The role of healthcare delivery in the outcome of meningococcal disease in children: case-control study of fatal and non-fatal cases

Abstract

Objective: To determine whether suboptimal management in hospital could contribute to poor outcome in children admitted with meningococcal disease.

Design: Case-control study of childhood deaths from meningococcal disease, comparing hospital care in fatal and non-fatal cases.

Setting: National statistics and hospital records.

Subjects: All children under 17 years who died from meningococcal disease (cases) matched by age with three survivors (controls) from the same region of the country.

Main outcome measures: Predefined criteria defined optimal management. A panel of paediatricians blinded to the outcome assessed case records using a standardised form and scored patients for suboptimal management.

Results: We identified 143 cases and 355 controls. Departures from optimal (per protocol) management occurred more frequently in the fatal cases than in the survivors. Multivariate analysis identified three factors independently associated with an increased risk of death: failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes. Failure to recognise complications of the disease was a significant risk factor for death, although not independently of absence of paediatric care (P = 0.002). The odds ratio for death was 8.7 (95% confidence interval 2.3 to 33) with two failures, increasing with multiple failures.

Conclusions: Suboptimal healthcare delivery significantly reduces the likelihood of survival in children with meningococcal disease. Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses.

Fig 1

Stages in presentation and progression in children with meningococcal disease. Patients with mild disease on presentation to hospital (A) may progress to severe illness or recover; adequacy of treatment may influence outcome. Patients who are severely ill on presentation to hospital (B) or develop severe illness after presentation at point A may recover or die; adequacy of treatment at point A may influence the outcome

Fig 2

Selection of fatal and non-fatal cases for inclusion in the study. Of 945 children with suspected meningococcal disease, we included 143 who died (cases) and 355 who survived (controls)