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Older, controversial guidelines still play role in lawsuits
Guidelines for the management of febrile children dating back to 1993 have complicated liability risks for EDs since they were published, and continue to play a role in ED medical malpractice litigation, says Jim Wilde, MD, director of pediatric emergency medicine at the Medical College of Georgia, who also is fellowship-trained in pediatric infectious diseases.1
"The guidelines were never endorsed by any major medical organization, and they were roundly criticized from the moment they were published, for a lot of very good reasons," says Wilde.
Although the guidelines stated that they were not meant to represent the standard of care, there was still the appearance of setting in stone how physicians should evaluate a child with fever, says Wilde. "They do have some value for giving us some framework in which to work, but they also gave all sorts of ammunition for trial lawyers," he says.
ED doctors: Not guilty
Wilde has testified at a number of trials alleging malpractice because the ED physician failed to order one of the diagnostic tests suggested in the guidelines, such as obtaining a complete blood count (CBC) or a blood culture. "The plaintiff's lawyers go after the ED doctor because they didn't meet a standard of care. The big question is whether the guidelines are standard of care. The answer is no, they are not," he says. In each case, the ED physician was found not guilty.
If the ED physician fails to order a CBC for a child with fever and vomiting but no other symptoms, the fact that the child comes back with bacterial meningitis two days later does not necessarily fit the definition of medical malpractice, says Wilde.
"I have not been involved in a case yet when the physician was faulted for not having followed the guidelines and as a result lost the case," he says. "If there was no clinical reason to order a CBC other than the mere presence of fever, the doctor was not at fault."
The recommendations for diagnostic testing in the guidelines have been largely abandoned because they were written before the advent of the Hib and Prevnar (pneumococcal 7-valent conjugate) vaccines, says Wilde. "A lot of folks argue that now that we have vaccines for the two main causes of occult bacterial infection in children, the guidelines are basically moot, so broad scale testing for children over 3 months of age with fever is not warranted anymore," says Wilde.
One big exception is children younger than 1 month of age who develop a fever, in whom an aggressive workup usually combined with admission is still common practice, notes Wilde. Some screening also is still done on children ages 1-3 months, depending on the clinical scenario. He also screens for urine infections in boys younger than age 1 and in girls younger than age 2 who have fever without a source.
By taking a good history and physical exam, you are screening for serious bacterial infections, which is what the guidelines purportedly were for in the first place, says Wilde. "There is a fairly substantial literature showing that the history and physical is where the evaluation should be focused," says Wilde. "Most children outside the neonatal period with serious bacterial infections are going to be recognized that way. If you have a sick 6-month-old, you don't need a bunch of laboratory tests. You need a good doctor, possibly combined with selected laboratory tests."
Since the guidelines were never standard of care, an ED physician who chooses to disregard them is on very solid legal ground, says Wilde. Only 2-5% of children who come in to an ED with fever end up having a serious bacterial infection such as pneumonia, cellulitis, sepsis, or meningitis, he adds.
If the child has signs and symptoms that are consistent with meningitis, then further testing is absolutely warranted, says Wilde. "If they don't have specific signs or symptoms pointing to meningitis, it's highly unlikely that is what they've got, but it's not impossible," he says. "The problem is that the public has come to believe, because of the legal profession, that if somebody comes in at the very beginning of a very serious illness and the doctor doesn't recognize it, then the doctor has screwed up."
If a child presents in the first hour of bacterial meningitis, it is unlikely that any ED physician will recognize it, says Wilde. "Does that mean I have to do a spinal tap on every child that comes in with a fever? Of course not. We'd be doing spinal taps on every child in America if we did that, several times a year," he says.
If the amount of information that is available points to a problem that is not serious and there are no signs or symptoms to warrant additional testing, then the ED physician has not committed malpractice even if the patient returns with meningitis 24 hours later, says Wilde. "Doctors are not required to have crystal balls," he says. "They are required to use sound clinical judgment."
1. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med 1993;22:1198-1120.
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