Bacterial meningitis and meningococcal septicaemia in ...

PLEASE NOTE: Comments received in the course of consultations carried out by the Institute are published in the interests of openness and transparency, and to promote understanding of how recommendations are developed. The comments are published as a record of the submissions that the Institute has received, and are not endorsed by the Institute, its officers or advisory committees.

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Consultation comments on the draft quality standard for bacterial meningitis and meningococcal septicaemia Comments grouped by statement and stakeholder

ID

Stakeholder

Statement No

Comments

Response

001 Royal College of Paediatrics and Child Health

General The ACCM/PALS guidelines could be referenced. Hypotension and shock have been given as adverse prognostic features for bacterial meningitis, especially with raised intracranial pressure. This could be specified as preservation of blood pressure may be important in terms of outcome. Delay in inotrope use has been shown to be an adverse factor in outcome, in patients with shock. Induction agents for ventilation have a risk of dropping blood pressure, therefore peripheral inotropes have been used and referred in the ACCM guidelines. Treatment for clinical signs suggestive of raised intracranial pressure could be mentioned, hypertonic saline, mannitol, etc. Should NICE guidelines on fluids be mentioned, re risk of hyponatraemia? We cannot see mention of steroids for meningitis.

1) Lumbar puncture a. In Wales we are just finishing an audit of practice versus the

existing guideline and about 80-90+ % of children in South-east and North Wales we have audited have not received an LP either acutely or delayed. We think this is related to the fact that if treatment is initiated in the A&E the Consultants tend to feel a delayed LP will not alter the further management. We think this is because the suspicion of MD being high treatment threshold is low then subsequent treatment duration wouldn’t be altered if it were MD (perhaps separating out suspected meningitis from MD would clarify).

2) Fluids a. The volume of fluid works out as 40mls/kg over 10-20 minutes vs

the Paediatric SS guideline of 60mls kg within the first 15 min if shocked.

b. There is a stronger evidence base (both theoretical/animal clinical) for the use of Hartmann’s Vs Saline or Albumin and the guideline should therefore at least include it on a par with saline. We know that in Wales when the anaethetists are involved their preference is to use Hartmann’s as is the preference of over half the PICU consultants here.

3) Audiology –Has consultation with Audiologist/ENT been undertaken as the panel is heavily weighted to ID.

a. Audiology assessment within 4 weeks of being fit (as defined as no

Thank you for your comments. The topic expert group identified the development sources they felt were most relevant to developing the standard, within the framework of the Quality Standards development process. The quality standards are based on evidence-based recommendations from NICE accredited guidance, i.e. the NICE Bacterial Meningitis and Meningococcal Septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base. Please refer to the full clinical guideline for a detailed summary of the underpinning evidence base for the clinical recommendations on which the quality standard is based, which addresses the points you have raised. The topic expert group prioritised the areas of care they felt were most important for patients and represented key markers of clinical and cost effective care, and it remains important that other evidence-based guideline recommendations continue to be implemented. Please see statements 8 and 9 in the final quality standard for reference to treatment for signs of raised intracranial pressure. Your comments on lumbar puncture are noted and are supportive of the discussions of the topic expert group during development of the standard. The group agreed that use of lumbar puncture was an important marker of high quality care (please see statement 5 in the final quality standard).


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ID

Stakeholder

Statement No

Comments

Response

longer requiring critical care) We question whether this short timeframe is achievable or necessary and if the guideline is therefore meant to be ‘aspirational’ or adhered to and would it therefore not be better to have a longer (6-8 week) target for assessment but be specific with a timeframe for assessment delivery of hearing aids And insertion of Cochlear implants in those for whom they are indicated. Reason the majority of children pass their hearing test and what is important is that those who fail have appropriate treatment expedited.

Quality standards aim to be aspirational but achievable, measurable, and derived from the underpinning clinical guideline, which in this case recommends that audiological assessment should take place preferably before discharge and within 4 weeks of being fit to test. Although we did not have an audiologist or ENT specialist on the topic expert group, our registered stakeholders for this topic included a number of relevant organisations, including the British Association of Otorhinolaryngologists (ENT UK). Please see statement 13 in the final quality standard.

002 Department of Health General The draft quality standard relates mainly to care following admission. It could have more impact if there were more emphasis on the recognition of the sick child. NICE states on its web site: “A new guideline from NICE published today (23 June) says prompt recognition of the signs and symptoms of bacterial meningitis and meningococcal disease is the key to preventing the deaths of children and young people who contract the diseases. The new guideline, jointly developed with the National Collaborating Centre for Women's and Children's Health, will help to save lives by giving frontline healthcare professionals, and families and carers of children and young people, the knowledge and confidence to recognise symptoms and signs of bacterial meningitis and meningococcal septicaemia and to seek appropriate clinical care”

Thank you for your comment. This was considered by the topic expert group who felt that recognition of the sick child would be covered in a quality standard on feverish illness in childhood, for which NICE has now received a referral.

003 Royal College of General Practitioners

General Statements 8-17 relate to specialist care – important for commissioning – do paediatricians really need this amount of detail?

Thank you for your comments. Quality standards will be of interest to health and social care workers, provider organisations and commissioners, as well as patients, carers and the public. We have therefore included enough detail to cover all of these audiences. The quality standard has also been reduced to 14 statements following consideration of consultation comments and revision of the statements in terms of their importance for quality improvement and impact on outcomes.

004 Leeds Teaching Hospitals NHS Trust

General In general excellent. I have restricted my comments to those areas that I have suggestions. I welcome the work of NICE, and the guideline group in this important area, and would not wish my comments to imply any other than constructive suggestions to an excellent piece of work.

Thank you.


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ID

Stakeholder

Statement No

Comments

Response


General Excellent. The difficulty is writing guidance for clinical conditions which overlap- but have differing presentations. In Leeds, we have developed guidance (based upon NICE & other best evidence, which is peer reviewed & contributes to our antimicrobial guidelines- please see attached files) for suspected CNS disease/ meningitis, and also for a non-blanching rash (in addition to fever without focus)- this is to reflect the nature of children presenting with symptoms, rather than a diagnosis. I do recognise that this approach, makes guideline writing difficult- but permits a stratified approach. Equally, the use of electronic publication & hyperlinks facilitates awareness of the overlap.

Thank you for your comments.

006 United Kingdom Clinical Pharmacy Association

General The UKCPA Infection Management Group are happy with the draft quality standard at it stands, and UKCPA are happy to endorse it.

Thank you.

007 Royal College of Nursing

General The standards are comprehensive following the pathway the child or young person may follow apart from something in relation to prevention although this is noted in the introduction itself.

Thank you.


General The title of the document has ‘children’ but in the introduction there is mention of young people. We would suggest that the title needs to be amended accordingly.

Thank you for your comment. The topic expert group considered this and agreed to amend the title of the quality standard to ‘Bacterial meningitis and meningococcal septicaemia in children and young people’.

009 Institute of Infection and Global Health

Question 1 Safety netting. Outcome ‘parent/carer satisfaction’, they could be given the wrong information and still be satisfied! Parent/carer understanding of the instructions, documentation in the notes about written or verbal info given, another form of outcome measurement.

Thank you. This comment is supportive of the discussions of the topic expert group during development of the quality standard, who acknowledged the challenges in measuring outcomes for this type of statement. Please see statement 1 in the final quality standard, which has been revised to focus on what the information given to the parents/carers should contain, as well as receipt of that information.


Question 1 An obvious outcome measure – how long does it take to get an paediatric audilogical assessment and time taken to get a cochlea implant

Thank you. The topic expert group considered the time taken to receive an audiological assessment to be included within the measure supporting statement 13 in the final quality standard. They considered referral for cochlear implant to be standard practice if indicated by the assessment, and that timely assessment was key to quality improvement in this area.


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ID

Stakeholder

Statement No

Comments

Response


Question 1 In terms of outcomes in respect of the standards, this one would consider to be a reduction in not just mortality but morbidity as a result of improved recognition and identification, earlier intervention and treatment etc. Ensuring that staff have the knowledge and skills is critically important as highlighted by the CEMACH report ‘why children die’.

Thank you. The topic expert group considered the overarching outcomes that could be impacted upon by the quality standard and did not feel they could use these outcome measures against any one statement. However, it is noted in the introduction that the quality standard as a whole does contribute to preventing people from dying prematurely (NHS outcomes framework).

012 Health Protection Agency

Question 2 Should there be an additional Draft Quality Statement about cases being reported to the HPA so that public health action can be undertaken to prevent further cases? E.g. Children and young people with suspected bacterial meningitis or meningococcal septicaemia should be promptly notified to the HPA to trigger public health action without waiting for microbiological confirmation.

Thank you. This was considered by the topic expert group at the scoping stage, and it was agreed that as notification is required by law this should be out of scope for the quality standard.

013 Association of Paediatric Chartered Physiotherapists

Question 2 The only long term effect addressed in the quality statements is hearing loss. Considering 1 in 7 of this patient population is left with long term effects such as amputation/neurological symptoms, there is no mention of therapy follow up or ongoing input for this patient group. Does this need to be thought of as Acute Management of Bacterial meningitis and meningococcal septicaemia?

The topic expert group prioritised the areas of care they felt were most important for patients, based on the development sources listed. Areas are prioritised where practice is variable, or where there is evidence to suggest that implementation could have a significant impact on patient care and improved outcomes. It is anticipated that quality acute care will result in improved outcomes and therefore reduced long term effects for patients. Hearing loss was specifically included as it is one of the most common morbidities associated with meningitis and requires an urgent intervention.


Question 2 Add the following quality statement: ‘Patients with CSF features of meningitis (frankly purulent CSF, CSF white blood cell count greater than 1000/microlitre, raised CSF white blood cell count with protein concentration greater than 1 g/litre or bacteria on Gram stain) are given dexamethasone intravenously at a dose of 0.15 mg/kg to a maximum dose of 10 mg, four times daily for 4 days: If dexamethasone was not given before or with the first dose of antibiotics, but was indicated, the first dose is administered within 4 hours of starting antibiotics, but dexamethasone is not started more than 12 hours after starting antibiotics (See NICE CG 102).’

All suggestions for additional statements were discussed by the topic expert group who considered they were inappropriate for inclusion (for example, outside the scope of the quality standard), or already covered by existing statements. The topic expert group focussed on those areas of care which were considered they most likely to have a significant impact on improved outcomes.

015 NHS Direct Question 2 Remote assessment not covered. The quality statements apply to all settings where


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ID

Stakeholder

Statement No

Comments

Response

appropriate, or where otherwise specified. Please see section 2 (overview) for specific reference to remote assessment.

016 Association of Anaesthetists of Great Britain and Ireland

Question 2 Comment about quality statement 6. The role of the GP as first responder to administer antibiotics should be addressed as an important point of care.

Thank you. The quality standard is based on evidence-based recommendations from national accredited guidance, i.e. the NICE Bacterial Meningitis and Meningococcal Septicaemia clinical guideline. The topic expert group focussed on those areas of care which were considered most likely to have a significant impact on improved outcomes, and the evidence that pre-hospital antibiotics alter the outcome is lacking (please refer to the full clinical guideline for a detailed summary of the underpinning evidence base). Please see the extended definitions section of statement 4 in the final quality standard which refers to administration of antibiotics in primary and community care.


Question 2 Important areas not covered 1) The need for immediate blood cultures, preferably before antibiotics

The inclusion of a standard on blood cultures has several advantages: I. It reinforces the message about not starting people on iv antibiotics without

doing a blood culture first II. If it's a non-meningitic illness then a blood culture is the only way of getting

sensitivities of the bug III. could be useful for epidemiological monitoring; are strains changing, is

resistance changing, etc.and 2) The need for notification of all types of meningitis and meningococcal disease to

the appropriate authorities so secondary prophylaxis can occur when necessary.

The topic expert group considered the taking of blood cultures to be routine practice (please refer to the full NICE clinical guideline on Bacterial Meningitis and Meningococcal Septicaemia which addresses the points you have raised). Areas of care are prioritised for the quality standard where practice is variable and where improvement is required. The need for notification to the appropriate authorities was considered by the topic expert group at the scoping stage, and it was agreed that as notification is required by law this should be out of scope for the quality standard.

018 British Infection Association

Question 2 Important areas not covered 1) The need for immediate blood cultures, preferably before antibiotics and 2) the need for notification of all types of meningitis and meningococcal disease to the appropriate authorities so secondary prophylaxis can occur when necessary.

The topic expert group considered the taking of blood cultures to be routine practice (please refer to the full NICE clinical guideline on Bacterial Meningitis and Meningococcal Septicaemia which


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ID

Stakeholder

Statement No

Comments

Response

addresses the points you have raised). Areas of care are prioritised for the quality standard where practice is variable and where improvement is required. The need for notification to the appropriate authorities was considered by the topic expert group at the scoping stage, and it was agreed that as notification is required by law this should be out of scope for the quality standard.


Question 2 Standards otherwise encompass recognition, diagnostics, intervention and follow-up. These standards do not appear to encompass a robust standard in respect of rehabilitation for a child who for example may have lost a limb(s) etc. This is an area that is often overlooked. We would suggest it would be pertinent to encompass a standard in this respect as it is not done well routinely.

The topic expert group prioritised the areas of care they felt were most important for patients, based on the development sources listed. Areas are prioritised where practice is variable, or where there is evidence to suggest that implementation could have a significant impact on patient care and improved outcomes. It is anticipated that quality acute care will result in improved outcomes and therefore reduced long term effects for patients. The topic expert group agreed that rehabilitation is important but this issue was not covered by the NICE guideline and was considered beyond the scope of the quality standard.


Question 3 Most important statements are 4, 6, 9, 10, 11, 12, 13, 16 as these address a) the need for urgent investigation and treatment and b) the recognition of unpredictable and sudden deterioration. They are also possibly some of the areas that aren’t as well done as others.

Thank you. Please see revised statements 4, 5, 6, 8, 9, 10 and 11 in the final quality standard.


Question 3 1. Recognition- hence 3 & 7 2. Identification and treatment of more severe illness- hence 14,15,17 3. Follow-up 20

Thank you. Please see revised statements 1, 2, 3, 9 and 14 in the final quality standard.


Question 3 Most important statements are 4, 6, 9, 10, 11, 12, 13, 16 as these address a) the need for urgent investigation and treatment and b) the recognition of unpredictable and sudden deterioration. They are also possibly some of the areas that aren’t as well done as others.

Thank you. Please see revised statements 4, 5, 6, 8, 9, 10 and 11 in the final quality standard.


Question 5 Population groups not clearly defined e.g primary/secondary care. The topic expert group discussed the population groups and settings and sought to clarify these in the final quality standard.


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ID

Stakeholder

Statement No

Comments

Response


Question 5 Population groups not clearly defined e.g primary/secondary care. The topic expert group discussed the population groups and settings and sought to clarify these in the final quality standard.

025 Meningitis UK S01 Meningitis UK rate quality statement 1 as highly important. All other quality standards are subject to the healthcare professionals’ ability to clinically recognise bacterial meningitis and meningococcal septicaemia. Whilst appropriate training is crucial for all healthcare professionals, would it be worth emphasising the importance of training for those based in primary care as they may have less direct experience due to the rarity of the disease and non-specific nature of symptoms? Meningitis UK is aware of several incidences of primary healthcare professionals delaying assessment and treatment in secondary care.

Thank you for your comment. The quality statements apply to all settings where appropriate, or where otherwise specified. Draft statement 1 did not progress to the final quality standard as it was recognised that appropriate training is a generic issue that underpins all quality standards. Please see section 2 (overview) for specific reference to this.

026 NHS Direct S01 The NICE draft quality standard does not define what is meant by ‘appropriate’ training or if healthcare professionals includes non-nurses who undertake a remote initial assessment. Can the standard be improved to define this?

Draft statement 1 did not progress to the final quality standard as it was recognised that appropriate training is a generic issue that underpins all quality standards. Please see section 2 (overview) for specific reference to this, including remote assessment.


S01 Should be more specific. Does this refer to primary or secondary care or both? If secondary care could be more specific by stating that ‘Children and young people are assessed in the Emergency Department or on the ward by an experienced doctor, registrar or consultant, and nursed on an appropriate ward with experience in managing bacterial meningitis and meningococcal septicaemia i.e. medical paediatric ward’. In the structure for the quality measure, ? some examples for the assessment of adequate training of healthcare professionals. There are a number of tools already available eg www.spottingthesickchild.com, www.etool.meningitis.org

Draft statement 1 did not progress to the final quality standard as it was recognised that appropriate training is a generic issue that underpins all quality standards. Please see section 2 (overview) for specific reference to this. Please see statements 8, 9, 10 and 14 for reference to specific healthcare professionals and their involvement in the care and treatment of children and young people with bacterial meningitis or meningococcal septicaemia.It is anticipated that training will be developed locally and utilise existing sources of relevant material where possible.

028 Department of Health S01 The feverish illness guideline (CG47) is referred to as a source, but not linked into the standard. That seems to be a lost opportunity to link these guidelines in a more practical way. For example, CG47 includes remote assessment and hence use of telephone triage for under 5 years. I wonder whether the standard should consider staff providing health advice as these may not be health professionals but trained advisors supported by professionals. Providing information to help families and carers recognise meningitis isn't included in

Thank you for your comment. This was considered by the topic expert group who felt that recognition of the sick child would be covered in a quality standard on feverish illness in childhood, for which NICE has now received a referral. Please see section 2 (overview) for specific

http://www.spottingthesickchild.com/

http://www.etool.meningitis.org/


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ID

Stakeholder

Statement No

Comments

Response

the standard at all. reference to training, including for those involved in remote assessment. In addition, statement 2 in the final quality standard refers to information given to parents and carers including information specifically about bacterial meningitis and meningococcal septicaemia.


S01 “cared for – add “in a timely way” because of access problems; also “trained in spotting a sick child and able to recognise” (could measure numbers of staff completing “spotting a sick child” e-learning. With changes in postgraduate education speciality training and exposure to OOH/urgent care will impact on who is ‘trained’. One outcome measure might be CCG’s provide educational updates for their staff relevant to this as part of paediatric ALS training.

Thank you for your comment. This was considered by the topic expert group who felt that recognition of the sick child would be covered in a quality standard on feverish illness in childhood, for which NICE has now received a referral. It is anticipated that training will be developed locally and utilise existing sources of relevant material where possible.


S01 Should be more specific. Does this refer to primary or secondary care or both? If secondary care could be more specific by stating that ‘Children and young people are assessed in the Emergency Department or on the ward by an experienced doctor, registrar or consultant, and nursed on an appropriate ward with experience in managing bacterial meningitis and meningococcal septicaemia i.e. medical paediatric ward’.

Draft statement 1 did not progress to the final quality standard as it was recognised that appropriate training is a generic issue that underpins all quality standards. Please see section 2 (overview) for specific reference to this. Please see statements 8, 9, 10 and 14 for reference to specific healthcare professionals and their involvement in the care and treatment of children and young people with bacterial meningitis or meningococcal septicaemia.

031 NHS Sheffield S02 Makes sense though assumes the diagnosis is known and certainly from the GP end and initial presentation that is not always clear. Certainly the issue of ?meningitis should perhaps be considered to always be ?bacterial meningitis with appropriate actions. Few GPs will have pulse oximeters suitable for smaller children and many will not have suitable BP cuffs-- they should!

This comment is supportive of the discussions of the topic expert group during development of the quality standard. Please see revised statement 2 in the final quality standard which relates to suspected or confirmed disease.

032 NHS Direct S02 Initial assessment could be described as that undertaken by remote telephone assessment such as NHS Direct and the 111 service. Could this standard be amended to include remote assessment of sign and symptoms?

The quality statements apply to all settings where appropriate, or where otherwise specified. The topic expert group felt that a statement on physiological assessment would implicitly include those patients who had been also referred for assessment following remote assessment.


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ID

Stakeholder

Statement No

Comments

Response


S02 Again is this primary or secondary care? Should this include GCS as well? It mentions assessing for decreased level of consciousness but doesn’t include mention of blood sugar assessment which should be done in anyone with lowered GCS

The quality statements apply to all settings where appropriate, or where otherwise specified. Please see revised statement 2 in the final quality standard, which is consistent with the evidence-based recommendations in the underpinning clinical guideline.


S02 Could measure numbers of practitioners using oximetry in their assessment, or making a record of these observations. These quantitative measures are easy to input into/though read coding so is auditable. Any case involving meningitis would be a significant event audit.

Thank you for your comments. The quality measures should form the basis for audit criteria developed and used locally to improve the quality of healthcare.

035 Royal College of Physicians

S02 It is not clear whether this assessment is in primary or secondary care. Does this apply to GP or primary care nurse assessment in the community and is O2 sat available in this setting?

The quality statements apply to all settings where appropriate, or where otherwise specified.


S02 Again is this primary or secondary care? Should this include GCS as well? The quality statements apply to all settings where appropriate, or where otherwise specified. Please see revised quality statement 2 in the final quality standard where assessment of neurological condition is included.

037 Meningitis UK S03 Meningitis UK suggest that this ‘safety netting’ information is always provided in writing as well as verbally. The appropriateness of providing ‘safety netting’ information as opposed to commencing treatment should be thoroughly explored and integral to the training provided in quality statement 1. Differentiation between ‘cases where bacterial meningitis and meningococcal septicaemia cannot be excluded’ and ‘suspected cases’ needs to be clearly presented and understood.

This comment is supportive of the discussions of the topic expert group during development of the quality standard, and the topic expert group sought to resolve this by revising the statement to focus on information given to parents and carers including information specific to bacterial meningitis and meningococcal septicaemia. Please see revised statement 1 in the final quality standard.

038 NHS Direct S03 Safety netting – definition suggests specific information on warning symptoms should be given to anyone looking after a person with non-specific symptoms yet later within definitions it states the warning symptoms is for a feverish child. Could clarification be given on whether the advice should be given to those looking after a feverish child or for any of the non-specific symptom/signs with or without fever. Also the suggested list of further advice has 7 options which seems too many for a carer to remember (unless able to give as a written list). Also could you consider adding to the list the value of parental/carer concern and that further advice should be sought if the carer notices any changes or has ongoing concerns. Some of the warning symptoms seem confused as to whether they are advice for the

The topic expert group sought to improve the statement by focussing on the ‘safety netting’ information given to all parents or carers of children and young people presenting with non-specific symptoms, and ensuring that it includes information specific to bacterial meningitis and meningococcal septicaemia. Please see revised statement 1 in the final quality standard. The definitions section includes circumstances in which further advice should be sought that relate


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ID

Stakeholder

Statement No

Comments

Response

patient or advice for the health care professional assessing the patient and it appears to be a mix of new symptoms, with the worsening of old along with general concerns. Consider recommending mandatory delivery of the ‘safety netting’ advice wherever the clinical presentation is of non specific symptoms where meningococcal disease cannot be excluded.

to the parent or carer’s concerns.

039 Department of Health S03 I am concerned about this statement. The term 'safety netting' is in inverted commas throughout and is not defined, although CG47 is again referred to, could its definition of a safety net as of one of the following:

Provide the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed;

Arrange a follow-up appointment at a certain time and place;

Liaise with other healthcare professionals, including out-of-hours providers, to ensure the

parent/carer has direct access to a further assessment for their child;

Be described to give this standard something more definite to audit against.

Please see statement 1 in the final quality standard, which includes a full definition of safety netting information.


S03 “Safety Netting” should be spelt out – “given information about what to look for and what to do if they need further help”. The use of the terms “consider” and “suspect” (as in Child Maltreatment guidelines would help clarify Agree about what this means and mentioning red flags of meningitis -

Please see statement 1 in the final quality standard, which includes a full definition of safety netting information.


S04 This sounds good in theory, but the devil is in the detail. Most children presenting to hospital do not have the label of “suspected meningitis” pinned on their forehead. If this is going to be an outcome measure, you need to be specific about what you mean. Table 1 in the NICE guidelines does not fulfil this role. Meningitis (as opposed to meningococcal septicaemia) is often only suspected to the point of action (ie LP and treatment) after initial assessment, and sometimes a period of observation. We think it would be difficult to define therefore when the clock starts ticking unless the child comes in the door with obvious fever, headache and nuchal rigidity etc. While we appreciate the sentiments behind it, in practice, measurement will be difficult and there is a risk of it becoming a source of unfounded litigation if the standard is perceived not to have been met. Comment: Non-panel member comments

Thank you for your comments. The topic expert group acknowledged the difficulties in measuring suspected disease and sought to clarify this in statements where possible. Draft statement 4 did not progress to the final quality standard as whilst it is important for children with suspected bacterial meningitis or meningococcal septicaemia to be transferred to hospital as a 999 emergency, the group felt that this was current practice.


S04 This is a fair standard, but could include administration of im benzylpenicillin before transfer – although transfer should not be delayed.

Thank you. Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible.


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ID

Stakeholder

Statement No

Comments

Response

The quality standard is based on evidence-based recommendations from national accredited guidance, i.e. the NICE Bacterial Meningitis and Meningococcal Septicaemia clinical guideline. The topic expert group focussed on those areas of care which were considered most likely to have a significant impact on improved outcomes, and the evidence that pre-hospital antibiotics alter the outcome is lacking (please refer to the full clinical guideline for a detailed summary of the underpinning evidence base).

043 NHS Sheffield S04 Comment about QS 4 There is little that a GP is being asked to do other than ring 999. I think that is an omission as we have previously advocated GP administration of penicillin whilst waiting for the ambulance. Perhaps a view on IM as opposed to IV may be helpful

Draft statement 4 did not progress to the final quality standard as whilst it is important for children with suspected bacterial meningitis or meningococcal septicaemia to be transferred to hospital as a 999 emergency, the group felt that this is current practice. The route for administration of antibiotics has been clarified in revised statement 4 in the final quality standard. The quality standard is based on evidence-based recommendations from national accredited guidance, i.e. the NICE Bacterial Meningitis and Meningococcal Septicaemia clinical guideline. The topic expert group focussed on those areas of care which were considered most likely to have a significant impact on improved outcomes, and the evidence that pre-hospital antibiotics alter the outcome is lacking (please refer to the full clinical guideline for a detailed summary of the underpinning evidence base).

044 NHS Direct S04 Emphasise that there are situations where transfer by ambulance is not the quickest route to emergency care, and that tele-healthcare professionals may initiate an alternate method of transport, for example, parents own car.

Draft statement 4 did not progress to the final quality standard as whilst it is important for children with suspected bacterial meningitis or meningococcal septicaemia to be transferred to hospital as a 999 emergency, the group felt that this is current practice.


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ID

Stakeholder

Statement No

Comments

Response


S04 999, “red” – even though the child may be conscious and breathing and triaged as “amber” or “green”, the most speedy response is required because of the rate of deterioration. Is there any action the ambulance personnel should take? Agree about need for speedy response. Surly this section should include the need to give Benzylpenicillin in the community if there is a high degree of suspicion – see QS5 comments

Draft statement 4 did not progress to the final quality standard as whilst it is important for children with suspected bacterial meningitis or meningococcal septicaemia to be transferred to hospital as a 999 emergency, the group felt that this is current practice. Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible.

046 Neonatal and Paediatric Pharmacists Group

S05 The word “immediate” could be open to interpretation if not defined. We would also advise that the words “appropriate intravenous antibiotics” are used.

The topic expert group discussed and sought to clarify the timeframe. Please see revised statement 4 in the final quality standard.

047 Association of Paediatric Anaesthetists

S05 We are not sure why there is a difference here. The presence of suspected meningitis or septicaemia should prompt the immediate administration of antibiotics on arrival at hospital, as with a petechial rash. In these children vascular access may be difficult and it may be necessary to give the first dose via an intraosseous route.

Thank you. The topic expert group discussed and sought to clarify the statements, including the route of administration for antibiotics. Please see revised statements 3 and 4 in the final quality standard.


S05 The term “ill” should be defined ie use guidance on NICE fever guideline – any red flag symptom or sign. The term “ill” is vague and does not have a medical definition. The danger is that nearly all children with a few petechial spots will be given iv antibiotics and there may be more morbidity or mortality from anaphylaxis than from septicaemia which is currently quite rare in the UK.

This wording was not progressed into the final quality standard. Please see revised statements 3 and 4 in the final quality standard.

049 NHS Barnsley S05 There does not seem to be any mention of primary care first contact. GPs have been taught that they should give penicillin stat when meningitis is suspected and not wait for admission to Hospital which even by 999 can take time. Is this still correct and should it be IM or IV. A lot of time can be saved if the first dose is given in Primary Care.

The quality standards are based on evidence-based recommendations from national accredited guidance, i.e. the NICE bacterial meningitis and meningococcal septicaemia clinical guideline The topic expert group focussed on those areas of care which were considered most likely to have a significant impact on improved outcomes, and the evidence that pre-hospital antibiotics alter the outcome is lacking (please refer to the full clinical guideline for a detailed summary of the underpinning evidence base). The quality


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ID

Stakeholder

Statement No

Comments

Response

standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline. Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible. The route for administration of antibiotics has also been clarified.

050 NHS Direct S05 With a rash of small red or purple spots that is non-blanching the glass test is mentioned as a means of identification. Could NICE consider whether for remote assessment the carer should be advised to carry out the glass test if a rash of this nature is suspected as remotely it cannot be clarified if the test is being carried out competently and the results could wrongly advise a caller not to access care.

This wording was not progressed into the final quality standard. Please see revised statements 3 and 4 in the final quality standard. The quality standards are based on evidence-based recommendations from national accredited guidance, i.e. the NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline.


S05 Why after arrival in hospital? NICE CG 102 (1.2.4) states that if meningococcal septicaemia is suspected antibiotics can be given in the community. Could read’….receive intravenous (or intramuscular if venous access is unobtainable) antibiotics immediately after being seen by an experienced doctor/healthcare professional.’ What about blood cultures? Not mentioned anywhere – KEY to the diagnosis in most

of these cases. Should read ‘antibiotics given immediately after blood cultures taken.’

Please see statement 4 in the final quality standard, where the wording has been revised to improve clarity. The topic expert group considered the taking of blood cultures to be routine practice. Areas of care are prioritised for the quality standard where practice is variable and where improvement is required.


S05 It is good practice where the diagnosis is suspected to give benzyl penicillin in Primary Care. All staff should have it available so there is no delay.(Measure where given in Primary Care)

The quality standard is based on evidence-based recommendations from national accredited guidance, i.e. the NICE Bacterial Meningitis and Meningococcal Septicaemia clinical guideline. The topic expert group focussed on those areas of care which were considered most likely to have a


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ID

Stakeholder

Statement No

Comments

Response

significant impact on improved outcomes, and the evidence that pre-hospital antibiotics alter the outcome is lacking (please refer to the full clinical guideline for a detailed summary of the underpinning evidence base). Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible.


S05 It is unclear whether provision exists, in defined circumstances, for antibiotics to be given before transfer to hospital – for example by assessing GP.

The quality standard is based on evidence-based recommendations from national accredited guidance, i.e. the NICE Bacterial Meningitis and Meningococcal Septicaemia clinical guideline, and contains key markers of clinical and cost effective care across a care pathway. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline. Please refer to the full clinical guideline for the full set of recommendations. For the quality standard the topic expert group focussed on those areas of care which were considered most likely to have a significant impact on improved outcomes, and the evidence that pre-hospital antibiotics alter the outcome is lacking (please refer to the full clinical guideline for a detailed summary of the underpinning evidence base). Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not


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Stakeholder

Statement No

Comments

Response

possible. 054 British Infection

Association S05 Why after arrival in hospital? NICE CG 102 (1.2.4) states that is meningococcal

septicaemia is suspected antibiotics can be given in the community. Could read’….receive intravenous (or intramuscular if venous access is unobtainable) antibiotics immediately after being seen by an experienced doctor/healthcare professional.’ What about blood cultures? Not mentioned anywhere – KEY to the diagnosis in most


Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible. The topic expert group considered the taking of blood cultures to be routine practice. Areas of care are prioritised for the quality standard where practice is variable and where improvement is required.

055 Meningitis UK S06 IV antibiotics are started immediately when a petechial rash is present – as stated in quality standard 5. As the rash is not always present in cases (and is usually a later symptom) of meningococcal septicaemia, and due to the rapid progression of disease, in cases where disease is strongly suspected, should healthcare professionals delay IV antibiotics by one hour?

The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured. The topic expert group agreed that antibiotics should be given immediately, but that a 1 hour timeframe could be used as an auditable measure.

056 Neonatal and Paediatric Pharmacists Group

S06 See comment above – this draft quality statement suggests that IV antibiotics should be administered within one hour – which is a defined and measurable standard. As above – we would advise insertion of the word “appropriate” so that it states that “appropriate intravenous antibiotics” are given within an hour of arrival at hospital.

The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured. Please see statement 4 in the final quality standard, where the wording has been revised to improve clarity. The route for administration of antibiotics has also been clarified.


S06 We are not sure why there is a difference here. The presence of suspected meningitis or septicaemia should prompt the immediate administration of antibiotics on arrival at hospital, as with a petechial rash. In these children vascular access may be difficult and it may be necessary to give the first dose via an intraosseous route.

The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured. Please see revised statements 3 and 4 in the final quality standard. The topic expert group agreed that antibiotics should be given immediately, but that a 1 hour timeframe could be used as an auditable measure.


S06 This standard conflicts with standard 5. A child with a spreading purpuric rash has suspected septicaemia and standard 5 states he should have antibiotics immediately – or does that mean within 1 hr?

The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured. Please see revised statements


16 of 33

ID

Stakeholder

Statement No

Comments

Response

3 and 4 in the final quality standard. The topic expert group agreed that antibiotics should be given immediately, but that a 1 hour timeframe could be used as an auditable measure.


S06 This sounds good in theory, but the devil is in the detail. Most children presenting to hospital do not have the label of “suspected meningitis” pinned on their forehead. If this is going to be an outcome measure, you need to be specific about what you mean. Table 1 in the NICE guidelines does not fulfil this role. Meningitis (as opposed to meningococcal septicaemia) is often only suspected to the point of action (ie LP and treatment) after initial assessment, and sometimes a period of observation. We think it would be difficult to define therefore when the clock starts ticking unless the child comes in the door with obvious fever, headache and nuchal rigidity etc. While we appreciate the sentiments behind it, in practice, measurement will be difficult and there is a risk of it becoming a source of unfounded litigation if the standard is perceived not to have been met. Comment: Non-panel member comments

Thank you for your comments. The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured. The quality measures are not a new set of targets or mandatory indicators for performance management. The quality standard will be reviewed for the development of potential indicators for the Commissioning Outcomes Framework, which will involve testing of potential indicators and full public consultation.

060 NHS Sheffield S06 Perhaps a view on IM as opposed to IV may be helpful The topic expert group sought to clarify the options for delivery of antibiotics. Please see revised statement 4 in the final quality standard.

061 South Western Ambulance Service NHS Foundation Trust

S06 1. The inclusion of this quality statement is not in alignment to the NICE meningitis guidance, which states that intravenous antibiotics must be given as soon as possible. UK Practice for the past decade has emphasised the importance of early administration, with a significant proportion of patients receiving antibiotics by Paramedics within the ambulance service. This statement de-emphasises the importance of paramedic administration. I would suggest that within one arrival of contact with a healthcare professional would be a far better reflection of the actual NICE guidance.

2. The statement includes purely ‘intravenous’ administration. It is common practice that Benzyl Penicillin is administered by the intraosseous route, which is used with increasing frequency in paediatrics. The Intramuscular route is also an acceptable alternative. The current wording of the standard means that a proportion of patients who appropriately receive anti-biotics within an hour but by an accepted alternative route, would not be considered as a pass.

The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured, and agreed that antibiotics should be given immediately, but that a 1 hour timeframe could be used as an auditable measure. Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible. The route for administration of antibiotics has also been clarified.


S06 Why after arrival in hospital? NICE CG 102 (1.2.4) states that if meningococcal septicaemia is suspected antibiotics can be given in the community. Could read’….receive intravenous (or intramuscular if venous access is unobtainable) antibiotics immediately after being seen by an experienced doctor/healthcare professional.’

Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to


17 of 33

ID

Stakeholder

Statement No

Comments

Response

What about blood cultures? Not mentioned anywhere – KEY to the diagnosis in most

of these cases. Should read ‘antibiotics given immediately after blood cultures taken.’ administration of antibiotics in primary or community care when urgent transfer is not possible.The topic expert group considered the taking of blood cultures to be routine practice. Areas of care are prioritised for the quality standard where practice is variable and where improvement is required.


S06 Even if penicillin given in Primary Care, dose of a/b given on arrival at hospital. (5&6 are very similar and could be amalgamated)

Thank you. Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible.


S06 This should specify; as soon as possible after arrival in hospital and not more than 1 hour after arrival.

The topic expert group sought to improve the clarity of the timeframe in these terms. Please see revised statement 4 in the final quality standard.


S06 Why after arrival in hospital? NICE CG 102 (1.2.4) states that is meningococcal septicaemia is suspected antibiotics can be given in the community. Could read’….receive intravenous (or intramuscular if venous access is unobtainable) antibiotics immediately after being seen by an experienced doctor/healthcare professional.’ What about blood cultures? Not mentioned anywhere – KEY to the diagnosis in most


Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible.The topic expert group considered the taking of blood cultures to be routine practice. Areas of care are prioritised for the quality standard where practice is variable and where improvement is required.

066 NHS Direct S07 With a rash of small red or purple spots that is non-blanching the glass test is mentioned as a means of identification. Could NICE consider whether for remote assessment the carer should be advised to carry out the glass test if a rash of this nature is suspected as remotely it cannot be clarified if the test is being carried out competently and the results could wrongly advise a caller not to access care.

This wording was not progressed into the final quality standard. Please see revised statements 3 and 4 in the final quality standard. The quality standards are based on evidence-based recommendations from national accredited


18 of 33

ID

Stakeholder

Statement No

Comments

Response

guidance, i.e. the NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline.

067 NHS Direct S07 The Meningitis Research Foundation and BMA recommend (Meningococcal Meningitis and Septicaemia, Guidance Notes Diagnosis and Treatment in General Practice 2008 edition) ‘examining the whole skin surface is worthwhile’ To this end it would be good to see something in the standard about checking the whole body for a rash, e.g. ‘In all cases where meningococcal disease is suspected, a full body check should take place and the presence/type/extent of any rash should be recorded.’

The quality standards are based on evidence-based recommendations from national accredited guidance, i.e. the NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline. Please refer to the full clinical guideline for a detailed summary of the underpinning evidence base for the clinical recommendations on which the quality standard is based.

068 South Western Ambulance Service NHS Foundation Trust

S07 As per Quality Statement 6: 1. The inclusion of this quality statement is not in alignment to the NICE meningitis guidance, which states that intravenous antibiotics must be given as soon as possible. UK Practice for the past decade has emphasised the importance of early administration, with a significant proportion of patients receiving antibiotics by Paramedics within the ambulance service. This statement de-emphasises the importance of paramedic administration. I would suggest that within one arrival of contact with a healthcare professional would be a far better reflection of the actual NICE guidance. 2. The statement includes purely ‘intravenous’ administration. It is common practice that Benzyl Penicillin is administered by the intraosseous route, which is used with increasing frequency in paediatrics. The Intramuscular route is also an acceptable alternative. The current wording of the standard means that a proportion of patients who appropriately receive anti-biotics within an hour but by an accepted alternative route, would not be considered as a pass.

Thank you for your comments. The topic expert group discussed and sought to refine the statements in terms of the timeframes being measured, and agreed that antibiotics should be given immediately, but that a 1 hour timeframe could be used as an auditable measure. Please see revised statement 4 in the final quality standard which relates to administration of antibiotics for children and young people for whom there has been no delay in their transfer to hospital. The definitions section refers to administration of antibiotics in primary or community care when urgent transfer is not possible. The route for administration of antibiotics has also been clarified.


S07 The NICE algorithm for petechial rash (in the Quick reference guide to meningitis p11) should be referenced and signposted.

Please see revised statement 3 in the final quality standard. The topic expert group sought to strengthen the reference in the definitions section.


S07 I recognise the key importance of identification- and the investigations in CG 012 section 1.3.1- 1.3.6. Does one need to highlight key actions- in the event of hypocalcaemia, or

The topic expert group considered that the quality standard covers the prevention of deterioration


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ID

Stakeholder

Statement No

Comments

Response

hypoglycaemia (our peer review suggested this was of high importance stipulating this and management- see non-blanching rash file)- I do recognise that the NICE guidance refers to the use of local or national guidance

through robust monitoring (please see statement 3 in the final quality standard), as well as recognition of unpredictable and sudden deterioration (see statements 8 and 9 in the final quality standard).

071 The Royal College of Pathologists

S08 The Royal College of Pathologists welcomes the statement that whole blood PCR should be performed in children and young people with suspected bacterial meningitis or meningococcal septicaemia.

Thank you.


S08 This is controversial and there are anecdotal reports that microbiologists disagree. The evidence base is limited. We think it sensible that a PCR is sent if the blood cultures / CSF cultures are negative, but we don’t think it needs to be done straight away, as children with likely disease will receive at least 5 days intravenous antibiotics anyway, and that gives time for the PCR to be done.

Thank you for your comment. NICE quality standards are derived from the best available evidence and this statement is consistent with the recommendations contained within NICE clinical guideline 102. The topic expert group considered this point and agreed to include additional clarification in the definition section. Please see statement 7 in the final quality standard.


S08 The standard is a PCR on all suspected meningococcal meningitis. Local microbiology practice is only to send these if meningococcal disease is strongly suspected and Health protection Agency has been notified. In children with status epilepticus and fever who the following day are fully recovered PCR is not sent. The difficulty is the statement “suspected meningitis” as one doctor may suspect at a lower threshold than a more experienced clinician. This is perfectly appropriate but makes reproducible and comparable measurements of the standard very difficult. This could be tightened up by specifying: suspected meningitis in whom antibacterial treatment has been started and public health notified as a case, or 7 days treatment planned by a doctor post MRCPCH.

Thank you for your comment. The topic expert group acknowledged the challenges of measuring suspected disease. Please see revised statement 7 in the final quality standard, which is consistent with the recommendations contained within the underpinning NICE clinical guideline.


S08 Whilst a PCR is important I am not sure why more emphasis is being given to it than blood cultures? Maybe this should read similar to the standard before that bloods should be taken in accordance with NICE guidance including especially blood cultures and PCR for meningococcus.

NICE quality standards are markers of high quality care. The topic expert group considered the taking of blood cultures to be routine practice. Areas of care are prioritised for the quality standard where practice is variable and where improvement is required.


S08 Would you also consider Pneumococcal PCR, in addition to Meningococcal PCR The pneumococcal PCR may be a useful addition but was not considered by the topic expert group for the quality standard in the absence of contemporary data (please refer to the full NICE clinical guideline on bacterial meningitis and meningococcal septicaemia for a detailed


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ID

Stakeholder

Statement No

Comments

Response

summary of the underpinning evidence base). 076 British Infection

Association S08 Whilst a PCR is important I am not sure why more emphasis is being given to it than

blood cultures? Maybe this should read similar to the one before that bloods should be taken in accordance with NICE GUIDANCE including especially blood cultures and PCR for meningococcus.

NICE quality standards are markers of high quality care derived from national accredited guidance, i.e. NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline, and it remains important that other evidence-based guideline recommendations continue to be implemented. The topic expert group considered the taking of blood cultures to be routine practice. Areas of care are prioritised for the quality standard where practice is variable and where improvement is required.

077 Meningitis UK S09 Quality statements 9 and 10 detail lumbar puncture and CSF examination for cases of suspected bacterial meningitis. Quality statement 11 details this information for suspected sepsis. As the number of quality statements will be reduced to 15 – could quality statement 11 be integrated into statements 9 and 10?

Thank you. The topic expert group considered that draft statement 11 was addressed by another statement (please see revised statement 4 in the final quality standard), and revised the final quality standard down to 14 statements.


S09 We would include tense, bulging fontanelle as a sign of raised ICP as well. Thank you. This has now been added to the definition section of statement 5 in the final quality standard.


S09 Recommendation for an immediate lumbar puncture is impractical and unattainable. Child must have assessment and stabilisation first, and immediate antibiotics according to standard 5. Term “immediate” requires clarification. In practice, if child is so ill that meningitis is suspected then there are often contradictions to lumbar puncture. There are anecdotal reports that paediatric staff are reluctant to perform a lumbar puncture in the A& E department, and when the child has been stabilised then the nurses request sedation as well as written parental consent so that several hrs elapse between decision to lumbar puncture and performance of the procedure.

Thank you. The topic expert group considered this and agreed that a timeframe may be unachievable for some hospitals, but that it was important that lumbar puncture should be undertaken for all children and young people with suspected bacterial meningitis when it was safe to do so. Please see revised statement 5 in the final quality standard.


S09 This standard is for lumbar puncture. Considering the same scenario as above febrile convulsion presenting as status epilepticus. Correctly ceftriaxone or similar are started. Lumbar puncture is not done because of the convulsion. The next day the child is fully recovered. Clinical practice in DGHs varies in this scenario: some lumbar puncture, most stop treatment and observe. The denominator could be tightened up by saying “lumbar puncture where meningitis is suspected beyond 24 hours after

Febrile convulsion presenting as status epilepticus is outside the scope of this quality standard.


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ID

Stakeholder

Statement No

Comments

Response

presentation”.


S09 This also concerns lumbar puncture. We know many infectious disease colleagues who say all meningococcal septicaemia should have a lumbar puncture. However we know equally many generalists and specialists who say if there is classical meningococcal disease a lumbar puncture will not alter management and therefore is an unnecessary painful procedure for the child. We doubt this debate can be resolved. However having a target of 100% meningococcal disease having a lumbar puncture will not be met for this reason (and that above). Saying a lumbar puncture is needed unless the diagnosis is confirmed by other means (PCR, blood culture, typical presentation of septicaemia) would allow the standard to be 100%.

The topic expert group considered that it was important that lumbar puncture should be undertaken for all children and young people with suspected bacterial meningitis when it was safe to do so. Levels of expected achievement should be decided locally. While typical aspirational achievements are likely to be 100% or 0%, realistic standards should take account of patient safety, patient choice and clinical judgement.


S09 Suggest adding in something about using clinical diagnosis and not CT to decide on contraindications – it is implied but not said. (See CG 102 1.3.27 and 1.3.30) They define antibiotics within 1 hour but then say ‘immediate’ LP; ? define timeframe for LP

The quality standard contains key markers of clinical and cost effective care across a care pathway and it remains important that other evidence-based guideline recommendations continue to be implemented. The topic expert group considered this and agreed that a timeframe may be unachievable for some hospitals, but that it was important that lumbar puncture should be undertaken for all children and young people with suspected bacterial meningitis when it was safe to do so. Please see revised statement 5 in the final quality standard.


S09 Suggest adding in something about using clinical diagnosis and not CT to decide on contraindications – it is implied but not said. (See CG 102 1.3.27 and 1.3.30)

The quality standard contains key markers of clinical and cost effective care across a care pathway and it remains important that other evidence-based guideline recommendations continue to be implemented.

084 The Royal College of Pathologists

S10 The Royal College of Pathologists welcomes the statement that children and young people with suspected bacterial meningitis have their CSF white blood cell counts available within 4 hours of lumbar puncture. The time from obtaining the CSF sample to processing is also of importance as white cell counts (particularly neutrophil counts) decrease significantly with time. Ideally, CSF samples should be processed within 10 minutes of collection, or within a maximum of 2 hours [Health Protection Agency (2008). Investigation of cerebrospinal fluid. National Standard Method BSOP 27 Issue 5. http://www.hpa-

Thank you. Please see revised statement 6 in the final quality standard, where the definitions have been extended to take account of this point.

http://www.hpa-/


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ID

Stakeholder

Statement No

Comments

Response

standardmethods.org.uk/documents/bsop/pdf/bsop27.pdf].






S11 Just a comment that these numbers don’t correlate with the HPA SOP on examination of CSF. Personally I think the numbers here are better but just a comment. (HPA state normal as neonates 0-30, 1-4 year olds 0-20, 5-puberty 0-10 and adults 0-5)

Thank you. The topic expert group considered that draft statement 11 was addressed by another statement (please see revised statement 4 in the final quality standard) and did not progress it to the final quality standard.


S11 Statement should read ‘children and young people who are evaluated for meningitis

with a lumbar puncture. If a pt presents with primarily septicaemia or signs of sepsis LP should NOT be attempted (See BIA guidelines on meningitis)



S11 Define ‘immediately’ – e.g. within 30 mins of LP results being available. Thank you. The topic expert group considered that draft statement 11 was addressed by another statement (please see revised statement 4 in the final quality standard) and did not progress it to the final quality standard.


S11 Just a comment that these numbers don’t correlate with the HPA SOP on examination of CSF. Personally I think the numbers here are better but just a comment. (HPA state normal as neonates 0-30, 1-4 year olds 0-20, 5-puberty 0-10 and adults 0-5)



S11 Statement should read ‘children and young people who are evaluated for meningitis

with a lumbar puncture. If a pt presents with primarily septicaemia or signs of sepsis LP should NOT be attempted (See BIA guidelines on meningitis)



23 of 33

ID

Stakeholder

Statement No

Comments

Response


S11 Define ‘immediately’ – e.g. within 30 mins of LP results being available. Thank you. The topic expert group considered that draft statement 11 was addressed by another statement (please see revised statement 4 in the final quality standard) and did not progress it to the final quality standard.


S12 Consideration should be given to them being assessed by an anaesthetist and/or intensivist as well.

Please see statement 9 in the final quality standard which refers to the involvement of an anaesthetist and intensivist.


S12 Define experienced paediatrician e.g. registrar or consultant. Timescale – within 30-60 mins of shock being apparent??

This wording did not progress to the final quality standard; please see statement 8 in the final quality standard which has been revised to improve clarity.


S12 We believe that this should include a definition of experienced paediatrican. If this is an SpR it should include a clause to require discussion with a consultant paediatrician.



S12 Define experienced paediatrician e.g. registrar or consultant. Timescale – within 30-60 mins of shock being apparent??



S13 We think this discussion should occur as early as possible. Thank you.


S13 Although it is usual practice to discuss severe cases with an intensivist, there are many suspected or mild cases which do not need such discussion, and provided that standard 12 is adhered to, standard 13 is not necessary.



S13 This should include a definition of paediatric intensivist. See comment above on QS 12.

The topic expert group felt that as a recognised paediatric career path the term ‘paediatric intensivist’ did not require a definition.


S14 –There should be early consideration of positive inotropic agents and invasive monitoring in patients who remain unstable after 40mls/kg volume resuscitation.

This draft statement did not progress to the final quality standard. The topic expert group felt compliance with this statement was already standard practice as it is part of CG102 and the APLS guideline. NICE quality standards are markers of high quality care derived from national accredited guidance, i.e. NICE bacterial


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ID

Stakeholder

Statement No

Comments

Response

meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline, and it remains important that other evidence-based guideline recommendations continue to be implemented.


S14 “Immediate” requires clarification. The NICE algorithm suggests antibiotic then fluid bolus, but probably the first fluid bolus is more life-saving than the antibiotic and in practice the first bolus is given while preparing the IV antibiotic and checking possibility of allergies.

This draft statement did not progress to the final quality standard. The topic expert group felt compliance with this statement was already standard practice as it is part of CG102 and the APLS guideline.


S15 –There should be early consideration of positive inotropic agents and invasive monitoring in patients who remain unstable after 40mls/kg volume resuscitation.

The topic expert group considered draft statement 15 to cover this aspect of care. Please see revised statement 9 in the final quality standard. NICE quality standards are markers of high quality care derived from national accredited guidance, i.e. NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline, and it remains important that other evidence-based guideline recommendations continue to be implemented.


S15 – In most hospitals you won’t always have an anaesthetist experienced in the paediatric airway or a paediatric intensivist available to intubate these patients. In their absence and under such circumstances the most experienced person available should undertake the procedure, with or without advice from a paediatric intensivist/paediatric retrieval consultant.

The topic expert group acknowledged this point. Please see revised statement 9 in the final quality standard where the definitions section has been extended to clarify this.


S15 We do not feel that it is always mandatory to intubate after 40 mls/kg of resuscitation fluid. Such children can often be managed in a DGH in HDU with frequent telephone consultation with an intensivist, and careful assessment in case they are developing respiratory distress or raised intracranial pressure. In fact, we have frequently given up to 80 mls/Kg resuscitation fluids without needing to transfer the child to intensive care.

This wording was not progressed to the final quality standard. Please see revised statement 9 in the final quality standard.

105 Association of Anaesthetists of Great

S15

Experience in paediatric anaesthesia is a requirement of the Royal College of Anaesthetists competency based training programme leading to a CCT in

Thank you. The topic expert group acknowledged


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ID

Stakeholder

Statement No

Comments

Response

Britain and Ireland anaesthesia. The Tanner report specifically addresses the need for local anaesthetists to support emergency care of the critically ill child in the district hospital (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062668). Many district hospitals do not have anaesthetists who specialise in paediatric anaesthesia, but they do have experienced anaesthetists who are competent to manage a child’s airway The quality standard as worded might lead to confusion and could mean excessive delay if a child is admitted to A&E and the team delays intubation to find a paediatric anaesthetist. It is very important that the anaesthetist is guided by the paediatric intensive care team, and this is covered in standard 13. Quality standard 15 would be better worded: Children and young people with meningococcal septicaemia who remain shocked after receiving 40 ml/kg of fluid resuscitation, or have signs of raised intracranial pressure and a Glasgow Coma Scale score of 8 or less, undergo urgent tracheal intubation and mechanical ventilation by the most experienced anaesthetist available (ideally one experienced in paediatric airway management) or a paediatric intensivist.

this point. Please see revised statement 9 in the final quality standard where the definitions section has been extended to clarify this.

106 Department of Health S15 I have one concern about the statements relating to care following admission to hospital in the use of the term 'Glasgow Coma Scale'. The guideline does at one point mention using Glasgow coma scale and/or APVU. I am aware that there is a Paediatric Glasgow Coma Scale and various modifications in view of age differences. Should this be clarified?

This wording was not progressed to the final quality standard. Please see revised statement 9 in the final quality standard.


S15 Is this to change the guidance currently 1.4.30- giving 40mL/kg, then as calling for anaesthetic support, giving further 20mL/kg- which I would endorse, and was the feeling of our peer review.

This wording was not progressed to the final quality standard. Please see revised statement 9 in the final quality standard. The quality standard is derived from the NICE clinical guideline on bacterial meningitis and meningococcal septicaemia and is consistent with its evidence-based recommendations.


S16 – Preferably by a Paediatric Retrieval Team

Thank you. Please see revised statement 11 in the final quality standard.


S16 In the DGH setting, the most appropriately trained person available should transfer the child, this will usually mean APLS training and the regional retrieval team, but occasionally an adult anaesthetist, who may not have done APLS, but has the appropriate competencies to do the transfer.

Thank you. Please see revised statement 10 in the final quality standard.


S16 Children with meningococcal disease frequently deteriorate within hours of presentation, and most deaths from sepsis occur within hours of presentation (information from CATS retrieval team). Transport of critically ill children with meningococcal sepsis requires appropriately trained teams who have access to the

This was discussed by the topic expert group who agreed that the distinction between transport within a hospital and transfer between hospitals

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062668

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062668


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ID

Stakeholder

Statement No

Comments

Response

appropriate equipment, including invasive monitoring and inotropes. This is a required standard of care that exceeds the statement relating to training in advanced life support in children. Most areas of England (but not all) have specialised paediatric transport teams. Standard 16 should clarify the difference between transport within a hospital and transfer between hospitals, and should be strengthened: Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to tertiary care are transferred by an experienced paediatric retrieval team.

should be clarified. Please see revised statements 10 and 11 in the final quality standard.


S17 – Consideration needs to be given to the use of End –Tidal monitoring of Carbon Dioxide levels, invasive arterial and central venous pressure monitoring and acid-base monitoring, through blood gases.

The quality standards are based on evidence-based recommendations from national accredited guidance, i.e. the NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base; therefore although the topic expert group are supportive of the use of end tidal CO2 monitoring it is outside of the remit of the quality standard to consider additional evidence beyond that which was assessed in the development of the source guideline.


S17 Comment about quality standard 17 Monitoring standards for a critically ill child should be differentiated monitoring during initial assessment (standard 2). Quality standard 17 should refer to the use of invasive blood pressure monitoring, also the use of end-tidal carbon dioxide monitoring for all intubated children. This is a recommended standard of care by the Association of Anaesthetists of Great Britain and Ireland. [http://www.aagbi.org/sites/default/files/Safety%20Statement%20-%20The%20use%20of%20capnography%20outside%20the%20operating%20theatre%20May%202011_0.pdf]

This wording was not progressed to the final quality standard. The quality standards are based on evidence-based recommendations from national accredited guidance, i.e. the NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base; therefore although the topic expert group are supportive of the use of end tidal CO2 and BP monitoring it is outside of the remit of the quality standard to consider additional evidence beyond that which was assessed in the development of the source guideline.


S17 Capillary refill time not mentioned as a monitoring observation, will become abnormal before the BP does.

Please see revised statement 2 in the final quality standard. The statement is consistent with the evidence-based recommendations in the

http://www.aagbi.org/sites/default/files/Safety%20Statement%20-%20The%20use%20of%20capnography%20outside%20the%20operating%20theatre%20May%202011_0.pdf




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ID

Stakeholder

Statement No

Comments

Response

underpinning NICE guidance and as such the topic expert group did not agree it was necessary to include capillary refill in the statement.

114 Department of Health S17 I have one concern about the statements relating to care following admission to hospital in the use of the term 'Glasgow Coma Scale'. The guideline does at one point mention using Glasgow coma scale and/or APVU. I am aware that there is a Paediatric Glasgow Coma Scale and various modifications in view of age differences. Should this be clarified?

This wording was not progressed to the final quality standard.


S17 Add “and receive the full recommended course of antibiotics, fluid replacement and intensive nursing care and family support”. Information (such as the algorithms in the quick reference guide) are made available, together with appropriate public health measures.

NICE quality standards are a set of specific, concise statements that cover a single concept or aspect of care that can be measured. We believe the other statements within the quality standard cover these additional aspects of care.

116 Health Protection Agency

S18 I wonder if this should make specific reference to providing information for parents / relatives of cases about charities providing support and information – Meningitis Trust and Meningitis Research Foundation

This was discussed by the topic expert group who agreed to include reference to charities that can provide further support in the definitions section. Please see revised statement 12 in the final quality standard.

117 Meningitis Trust S18 Suggest changes/additions to the statement:…………..”potential long-term effects discussed before discharge, and are offered written information about access to further care, support and information.” This suggested change would then need to

be reflected in the quality measure and description

Please see revised statement 12 in the final quality standard, which we believe cover these aspects of care.

118 Meningitis UK S18 The information given at discharge needs to be regulated and formalised. Thank you. 119 Royal College of

Paediatrics and Child Health

S18 Discussions should take place throughout the child’s stay in hospital, not just at discharge, this does not need to be a quality standard, as it is normal paediatric practice with any serious illness, but difficult to audit as the exact content of any discussions may not be recorded.

This was discussed by the topic expert group who revised the statement to focus on the information given to parents and carers. Please see statement 12 in the final quality standard.


S18 This suggests that patients/parents are offered ‘written information about access to further care’. We do not feel that this info needs to be written. Clearly there needs to be a discussion about this, but very little written info is currently available, and having it as a quality standard seems unnecessary. It would be easy to give written info rather than having a discussion.

The topic expert group agreed and removed reference to ‘written’ information from the statement. Please see revised statement 12 in the final quality standard.


S18 Sounds very paternalistic – suggest “have a discussion about the treatment and progress to date and the expected period of recovery”, (with the emphasis on recovery rather than sickness). Given information about “support services” is more multi-agency. Measuring physio assessments on discharge.

Thank you. Please see revised statement 12 in the final quality standard, and the extended definitions section that references the support available from charities.

122 Royal College of S19 This standard is important, but provided that standard 12 is adhered to, the The topic expert group highlighted this area as


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ID

Stakeholder

Statement No

Comments

Response


paediatrician will know that audiology assessment is required within 4 weeks. one of variable practice, where there was potential for improvement.


S19 Audiology assessment is needed, but why does this need to be within 4 weeks. We don’t think this statement is evidence-based. Children with severe disease would benefit from an assessment earlier. When the parents / child feel that the hearing is reduced, earlier assessment is required, but if the child appears to have normal hearing to the parents, and the child was not that ill, the assessment can wait.

The timeframe within this draft statement is consistent with the recommendations in the underpinning NICE clinical guideline and supports the measurability of this aspect of care. Levels of expected achievement should be decided locally. While typical aspirational achievements are likely to be 100% or 0%, realistic standards should take account of patient safety, patient choice and clinical judgement.

124 Meningitis Trust S20 Suggest additions to the statement:………”to assess for potential long term complications and provide information about potential late complications.” This

will help to identify the children who appear to have made a full recovery but who later experience learning difficulties once they start school ( Ref: de Louvois, 2007 and MOSAIC, Meningitis Trust, 2011 unpublished)

We believe these aspects of care to be covered by statement 12 in the final quality standard.

125 Meningitis UK S20 NICE guidelines CG102, section 1.5.7 state the need to be aware of possible late-onset deficits. This is not recognised in quality statement 20, which solely mentions a follow-up appointment within 6 weeks. As the majority of cases will occur in those under 5 years (particularly under 1 year), developmental deficits will not necessarily be apparent within 6 weeks. There should be additional later follow-ups recommended for standard practice.

We believe that statement 12 in the final quality standard addresses the issue of raising awareness about late onset complications. NICE quality standards are markers of high quality care derived from national accredited guidance, i.e. NICE bacterial meningitis and meningococcal septicaemia clinical guideline. The quality standards do not seek to reassess or redefine the evidence base or recommendations in the source guideline, and it remains important that other evidence-based guideline recommendations continue to be implemented.


S20 Although we agree that children who have had meningococcal sepsis should have a follow up appointment, we think that the timing of the follow up appointment can be left to the discretion of the team caring for the child at the time.

The timeframe within this draft statement is consistent with the recommendations in the underpinning NICE clinical guideline, and supports the measurability of this aspect of care. Levels of expected achievement should be decided locally. While typical aspirational achievements are likely to be 100% or 0%, realistic standards should take account of patient


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ID

Stakeholder

Statement No

Comments

Response

safety, patient choice and clinical judgement. 127 Royal College of


S20 ‘Are seen by a paediatrician within 6 weeks to assess for potential long term complications’. We feel this time limit is arbitrary and not evidence-based. Child with severe disease may be known at discharge to have long term problems. Children who are well are unlikely to develop them. Sometimes problems become evident with time. Most paediatricians out patient clinics are fully booked 6 weeks in advance, especially for new patients. Yes they need to be seen, but a 3 month limit for most would be fine, and children with known problems should be seen earlier. We don’t feel that quality is measured by a time limit.

The timeframe within this draft statement is consistent with the recommendations in the underpinning NICE clinical guideline, and supports the measurability of this aspect of care. Levels of expected achievement should be decided locally. While typical aspirational achievements are likely to be 100% or 0%, realistic standards should take account of patient safety, patient choice and clinical judgement.

These organisations were approached but did not respond:

Action for Sick Children Alder Hey Children's NHS Foundation Trust Arrowe Park Hospital Arthritis Care Association for Spina Bifida and Hydrocephalus Association of British Neurologists Association of Paediatric Emergency Medicine Astrazeneca UK Ltd Barnsley Hospital NHS Foundation Trust Bedfordshire Primary Care Trust Berkshire East Primary Care Trust Birmingham City Council Black Country Partnership Foundation Trust Bradford District Care Trust BRAHMS AG Brahms UK Limited-Thermo Fisher Scientific Brighton and Sussex University Hospital NHS Trust Britannia Health Products Ltd British Academy of Childhood Disability British Association for Community Child Health British Association of Neuroscience Nurses British Association of Otorhinolaryngologists, Head and Neck Surgeons British Association of Plastic Reconstructive and Aesthetic Surgeons British Medical Association British Medical Journal British National Formulary British Paediatric Allergy, Immunology & Infection Group


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British Paediatric Mental Health Group British Paediatric Neurology Association British Psychological Society British Society for Antimicrobial Chemotherapy British Society for Children's Orthopaedic Surgery Calderdale and Huddersfield NHS Trust Calderdale Primary Care Trust Cambridge University Hospitals NHS Foundation Trust Camden Link Care Quality Commission (CQC) College of Emergency Medicine Commission for Social Care Inspection David Lewis Centre, The Department for Communities and Local Government Department for Education Department of Health, Social Services and Public Safety - Northern Ireland Derbyshire Mental Health Services NHS Trust Division of Public Health & Primary Health Care Dorset Primary Care Trust East and North Hertfordshire NHS Trust Epilepsy Action Faculty of Dental Surgery George Eliot Hospital NHS Trust Gloucestershire Hospitals NHS Foundation Trust Gloucestershire LINk Greater Manchester West Mental Health NHS Foundation Trust Group B Strep Support Harrogate and District NHS Foundation Trust Health and Safety Executive Health Quality Improvement Partnership Healthcare Improvement Scotland Heart of England NHS Foundation Trust Hertfordshire Partnership NHS Trust Hindu Council UK Hospital Infection Society Hull and East Yorkshire Hospitals NHS Trust Humber NHS Foundation Trust Imperial College Healthcare NHS Trust Infection Control Nurses Association Institute of Biomedical Science Intensive Care Society Lambeth Community Health Lancashire Care NHS Foundation Trust Leeds Primary Care Trust (aka NHS Leeds)


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Letterkenny General Hospital Livability Icanho Liverpool Community Health Liverpool Primary Care Trust Luton and Dunstable Hospital NHS Trust Maidstone and Tunbridge Wells NHS Trust Mast Diagnostics Medicines and Healthcare products Regulatory Agency Medicines for Children Research Network Meningitis Research Foundation Ministry of Defence National Clinical Guideline Centre National Collaborating Centre for Cancer National Collaborating Centre for Mental Health National Collaborating Centre for Women's and Children's Health National Institute for Health Research Health Technology Assessment Programme National Patient Safety Agency National Public Health Service for Wales National Treatment Agency for Substance Misuse Newham University Hospital NHS Trust NHS Bournemouth and Poole NHS Clinical Knowledge Summaries NHS Connecting for Health NHS Cornwall and Isles of Scilly NHS Derbyshire County NHS Kirklees NHS Milton Keynes NHS Nottingham City NHS Plus NHS Warwickshire Primary Care Trust NHS Yorkshire and the Humber Strategic Health Authority North Tees and Hartlepool NHS Foundation Trust North Yorkshire & York Primary Care Trust Northwick Park and St Mark's Hospitals Nottingham City Hospital Nottinghamshire Healthcare NHS Trust Novartis Pharmaceuticals Office of the Children's Commissioner Paediatric Intensive Care Audit Network Paediatric Intensive Care Society Patients Watchdog PERIGON Healthcare Ltd Pfizer Primary Care Pharmacists Association


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Public Health Medicine Environmental Group Public Health Wales NHS Trust Royal Berkshire NHS Foundation Trust Royal College of General Practitioners in Wales Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists Royal College of Paediatrics and Child Health, Gastroenterology, Hepatology and Nutrition Royal College of Psychiatrists Royal College of Radiologists Royal College of Speech & Language Therapists Royal College of Surgeons of England Royal National Institute of Blind People Royal Pharmaceutical Society Royal Society of Medicine Royal United Hospital Bath NHS Trust Salford Royal Foundation Hospital Sandwell Primary Care Trust School and Public Health Nurses Association Scottish Intercollegiate Guidelines Network North Wales NHS Trust Sheffield Childrens Hospital Sheffield Teaching Hospitals NHS Foundation Trust Social Care Institute for Excellence Society for Acute Medicine South Asian Health Foundation South East Coast Ambulance Service South East Wales Critical Care Network South Staffordshire and Shropshire Healthcare NHS Foundation Trust Southampton University Hospitals Trust St Georges Healthcare NHS Trust Staffordshire Ambulance Service NHS Trust STEPS Charity Worldwide Tameside Hospital NHS Foundation Trust The British In Vitro Diagnostics Association The Children's Trust The Neurological Alliance The Rotherham NHS Foundation Trust University College London Hospital NHS Foundation Trust University Hospital of North Staffordshire NHS Trust University of Leeds University of Sheffield University of Southampton Walsall Teaching Primary Care Trust


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Welsh Government Welsh Scientific Advisory Committee West Midlands Ambulance Service NHS Trust Western Cheshire Primary Care Trust Western Health and Social Care Trust Whipps Cross University Hospital NHS Trust Wirral University Teaching Hospital NHS Foundation Trust Worcestershire Acute Hospitals Trust York Hospitals NHS Foundation Trust

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