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Type and Title of Submission


Title:

Management of the child with fever: an audit

Description:

The aim of this audit was to look at all children under the age of six months presenting to A&E in the MidYorkshire Hospital Trust to find out whether the standards set out in the 2007 NICE guidance for managing febrile children were being met. We hoped to highlight areas where these NICE guidelines could be followed to provide a better standard of care of febrile children.

Please note that this example was submitted to demonstrate implementation of CG47. This guideline was updated and replaced in May 2013 by CG160. The practice in this example remains consistent with the updated guidance.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG160 - Feverish illness in children

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The aim of this audit was to look at all children under the age of six months presenting to A&E in the MidYorkshire Hospital Trust to find out whether the standards set out in the 2007 NICE guidance for managing febrile children were being met. We hoped to highlight areas where these NICE guidelines could be followed to provide a better standard of care of febrile children. This audit was important given that the average child is predicted to have eight febrile episodes before the age of 18 months, fever is the commonest presenting complaint to GPs in children aged under five years and febrile illness is the commonest reason children are admitted to paediatric wards from the A&E department. In May 2007 NICE published guidance for the management of febrile children aged under five years aiming to streamline assessment and care. These guidelines are currently not followed routinely via any protocols in our trust.

Objectives

1. To look at the case notes of all children aged under six months presenting to A&E at the MidYorkshire Hospitals Trust with certain red features outlined in the NICE guidelines for managing febrile children (temperature above 38 degrees Celcius aged 0-3 months or temperature above 39 degrees Celcius aged 3-6 months) from May 2007 to April 2008 (n=1785). We looked to see if they had a full set of observations documented in A&E and were referred to paediatrics as per NICE guidelines. 2. If the child was referred to paediatrics were they fully investigated for 'red features' as outlined by the NICE guidelines? If they were not, were reasons for this documented? 3. If the child was discharged from A&E, who were they discharged by and was this appropriate?

Context

Prior to our audit A&E doctors assessing febrile children under the age of six months in our trust were not following any specific national guidelines or clearly documented local guidelines. Assessment and referral of these children was undertaken by doctors of varying grades. The current process means a varying standard of care for febrile children and we wished to see if this could be improved.

Methods

1. We found 43 cases across the trust. 88% were aged < 3 months with temperatures above 38 degrees Celcius. We examined A&E notes for a full set of observations, referrals to paediatrics and details of any discharges. If the child was referred to paediatrics we also examined hospital notes to see which investigations were ordered. The NICE guideline recommends non-paediatric practitioners record respiratory rate, heart rate, capillary refill and temperature. 76% of cases had a full set of observations. This varied across the trust with one site achieving 100% and another only 36%. This may be explained by the fact that one site has a dedicated paediatric assessment room in A&E. All cases had temperature recorded. The parameter most often missed was a measure of perfusion (capillary refill or BP). 2. The NICE guidelines state any child < 3 months with a red feature should have a full blood count, CRP, urine culture and, with certain provisos, a lumbar puncture (LP) as a minimum of investigation. Children aged 3-6 months with a red feature should have a full blood count, C reactive protein and urine culture. Need for LP is judged clinically. Of the children <3 months who were referred to paediatrics, 83% had appropriate blood tests, 86% had urine collected and 34% had a LP. Only 3 cases had a documented reason, something specified in the guidelines, for not having a LP. In those cases without a documented reason, the most likely explanation was a positive urine dip or the child was apyrexial on the ward. This was a worrying finding regarding levels of documentation. 3. We looked at the grade of discharging A&E doctor and found that 9 out of 10 cases were discharged by an SHO, only two of which had documented discussions with seniors. This was concerning as all of these children should have been seen urgently by a paediatrician. The only 3-6 month old child sent home had a temperature of 41 degrees Celcius which was also of concern.

Results and evaluation

We are not intending to publish these results. We do intend to reaudit management of febrile children in the MidYorkshire Trust A&E departments in the future to see whether the measures we have taken to disseminate the results of this audit have improved care of children with fever. We should be able to monitor progress by assessing how many children have a full set of observations documented and the recommended tests performed when presenting with a "red" feature as outlined in the NICE guidance.

Key learning points

- It is important that all children presenting to A&E with fever should have a full set of observations - this varied across sites despite the same A&E clerking sheet being used. We recommend a reminder being sent to all staff who perform observations on children to record parameters of perfusion and, if possible, all A&E departments having a designated paediatric assessment room. - All children under 3 months with a temperature > 38 degrees Celcius and all children aged 3-6 months with a temperature > 39 degrees Celcius should be referred to paediatrics. We recommend clear local guidelines for A&E staff of when to refer the febrile child to paediatrics. - Children with fever should be investigated as per the NICE guidance, accounting for physicians opinion when deciding on the need for lumbar puncture in children aged over three months. Not all children were being fully investigated and we have presented our audit findings to the paediatric teams to allow the NICE guidelines to be implemented. - If investigations are not done, the reason behind the decision should be documented. This is very important, especially in regards to lumbar puncture in children aged less than three months as it is a decision that could have very serious implications to the child and medicolegally. We recommend disseminating this to all paediatric trainees. - The grade of doctor discharging children with fever reaching the category of a 'red' feature in the NICE guidelines was generally that of an SHO. We recommend that any protocols for managing febrile children incorporate NICE guidelines and require senior review of any child with fever aged <6 months being discharged from A&E without paediatric input.

Contact Details

Name:Amy Illsley
Job Title:Foundation Year 2 Doctor
Organisation:MidYorkshire NHS Trust
Address:Pinderfields General Hospital
Town:Wakefield
Postcode:WF1 4DG
Phone:07977555354
Email:aillsley@doctors.org.uk

 

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This page was last updated: 11 November 2008

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.