641 Lumbar punctures in <3 months old presenting with fever: a quality improvement project

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Aims Our aim was to review Bristol Royal Hospital for Children Emergency Department clinicians’ adherence to the NICE guideline ‘Fever in under 5s: assessment and management’ in children under 3 months, particularly regarding investigation with lumbar puncture (LP), in order to improve practice. Methods We initially carried out a retrospective case note review of all children < 3months old presenting to BRHC ED with ‘fever’, ‘temperature’ or ‘temp’ over an 8 month period. We assessed which investigations were done following reported fever (bloods, cultures, LP, urine), whether an LP was indicated by NICE guideline, LP documentation, LP result, antibiotic administration within 1 hour and final diagnosis. We re-evaluated our data set to include all children <3months old in ED who had an LP due to a large number of patients being missed in the original investigation. Concurrently, we reviewed nursing staff numbers during this period to evaluate whether this had an impact on timely LP investigation and antibiotic administration. Results We reviewed 183 case notes from January - September 2021: 78 from the original data set and a further 105 following methodology review. 119 patients were investigated with an LP - 91% of LPs were done by ED and 97% occurred within 24 hours of presentation. All patients <1 month old presenting with fever were investigated with an LP, although 30% did not have a full septic screen due to missed urine sample. Only 10 LPs did not follow NICE guidance (5.4%) - 4 patients had an LP where not clearly indicated and 6 LPs were ‘missed’. 0.8% of LPs were positive in this data set, of which none were missed by ED clinicians. Only 17% lumbar punctures done in ED had complete documentation including consent, risk/benefits and a procedure note. Administration of IV antibiotics <1 hour from clinician review was 27%. There were significant nursing staffing issues during this period with an average of 46% shifts without full staffing. Conclusion BRHC ED generally adhered to NICE guidelines regarding investigation of children <3months with fever, particularly in regards to lumbar puncture, and very few patients are ‘missed’. However, LP documentation was poor and antibiotics were often not administered within 1 hour of clinician review. Nursing staff shortages were significant in this period, which may have contributed to delayed antibiotic administration. We therefore identified some areas requiring improvement. We have designed a ‘Septic screen’ proforma to be used in the notes to improve documentation; we are presenting this QIP at multiple staff education sessions; nursing staffing shortages have been escalated to a Trust level; and the risk register has been updated. We intend to re-evaluate our changes to practice in 6 months.

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