SUPPORTING MATERIAL:

Results: Table

1. To improve consistency in assessment and management of children with fever to the standard set by NICE, comparing the management of these patients before and after introduction of the pathway

Introduction of the clinical decision pathway improved assessment of children presenting with fever (see table below).

CRITERION / PRE-PATHWAY / POST-PATHWAY
Assessment and record of skin colour / 46.8% / 96%
Record of activity / 91% / 96%
Assessment and record of hydration state / 92% / 100%
Record of heart rate / 92% / 100%
Record of respiratory rate / 76.6% / 96%
Record of capillary refill time / 90% / 100%
Low Risk: Urine Test / 80% / 92%
Low Risk: No routine bloods / 91% / 92%
Low Risk: No routine Chest X-Ray / 22% / 92%
Intermediate Risk: Urine Test / 100% / 100%
High Risk: Urine Test / 62.5% / 100%
High Risk: Full Blood Count / 81% / 67% *
High Risk: C-Reactive Protein / 75% / 67% *
High Risk: Blood Culture / 75% / 33% *
Safety-net advice sheet for those discharged / Not Measured / 100%

*These results were surprising and having completed the audit and reviewed the notes a typographical error was noted on the pathway, which, if followed by staff, would have inappropriately placed older patients into the high risk group purely because of a temperature greater than 39 Degrees Celsius. There was reluctance of staff to place older children into the high risk group purely because of the height of the fever and a consequent reluctance to perform invasive investigations on these patients. We believe that removing those patients who should not have been high risk would have increased the percentage of true high risk patients who did have a Full Blood Count, CRP and Blood Culture performed, but on an “intention to treat” basis we have not adjusted the figures given that we do not have the data readily available to calculate the exact effect removing these older children from the analysis would have made on the results. The typographical error has now been corrected and the audit cycle will continue.

OTHER SUPPORTING INFORMATION:

1.Implementation of a clinical decision-making pathway improved the assessment of children with fever and helped clinicians identify those patients who were at risk of serious illness. We anticipate this will have had a significant impact for patients given the diverse aetiology of fever in children

2.Whilst the pathway was very good at improving recognition of ill children, it is difficult for a pathway to ensure that the next steps (investigations and management) are consistently applied given that subjective clinician preferences can have an impact on the care of children

3.Review of the NICE guideline revealed some inconsistencies and discrepancies that we had to address and agree an interpretation of. Clinicians have difficulty differentiating between “pale” and “pallor”. Such differentiation is important within the guidance as it is one of the determinants of whether a patient is low or intermediate risk. In future more objective terms should be used

3.There was difficulty in using the NICE guideline criteria of a Capillary Refill Time of >3 seconds to place a patient into the Intermediate Risk group. This was not consistent with other guidance familiar to clinical staff which referred to a capillary refill time of less than 2 seconds as normal. The department therefore decided to use the familiar standard of 2 seconds for this section of the guidance

4.There were difficulties communicating introduction of the pathway to all clinical staff, including those who visited the Emergency Department but who did not routinely work here. This was overcome by presenting the pathway in a number of fora, and using coloured posters around the department to refresh staff memories. The presence of clinically-based senior staff within our Emergency Department for 16 hours out of every 24 helped facilitate implementation of this guidance

5.The Trust employs a dedicated clinical pathways coordinator and this key member of staff makes implementing national guidance significantly easier, and enables standardisation to take place throughout the Trust

6.Having a system to be able to collect the notes of patients where the pathway was used facilitated easier audit of implementation of the guidance. We are grateful to the medical students from the University of Liverpool who assisted us with this (John Canny, Helen Moore, Claire Sweeney).

Important Information

Disclaimer

The Fever without a Focus Care Pathway has been produced by Dr Andrew Rowlandat Alder Hey Children’s NHS Foundation Trust for use internally at Alder Hey Children’s NHS Foundation Trust as a fever without a focus screening tool for children aged <5 years.

The information contained in the Fever without a Focus Care Pathway is provided for use by appropriately qualified professionals and the making of any decision regarding the suitability of appropriate health care support and of a particular treatment or therapy for a patient, is subject to the reader’s professional judgement. Whilst every reasonable care has been taken to ensure the accuracy of its contents, neither the author nor the publisher can accept any responsibility for any action taken, or not taken, on the basis of this information.

The Fever without a Focus Care Pathwayis not a substitute for the exercise of appropriate professional skill and judgement.

Alder Hey Children’s NHS Foundation Trust shall not be liable to any person for any loss or damage which may arise from the use of any of the information contained in this publication.

The above disclaimer is not intended to restrict or exclude liability for death or personal injury caused by the negligence of Alder Hey Children’s NHS Foundation Trust.

Copyright

© 2008 Alder Hey Children’s NHS Foundation Trust. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright holder.

The document may only be reproduced for non-commercial clinical internal use provided that the existing copyright statement is retained.

This document must not be used, distributed or the content changed in any way other than with the express written consent of the Alder Hey Children’s NHS Foundation Trust and on such terms as the Alder Hey Children’s NHS Foundation Trust may specify.

The document must not be sold, licensed, transferred, copied or reproduced in whole or in part in any manner or in or on any media to any person without the prior written consent of the Alder Hey Children’s NHS Foundation Trust.

In case of any kind of publication or presentation mentioning use of the document it shall be acknowledged that the document originated from Alder Hey Children’s NHS Foundation Trust.

Any intention to publish or present material mentioning the document must be authorised in writing prior to publication by Alder Hey Children’s NHS Foundation Trust.


Enquiries regarding copyright should be addressed to

This document is a screening tool for the risk of serious illness after a diagnosis of ‘fever without a focus’ has been made by full history and clinical examination in a child aged under 5 years.
All patients with ‘fever without a focus’ should be assessed for shock and dehydration and treated according to Emergency Department guidelines.Also consider using other departmental pathways, as appropriate eg: Limping Child
Tick all boxes which apply, and follow the HIGH, MEDIUM or LOW risk management pathways overleaf as indicated. A patient with any one or more high risk sign(s)or symptom(s) should be managed as high risk. Only manage as low risk if all ticks are in low risk boxes.
COLOUR / / Pale ORMottled ORAshen ORBlue / / HIGH RISK / 
Pallor ORPallor reported by parent or carer / / MEDIUM / 
None of the above ANDNormal colour of skin, lips and tongue / / LOW RISK / 
ACTIVITY / / No response to social cues OR
Looks unwell OR
Unable to rouse or does not stay awake OR
Cry is weak ORHigh pitched ORContinuous / / HIGH RISK / 
/ Does not respond normally to social cues OR
Wakes only with prolonged stimulation OR
Decreased activity OR
No smile / / MEDIUM / 
/ Has a normal response to social cues AND
Content or smiles AND
Stays awake or awakens quickly AND
Strong normal cry or No cry / / LOW RISK / 
HYDRATION / / Reduced skin turgor ORWeak pulse / / Assess % dehydration & treat / / HIGH RISK / 
/ Dry mucus membranes OR
Poor feeding in infants OR
Capillary Refill Time ≥ 2 seconds OR
Decreased urine output / / / MEDIUM / 
Assess % dehydration & treat
/ Normal skin and eyes AND
Moist mucus membranes AND
Capillary Refill Time <2 seconds / / LOW RISK / 
RESPIRATORY / / Grunting OR
Respiratory Rate > 60 breaths/min OR
Moderate or severe chest wall recession OR
Exhausted OR
Abnormal respiratory pattern / / HIGH RISK / 
/ Nasal Flaring OR
Respiratory Rate >50 breaths/min (age <12 months) or >40 (age >12 months) OR
Oxygen Saturations ≤ 95% in air OR
Crackles heard on chest auscultation / / MEDIUM / 
/ None of the above respiratory signs ANDNormal respiratory examination / / LOW RISK / 
OTHERS / / Temperature ≥ 38oC aged < 3 months OR ≥ 39oC aged 3 to 6 months / / HIGH RISK / 
/ Non-blanching rash OR
Bulging Fontanelle ORNeck Stiffness OR
Status Epilepticus ORFocal Seizures ORFocal Neurological Signs OR
Bile-stained vomiting / / HIGH RISK / 
/ Fever for > 5 days OR
Swollen joint ORSwollen limb OR
Child is non-weight bearing ORChild is not using an extremity OR
New neck lump > 2 cm / / MEDIUM / 
/ No HIGHOR MEDIUM symptoms or signs from any of the above sections / / LOW RISK / 
FEVER WITHOUT FOCUS: Management of a child aged <5 yrs atHIGHRISKof serious illness
Refer to medical on-call team for admission andproceed with investigations.
If symptoms or signs of shock and/or dehydration are present, treat according to departmental guidelines.
Also see departmental guidelines for lumbar puncture and NICE guidelines for UTI investigation.
INVESTIGATIONS TO BE COMPLETED IN THE EMERGENCY DEPARTMENT
Child aged
< 3 months / Time sent / Time checked / Comment / Child aged
3 months to 5yrs / Time sent / Time checked / Comment
FBC / FBC
CRP / CRP
Chest X-Ray / Chest X-Ray
Blood culture / Blood Culture
Lumbar puncture / Urine test for UTI
Urine test for UTI / Consider the following for a child aged 3 months - 5yrs
Discuss with senior Emergency Department doctor or Medical Registrar
(ST3/4) and document reason for decision in clinical notes below
Faeces culture
(if diarrhoea present)
ALL HIGHRISK PATIENTS SHOULD HAVE: / Lumbar puncture
½ hourly observations and intravenous antibiotics / Blood gas
Referral to Medical on call team / at ____ : ____
Serum electrolytes
Review within 1 hour
by Medical Registrar (ST3/4) or above / at ____ : ____ / Faeces culture
(if diarrhoea present)

Please document reasoning for clinical decisions, including any deviation from the guidelines

CLINICAL NOTES (time all entries) Attach urine test printout here
Intravenous antibiotics given  / Identification of clinician
Surname:
Grade:
Signature:
Specialty:
Date: ___ / ___ / _____
FEVER WITHOUT FOCUS: Management of a child aged <5 yrs at MEDIUMRISK of serious illness
Upon completion of your history and examination discuss the need for further investigations with a senior Emergency Department doctor (if available) or the 1st on-call Medical Registrar (ST3/4). Document discussion and reasons for decision in clinical notes section below. As a minimum all patients should have an appropriate urine test for UTI, as per the NICE UTI Guidelines.
If symptoms or signs of shock and/or dehydration are present, treat according to departmental guidelines.
Also see departmental guidelines for lumbar puncture and NICE guidelines for UTI investigation.
INVESTIGATIONS
(if appropriate) / Needed
YES / NO / Time sent / Time checked / Comment
Urine test for UTI / YES
FBC
CRP
Blood culture
Lumbar puncture
Chest X-Ray
ALL MEDIUMRISK PATIENTS SHOULD HAVE:
 Hourly observations
Review of clinical condition & results with a senior doctor (within 2 hours of starting this pathway) / at ____ : _____
DISPOSAL / Discharge with Fever Management Advice leaflet
(Record reasons for decision in clinical notes) / Admit
(Record reasons for decision in clinical notes)

Please document reasoning for clinical decisions, including any deviation from the guidelines

CLINICAL NOTES (time all entries) Attach urine test printout here
Identification of clinician
Surname:
Grade:
Signature:
Specialty:
Date: ___ / ___ / _____
FEVER WITHOUT FOCUS: Management of a child aged <5 yrs at LOWRISK of serious illness
Upon completion of your history and examination all children should have an appropriate urine test for UTI, as per the NICE UTI guidelines
INVESTIGATION / Needed / Time sent / Time checked / Comment
Urine test for UTI / YES
ALL LOW RISK PATIENTS SHOULD HAVE:
Re-examination for signs or symptoms of pneumonia andrecord details in the clinical notes below
(remember that signs may be subtle)
 Respiratory rate and respiratory effort re-recorded on the Emergency Department observation sheet
DISCHARGE CRITERIA UTI & pneumonia excluded Fever Management Advice leaflet given

Please document reasoning for clinical decisions, including any deviation from the guidelines

CLINICAL NOTES (time all entries) Attach urine test printout here
Identification of clinician
Surname:
Grade:
Signature:
Speciality:
Date: ___ / ___ / _____

Does your patient have a Fever but no Focus?

USE THE FEVER PATHWAY: INVESTIGATE AND MANAGE PATIENTS APPROPRIATELY!

AGE / HIGH RISK
(Give all patients iv antibiotics) / MEDIUM RISK / LOW RISK
< 3 months / FBC
CRP
Blood Culture
Chest X-Ray
Urine Test for UTI*
Lumbar Puncture / Urine Test for UTI*
…and DISCUSS the need for other investigations with a senior doctor and document this discussion clearly on the pathway / Urine Test for UTI*
> 3 months / FBC
CRP
Blood Culture
Chest X-Ray
Urine Test for UTI*
Consider Lumbar Puncture, Blood Gas, Serum Electrolytes, Faeces Culture
(DISCUSS with a senior doctor and document this discussion clearly on the pathway) / Urine Test for UTI*
…and DISCUSS the need for other investigations with a senior doctor and document this discussion clearly on the pathway / Urine Test for UTI*

*See NICE guidelines for the investigation of possible UTI

Alder Hey Children’s NHS Foundation Trust

Shared Learning Award submission – Feverish Illness in Children

We think that your child is well enough to go home now, but please telephone the number below if:

  • your child’s health gets worse
  • you are worried about your child
  • you have concerns about looking after your child at home
  • your child has a fit
  • your child develops a rash that does not disappear with pressure (see the ‘tumbler test’ at the end of this sheet)
  • your child has a fever lasting longer than 5 days.

Phone this number for further advice: 0845 46 47 (NHS Direct)

or take your child to your GP or the nearest Accident and Emergency Department as soon as possible.

The tumbler test

(Photo courtesy of the Meningitis Research Foundation)