ED Accreditation Update: Joint Commission urges protocols for meningitis 

Most frequently missed diagnosis among delay-related ED sentinel events

Meningitis is the most frequently missed diagnosis among sentinel events arising from delays in treatment in the emergency department (ED), according to a 2002 report from the Joint Commission on Accreditation of Healthcare Organizations, and ED managers can expect surveyors to ask about strategies for handling the potentially fatal disease.

As a result of the findings, published in Sentinel Event Alert in June 2002, the Joint Commission issued a pointed recommendation that EDs implement strategies and policies for dealing with meningitis. (See "Sources and Resources" section at end of article for information on accessing the Sentinel Event Alert report.)

While Joint Commission surveyors did not select a meningitis policy as a criterion for evaluation, EDs are strongly encouraged to formulate such policies and can expect the disease to come up when surveyors make site visits, says Richard J. Croteau, MD, the Joint Commission executive director for strategic initiatives.

"As a consultative thing, it may come up for discussion," Croteau says.

When the Joint Commission reviewed data on sentinel events, it found a significant number of meningitis cases listed. Among reported sentinel events, 55 involved delays in treatment, and of those, 29 were ED-related. Twenty-three cases involved misdiagnoses, and meningitis was the most frequently missed (seven missed cases). (See table below.)

Joint Commission Recommendations on Delays in Treatment

Because organizations experiencing delays in treatment often cite problems with communication, the Joint Commission recommends that organizations:

  • implement processes and procedures designed to improve the timeliness, completeness, and accuracy of staff-to-staff communication, including communication with and between resident and attending physicians;
  • implement face-to-face interdisciplinary change of-shift debriefings;
  • take steps to reduce reliance on verbal orders and require a procedure of "read back" or verification when verbal orders are necessary;
  • develop strategies in hospital EDs to maintain a high index of suspicion for meningitis.

Croteau says because most involved delay in diagnosis or treatment, "it would appear that it’s just a matter of not thinking about the diagnosis when there’s not a classical presentation."

What should raise the level of suspicion for the ED physician or nurse? Croteau acknowledges that conventional wisdom — "Don’t do a lumbar puncture on every child who presents with a fever" — works against ED practitioners.

"There needs to be some criteria that would raise the possibility of that diagnosis, based on the clinical findings, signs, and symptoms," he states. "And then, we need staff orientation and education in relation to those criteria, since we don’t see those kinds of cases all the time."

Strategy not difficult to develop

Developing a strategy doesn’t necessarily require reinventing the wheel, says Cindy Bruns, RN, BSN, CEN, quality management coordinator for the Emergency Center at Tallahassee (FL) Memorial Hospital. Bruns recently developed a discharge instruction sheet for the "worried well" person exposed to meningococcal meningitis, listing symptoms and incubation information about meningitis. And information on meningitis (e.g., incubation, symptoms, treatment, etc.) has been added to Tallahassee Memorial Hospital’s disaster/bioterrorism policy. "I finished the instruction sheet using, almost verbatim, information from the [Centers for Disease Control and Prevention] web site," Bruns says. (See "Sources and Resource" section at end of article.)

Adverse outcomes of meningitis commonly lead to lawsuits against ED physicians, often based upon allegations of physician negligence and delay in treatment. Developing a strategy for reducing the chance of missing a meningitis case involves taking some precautionary steps, according to Gregory P. Moore, MD, JD, adjunct associate professor at Indiana University School of Medicine and attending physician at Methodist Hospital in Indianapolis. Specifically,

Moore recommends specific risk management steps when dealing with a possible meningitis case:

  • When a child with nonspecific symptoms and fever with no source is examined, document a thorough history and exam.
  • Have a low threshold for lumbar puncture in children with fever and no source, particularly if the child is ill-appearing, lethargic, or irritable.
  • When discharging febrile children from the emergency department, give caregivers clear instructions to have the child reevaluated if his or her condition worsens in any way.

EDs are sure to be asked about their policies for dealing with suspected meningitis cases now that the Joint Commission has published its recommendations in Sentinel Event Alert. Surveyors assess, for educational purposes only, accredited organizations’ familiarity with and use of information and suggestions that appear in Sentinel Event Alert. Since January 2003, when on-site surveyors began assessing organizations’ compliance with the Joint Commission’s National Patient Safety Goals, recommendations published in Sentinel Event Alert are discussed as suggestions for improvement.

The National Patient Safety Goals for 2003, upon which accredited organizations will be evaluated for compliance, focus on improved patient identification; effective communication among caregivers; safe use of high-alert medications (e.g., potassium phosphate and sodium chloride in greater concentrations than 0.9%); elimination of wrong-site, wrong-patient, and wrong-procedure surgeries; safer use of infusion pumps; and improved effectiveness of clinical alarm systems. (See "Sources and Resources" section for information about the 2003 National Patient Safety Goals.)

Sources and Resources

For more information on sentinel events and meningitis, contact:

Richard J. Croteau, MD, Executive Director for Strategic Initiatives, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Fax: (630) 792-5005. E-mail: rcroteau@JCAHO.org.

Cindy Bruns, RN, BSN, CEN, Quality Manage-ment Coordinator, Emergency Center, Tallahassee Memorial Hospital, 1300 Miccosukee Road, Tallahassee, FL 32308. Telephone: (850) 431-5079. Fax: (850) 431-6537. E-mail: bruns-c@mail.tmh.org.

Information on meningitis may be found at the Centers for Disease Control and Prevention web site: www.cdc.gov; click on "Health Topics A-to-Z," click on "M," click on "meningitis."

Joint Commission findings on meningitis and delays in treatment may be accessed at the Sentinel Event Alert web site: www.jcaho.org; scroll down to "Latest Newsletters" and click on "Sentinel Event Alert" scroll to "Index of Past Issues," and click on "Issue 26 — June 17, 2002."

• For a detailed explanation of the Joint Commission’s 2003 National Patient Safety Goals, access the web site: www.jcaho.org; scroll to "Top Spots," click on "National Patient Safety Goals."