When the Joint Commission on Accreditation of Healthcare Organizations looked at delays in treatment, 23 of 29 ED-related cases involved misdiagnosis, and meningitis was missed in seven of these cases, according to a Sentinel Event Alert.1 The Joint Commission specifically recommends that EDs implement strategies to maintain a high index of suspicion for meningitis. Problems that were identified in the root-cause analyses included:
- insufficient staffing levels;
- insufficient inservice education regarding meningitis;
- communication problems;
- communication with or between physicians;
- incomplete change of shift reports;
- emergency room overcrowding.
According to Rick Croteau, MD, the Joint Commission’s executive director for strategic initiatives, "Meningitis is one of the most common missed diagnoses, primarily because it simply isn’t taken into consideration as a possibility."
Here are effective strategies:
• Give further work-up to all children presenting with high fever or seizures.
Meningitis is most often seen in children 1 month to 5 years of age, who usually present with a fever and other symptoms indicative of an infection, says Nancy Blake, RN, MN, CCRN, CNAA, director of critical care services at Children’s Hospital Los Angeles. However, children younger than 6 months of age may not present with specific symptoms, says Blake, who adds that all children should get further work-up if they present with a high fever and/or seizures. This step could mean obtaining blood, urine, or cerebrospinal fluid cultures, or a complete blood count with differential to see if there are signs of increased infection, she says.
• Know signs to watch for.
If you suspect meningitis, check children for "nuchal rigidity," which usually is present when their chin is put to their chest, says Blake. "It is an extreme stiffness and pain is present when their head or neck is moved," she says. "This is a classic sign of meningitis." A child with meningitis may have other neurological signs, such as a blank look or failing to follow others with their eyes, Blake adds. Older children may present with a headache and sensitivity to light, she says.
• Start treatment as quickly as possible.
Blake recalls seeing dozens of cases of meningococcal meningitis in her ED during a terrible outbreak in Los Angeles about 15 years ago. "Many of the children arrived with legs, fingers, and toes that already were so purple you knew they were going to have to be amputated," she says. Many of the children died, as there was nothing that ED staff could do to stop the infection, says Blake. "It had spread so fast that they were already in profound shock by the time they were admitted or transferred from other institutions," she says.
This tragedy underscores the importance of early diagnosis and early administration of antibiotics if it is bacterial meningitis, says Blake. Many children who present with meningitis already have been seen in the previous 24 hours for an infection or other illness, so they already are very sick by the time they arrive at your ED, she explains.
It is helpful to obtain cultures such as blood, urine, and cerebrospinal fluid before starting antibiotics, says Blake. "However, starting the medication should not be delayed if it will take too long to obtain the cultures," she cautions. "Antibiotics should be started immediately if the delay is more than 30 minutes."
1. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert. Accessed at www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_26.htm.
For more information on meningitis, contact:
• Nancy Blake, RN, MN, CCRN, CNAA, Director of Critical Care Services, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Mailstop 74, Los Angeles, CA 90027. Telephone: (323) 669-2164. Fax: (323) 953-7987. E-mail: email@example.com.
• 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: firstname.lastname@example.org.