Is your care of children with fever outdated? Don’t miss warning signs

If you don’t assume the worst, you may overlook sepsis or meningitis

An infant with a moderate fever dies of septic shock after being left in the waiting room for hours. Could this unthinkable scenario happen at your ED?

There’s no question that poor ED nursing assessment of young children with fever can be life-threatening, says Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, clinical educator for the ED at Northwestern Memorial Hospital in Chicago.

"If the triage nurse doesn’t recognize that a newborn with fever is an emergency, and they wait for hours as can happen in many EDs, the adverse outcomes potentially can be devastating," she warns, referring to septic shock and neurologic devastation from meningitis. "In the ED, missed cases of serious bacterial infection or sepsis may result in a child’s death."

In addition, if an adverse outcome is linked directly to inappropriate assessment resulting in undertriaging of the child, you could be found liable, says Steinmann, adding that missed meningitis is a common cause of ED malpractice lawsuits.

A patient’s attorney could argue that you failed to make sure that an emergent patient was seen by a physician in a timely basis, explains Mary Ellen Wilson, RN, BSN, nurse clinician for the pediatric ED at Johns Hopkins Children’s Center in Baltimore. "However, if the nurse has alerted the physician and the physician fails to respond, the nurse should be blameless if she has taken appropriate steps to have someone see the patient," she adds.

That’s why your documentation must be consistent and thorough, stresses Wilson. "This demonstrates that the ED nurse followed the standard of care, which should minimize risk of liability," she says, adding that your ED should implement updated recommendations from the Dallas-based American College of Emergency Physicians (ACEP) for pediatric patients with fever. (To access the guidelines, go to www.acep.org. Click on "Clinical Policies" and "Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever."

To improve assessment of children with fever and comply with the new ACEP guidelines, do the following:

• If an infant younger than 30 days of age presents with fever, initiate a septic work-up.

"Fever in young infants can be very significant," says Michelle Widecan, RN, MSN, CPNP, nurse practitioner for emergency services at Cincinnati Children’s Hospital Medical Center. A full septic work-up, including a blood culture; complete blood count; catheterized urinalysis and urine culture; and a lumbar puncture for gram stain, culture, protein, glucose, and cell count should be done to rule out a serious bacterial infection, she advises.

Infants have an immature immune system and are unable to mount their own response to bacterial invaders, Steinmann explains. "The consequences of missing a serious bacterial infection are immense," she says.

At Cincinnati Children’s, the ED’s protocol recently was updated to allow nurses to begin the septic work-up if an infant younger than 60 days of age has a documented fever of 100.4°F or greater, notes Widecan. (See resources at the end of this article for information on how to obtain the protocol.)

"The nurses know that if an infant has a documented fever at home or in the hospital of 100.4° or greater, they can begin the septic work-up," she adds. "We will obtain a full set of vital signs, catheterize the child, get a complete blood count, get an intravenous line placed for antibiotics, and then set up for a spinal tap," she says.

All infants younger than 30 days with fever of 100.4° or greater are admitted. Infants 30 to 60 days old still receive a full septic work-up, including a spinal tap, but they may not be admitted depending on preliminary lab results, how the infants look, and whether they can receive follow-up care the next day, Widecan explains.

• Don’t consider a child’s response to antipyretics to assess the likelihood of a serious bacterial infection.

Instead, base treatment decisions on the child’s history and physical examination at triage, recommends Steinmann. "I think many nurses are under the mistaken belief that if a fever responds to acetaminophen or ibuprofen, the child is not as ill as the child whose temperature doesn’t decrease with medication," she says.

• Ensure close follow-up if empiric antibiotics are not prescribed in children with fever without a source.

"I think this recommendation poses the biggest challenge for emergency nurses discharging patients," says Steinmann.

That’s because parents are looking for a quick-fix for their ill child and don’t want to be told to follow-up with their own physician the following day, says Steinmann. "They expect to leave the ED with a prescription for antibiotics, even if it is not warranted, and will voice their displeasure when this does not occur," she says.

In addition, many families use the ED as their source of primary care and don’t have a pediatrician, notes Steinmann. "The best strategy is parent education," she says, adding that nurses distribute pamphlets to explain antibiotic use in children. (For ordering information, see resources at the end of this article.)

Explain that not all fevers are caused by bacterial infections and, therefore, they don’t all require antibiotics, recommends Wilson.

• Give antibiotics as soon as possible.

According to the ACEP guidelines, you should consider antibiotics for previously healthy children ages 3-36 months with fever without a source, with a temperature of 102.2°F or greater and a white blood count more than 15,000/mm3.

Antibiotics generally are given only after blood work, spinal tap, and urine culture are completed, says Widecan. "But if the child goes to the trauma room, and they think it is a septic child, the goal is to get in antibiotics in even if a spinal tap isn’t done yet," she says.

Usually while the infant is getting a lumbar puncture, the nurse is drawing up the antibiotics and setting up fluids if needed, says Widecan. "Our goal is for antibiotics to be given to infants younger than 60 days in 90 minutes from the time they walk in the door with a fever," she says.

• Obtain a sterile urine specimen.

A catheterized specimen is the gold standard for obtaining urine specimens in infants and toddlers, advises Widecan. "Sometimes we get kids transferred by other hospitals that use a bag specimen, which is definitely not recommended by ACEP," she says.

• Reassess as needed.

Pediatric patients may rapidly deteriorate, so ongoing re-evaluation and assessment for progression of symptoms is essential, warns Wilson. "Children may rapidly decompensate with few signs of impending arrest," she says.

Signs and symptoms of bacterial meningitis, such as neck stiffness, may not develop in young children until late in the course of the disease, adds Wilson. "Early recognition of abnormal findings and interventions to correct underlying problems is crucial for a positive patient outcome," she says.

• Take a thorough history.

"Recognizing subtle but significant alterations in vital signs and assessment at triage is essential," underscores Wilson.

Ask about the child’s medical history, feeding patterns, changes in elimination patterns, activity level, exposures to illness, medication administration, presence of pain or discomfort, recent travel, and timing of the current illness, says Wilson. "Interpret these findings based on the child’s age and developmental level," she advises.

You also should ask whether the child has been vaccinated recently, because routine administration of childhood vaccinations commonly causes a fever within a few hours of administration that may persist up to 48 hours, notes Wilson. "If the child has received the measles-mumps-rubella vaccination, temperature elevation may be delayed up to 10 days after vaccine administration," she adds.

Resources

For more information on assessment of children with fever, contact:

  • Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, Clinical Educator, Emergency Department, Northwestern Memorial Hospital, 251 E. Huron St., Chicago, IL 60611. Telephone: (312) 926-7069. Fax: (312) 926-6288. E-mail: rsteinmann@ameritech.net.
  • Michelle Widecan, RN, MSN, CPNP, Nurse Practitioner, Emergency Services, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039. Telephone: (513) 636-0461. E-mail: Michelle.Widecan@cchmc.org.
  • Mary Ellen Wilson, RN, BSN, Nurse Clinician, Base Station Coordinator, Johns Hopkins Children’s Center, Pediatric Emergency Department, 600 N. Wolfe St., Park 106, Baltimore, MD 21287. Telephone: (410) 955-5680. E-mail: mewilson@jhmi.edu.

A variety of educational brochures are available from the American Academy of Pediatrics (AAP). "Fever and Your Child" (ID No. HE0318) gives practical guidance for identifying and managing fever. "Your Child and Antibiotics" (ID No. HE0219 for English Version, ID No. HE0263 for Spanish version) discusses when antibiotics are needed and why antibiotics should not be used to treat common viral infections. The cost is $34.95 plus $7.95 shipping and handling charge for a pack of 100. To order, contact AAP, Customer Service, 141 N.W. Point Blvd., Elk Grove Village, IL 60007-1098. Telephone: (866) 843-2271 or (847) 434-4000. Fax: (847) 228-1281. E-mail: pubs@aap.org.

Clinical practice guidelines can be accessed free of charge on the Cincinnati Children’s Hospital Medical Center web site (www.cincinnatichildrens.org). Under "Services," click on "Departments/Divisions, "Health Policy and Clinical Effectiveness," and "Evidence-Based Clinical Practice Guidelines." For guidelines pertaining to treatment of fever in children, click on "Fever of Uncertain Source 2-36 Months" or "Fever of Uncertain Source 0-60 Days."