22 July 2019

The Royal College of Emergency Medicine’s 2018/9 Feverish Child national quality improvement project (QIP) has found that Emergency Departments (EDs) are struggling to achieve timely initial assessment and senior decision maker review of children presenting with fever symptoms.

A total of 17,235 patients under 5 years of age from 181 EDs were included in this year’s QIP – the first since a clinical audit in 2012/13 – and presented with fever or febrile illness as part of their presenting complaint.

The key findings included:

• 31% of children presenting with fever required admission, but only 65% of these could be admitted within four-hours. It was clear that this was more of a challenge for departments to achieve in the winter months.
• Just over half of feverish children had their pulse, temperature and respiratory rate measured and documented within 15 minutes of arrival in the ED. Pressure in the winter months made it harder for departments to achieve this fundamental standard.
• 38% of high-risk children with fever received a timely review (in under four hours) by a senior Emergency Medicine or Paediatric Clinician. This was more of a challenge to achieve in the winter months.
• While 92% of EDs have a tool to assess the risk of sepsis in children, it was only used on average 38% of the time, this suggested the tools were challenging for departments to use.

President of the Royal College of Emergency Medicine, Dr Taj Hassan said: “These results are concerning and show the scale of the challenge faced by EDs, particularly in busy winter months. It is clear from the data that EDs are struggling to staff teams with the necessary resources to meet their own demands and that this is having implications in achieving high quality standards of safe care.”

More positively the QIP found that:

• Almost all (97%) EDs reported to be using an early warning score for feverish children which demonstrated good practice.
• 92% of EDs use a clinical management tool if a child has been identified as high risk for sepsis.
• There was generally good use of the established NICE guidance for assessment and management of children under five years without a clear diagnosis (70% of EDs).
• Providing good quality safety net advice was important to help carers identify those children with fever who had an evolving serious bacterial illness or sepsis; 67% of children discharged were provided with information and advice, usually in the form of a leaflet.
• Most hospitals have been providing training for clinicians in the management of children presenting with febrile illness including recognition of sepsis (70% taught how to recognise paediatric sepsis, 59% taught NICE guidance for fever in under 5s, and 32% provided simulation training).

Dr Taj Hassan said: “While there are clearly systemic challenges ahead, we must recognise the good practice that is happening. It is fantastic to see such an increase in the number of EDs using early warning scores (EWS). We strongly encourage all EDs to continue using EWS to identify and manage febrile children.

“We also applaud the enthusiasm with which departments have embraced our new style of national clinical audit with integrated QIP methodology. The commitment of EDs to engage in quality improvement is a source of great pride to us.

“RCEM recognises the pressurised environment most departments continue to work in and is keen to support their fantastic efforts by keeping this QIP open online for use locally whenever required.

“A key area to improve is access to senior decision makers. We know that senior decision makers are vital to the proper running of an ED, particularly during peak activity times. By working with management teams to ensure good cover we are moving closer to consistent safe management of acutely unwell febrile children. Being mindful of local challenges, I encourage departments to investigate how to consistently improve timeliness of initial assessment of feverish children under five, and especially the under two-year-old group.

Chair of the RCEM Quality Assurance and Improvement Sub-Committee, Dr Elizabeth Saunders said, “We would welcome the sharing of best practice and learning by those achieving the standards with others, to help provide better levels of patient care. We also encourage all departments to consider how they can make progress on the four recommendations, particularly if their data shows that these are challenging areas.”

To improve the care of patients presenting with fever or febrile illness as part of their presenting complaint, RCEM makes four key recommendations:
EDs should look at ways to improve timely initial assessment consistently at time of pressure and peak activity, ensuring all parameters are checked and recorded to give a comprehensive assessment of febrile children within 15 minutes.

1. EDs should work closely with management teams to ensure adequate senior decision maker cover at peak times of activity to ensure safe assessment and management of the acutely unwell febrile child.
2. EDs should adopt or develop a tool to stratify risk of sepsis for feverish children so that they receive appropriate escalation or de-escalation of treatment and senior review.
3. Adequate training should be in place for all staff managing children less than 5 years presenting with fever. Training should enable complete sets of observations to be performed and responded to, with recognition of risk regarding serious bacterial illness or sepsis, and appropriate treatment instigated.

-ENDS-

Notes to Editors
Feverish Child Clinical Audit 2018/19 is one of three QIPs published by the Royal College of Emergency Medicine in July 2019.

The purpose of the QIP was to monitor documented care against the standards published in July 2018, and to facilitate improved care using QIP methodology and weekly data feedback.

QIP methodology was promoted to encourage EDs to improve towards more consistent delivery of these standards, helping clinicians examine the work they do day-to-day, benchmark against their peers, and to recognise excellence.

A total of 17,235 patients presenting to 181 Emergency Departments were included in this QIP. This was the third time this topic had been conducted, and the first time the topic had been conducted using QI methodology.

RCEM have since revised the standards to reflect more recent national developments, making some direct comparison more challenging.

If you have any queries about the report, please e-mail audit@rcem.ac.uk or phone 020 0674812.