charts in one hour time periods with the time of arrival at hospital taken as time 0 hours. The treatments initiated were also recorded for each hour. The clinical findings and laboratory results were then presented to the panel by revealing the information available at each hour after admission. On the basis of the information available at each hour, the panel members assessed each patient for the presence of diagnostic features of meningococcal disease and its complications. Using the agreed protocol11 they recommended standard management of each complication. CP recorded the panel's decisions and recommended management for each hour. The panel members became aware of the outcome (fatal or not) only after their scoring had been recorded.

By comparing the time after admission at which the panel diagnosed the disease and complications with the time that the hospital team caring for the child reached the diagnosis, and comparing the recommended management of each complication with that which the patient received, we evaluated the actual hospital management, both in terms of timing and the actions undertaken. Delay of more than an hour between the action recommended by the panel and what actually occurred was defined as a failure of care and delay of more than 24 hours in being seen by a consultant as a failure in supervision. The panel assessed whether the failure in care resulted from a failure to recognise the complication or a failure to recognise the severity and to adhere to the protocol. For example, in a hypotensive patient if fluid resuscitation was never instituted at all this was considered a failure to recognise the complication of shock. If fluid resuscitation was started but was inadequate in speed of administration or quantity this was considered to be a failure to appreciate the severity of shock.

The assessment panel scored all patients on admission with the Glasgow meningococcal septicaemia prognostic score,8 and patients were assigned to three groups based on objective clinical features: meningitis (depressed Glasgow coma score, stiff neck, photophobia, and central nervous system failure), septicaemia (shock or multiorgan failure, absence of meningitis), or a mixed picture (some features of meningitis and septicaemia). We also recorded what sort of team (paediatric or adult) primarily cared for the child.

Univariate analysis

Table 3 shows the frequency of management failures in cases and controls along with the univariate odds ratios for death. Failures in management were significantly more common in children who died than in survivors. With the exception of serogroup, probability of death was significantly correlated with Glasgow meningococcal septicaemia prognosis score, presence of organ failure, and disease type. Failure to recognise complications, failure to appreciate disease severity, failure in supervision, lack of involvement of a paediatric team in care, and inadequacies of fluid and inotrope administration were all significantly associated with death. Multiple treatment failures significantly increased the risk of death (table 4).

Multivariate analysis

We excluded sex from the model as it was not significant at the univariate level. We included Glasgow meningococcal septicaemia prognostic score, organ failure, disease type (septicaemia or meningitis), meningococcal serogroup, and the need for fluid or inotrope therapy as potential confounders. The full model indicates that not being under the care of a paediatrician (odds ratio 66.0, 95% confidence interval 3.6 to 1210; P = 0.005), failure of supervision (19.5, 1.8 to 213; P = 0.015), and failure to administer inotropes (23.7, 2.6 to 213; P = 0.005) are independent risk factors for death (table 5). Not being under paediatric care was highly correlated with a failure to recognise complications (P = 0.002; Fisher's exact test). When we removed absence of paediatric care from the model, failure to recognise disease complications became highly significant (6.1, 1.7 to 22; P = 0.006, table 5). This association suggests that failure to recognise complications is one of the consequences of absence of paediatric care. We used the risk factors identified in the multivariate analysis to assess the effect of multiple failures of care on the risk of death. The odds ratio for death with one failure was 8.7 (2.3 to 33) and increased with additional failures (table 6).

Why care may be suboptimal

There were often obvious reasons for suboptimal care. Vital signs were often inadequately documented in the nursing records. If signs of compensated shock were recorded but not appreciated, delays in diagnosis and treatment were inevitable. In children there are age related differences in normal values for blood pressure, heart rate, and respiratory rate, which were often not appreciated by medical teams. Many children had extreme increases in pulse rate and respiratory rate without apparently attracting the attention of the medical team. The recognition of compensated shock in children is more difficult than in adults as hypotension is a late sign and blood pressure is often maintained by compensatory vasoconstriction and tachycardia until late into the illness. Many children with signs of shock were not recognised as seriously ill. Often this seemed to be due to their care being undertaken mainly by doctors trained to recognise serious illness in adults—emergency teams, intensive care specialists, and anaesthetists—who documented but did not seem to appreciate the importance of signs of serious illness.

We found that children being looked after by doctors without paediatric training were at increased risk of dying. Lack of supervision by a consultant was also an independent risk factor for death. Unsupervised junior doctors managing sick children may lack the experience to recognise the speed of disease progression, the need for paediatric intensive care, and the need for inotrope therapy. The significantly increased odds ratio for death associated with failure to administer appropriate inotrope therapy emphasises the importance of protocols for management of meningococcal disease.

The procedure developed for this study helped to ensure that the panel's diagnosis and management decisions were applied to cases and controls in a similar manner. Panel members were blinded to outcome while they assessed clinical and laboratory information, available in hour time periods from the case records.

Conclusions

Earlier recognition of the signs and symptoms of meningococcal infection may lead to earlier diagnosis, earlier treatment intervention, and reduced risk of a fatal outcome. Meningococcal disease shares many features with other life threatening acute illnesses. The difficulties in recognition of the seriously ill child and in treatment of shock and organ failure that we have examined in the context of meningococcal disease might be equally apparent in the management of children with other life threatening disorders, including multiple trauma, respiratory and cardiac failure from any cause, and acute neurological conditions. The implications from our study for improved training of medical and nursing teams in the management of life threatening illnesses and for better supervision might thus be generalised to many other settings.