22 July 2008
MANAGEMENT OF CHILDREN WITH FEBRILE CONVULSIONS: A PATHWAY-BASED APPROACH
The need for a clinical pathway for the management of children with febrile convulsions has been highlighted by Dunlop and Taitz.1 In their retrospective review of medical records of 288 children with a discharge diagnosis of febrile convulsions they concluded that a clinical pathway could have an impact on over-investigation and over-treatment of children with febrile convulsions. Since to date there is no published evidence of a clinical care pathway for febrile convulsions in children,2 we report our experience of using a febrile convulsions care pathway in children in the Wirral University Teaching Hospital, NHS Foundation Trust, a busy University Teaching Hospital in Wirral, Merseyside, UK.
The febrile convulsions care pathway was developed in 1998 by a multidisciplinary team aiming to enable both medical and nursing staff to follow a uniform management protocol in children with febrile convulsions. In April 1999 the pathway was implemented in clinical practice. The criteria of children that are included in the pathway are (i) temperature-evidence of pyrexia documented on admission or by a good history of fever at home; (ii) generalised, not focal fit; (iii) no underlying neurological disorder; (iv) length of fit should be no more than 15 min duration; (v) child age range 6 months to 5 years; (vi) no previous afebrile seizures; and (vii) no evidence of meningitis, including no neck stiffness, reduced level of consciousness or rash.
The pathway consists of the signature log page; the nursing admission sheet; the medical admission sheet; the progress sheets where the nursing plan, parental comments and medical review are documented; supplementary sheets; the discharge sheet; and the variance sheet. Everybody using the pathway has to sign the signature log, including parents and guardians who are encouraged to participate in the pathway. The variance sheet is used to identify areas of the pathway where patient management deflects from the pathway. At the end of the pathway the discharge goals are documented. The pathway is available on request from the Directorate Clinical Governance Co-ordinator, A&E and Paediatrics, Wirral University Teaching Hospital, NHS Foundation Trust.
Recently, the pathway was evaluated by a retrospective review of the case notes of all children admitted to our Paediatric Department last year with a diagnosis of febrile convulsion. Out of a total of 50 cases of children with febrile convulsions, the clinical care pathway was followed in 41 children. The pathway was not used in two children with an age less than 6 months, in three children with a floppy/vacant episode without an initial suspicion of pyrexia on admission, in two children with pyrexia and poorly described febrile convulsion episodes on admission, in one child with chicken pox and in one case of prolonged febrile convulsions more than 15 min. In all children paracetamol and ibuprofen was ordered according to the pathway, and information sheets were given to all parents/guardians. All children's parents included in the pathway were educated by both medical and nursing staff. Documentation of parental education was poor in children not included in the pathway.
The role of clinical care pathways is to improve the quality of treatment, the coordination of care and the satisfaction of patients treated in hospitals.3–5 The outcomes and the benefits following their introduction in clinical practice vary considerably depending on disease entity. A clinical pathway can have an impact on prescribing of medications, length of hospital stay, cost, number and rate of ordered investigations, patient's satisfaction, clinical parameters and mortality. In children the experience of the usage of pathways is limited. In asthma, it has been shown that the use of a clinical pathway reduces the length of stay, the usage of β-2 blockers with no adverse outcomes and reduces the rate of readmission to the hospital.5 A clinical pathway in the management of children with bronchiolitis reduced the usage of antibiotics.6 In children with gastroenteritis the usage of a clinical pathway reduced the length of stay and the number of laboratory investigations.3,4
In the future, further review and feedback on the existing pathway can improve its usage in the care of children with febrile convulsions. In Dunlop and Taitz study,1 it would be of great interest to re-audit the management of children with febrile convulsions after the implementation of the existing clinical care pathway. This will enable us to observe any possible improvements in the care of children with febrile convulsions after its usage in clinical practice. We suggest that a clinical care pathway could be introduced to hospitals with no pathway after further evaluation of its role in investigation, diagnosis and treatment of children with febrile convulsions.