Major changes have taken place in the delivery of out-of-hours primary care. There is a growing trend towards help-lines and drop in centres. Many patients will often first speak to a nurse, who will triage the calls with or without the help of guidelines or algorithms. The concern arises as to whether this is safe. In the last few years of my training, I have come across two children whose parents mentioned a ‘bulging fontanelle’ as part of their concerns, and who were falsely reassured over the phone.
Both infants presented with a non-specific febrile illness. They contacted NHS Direct in one case, and a local nurse-led call centre of the local GP cooperative in the other. This last centre used the same guidelines/algorithms as NHS Direct. In both cases, parents mentioned the protruding soft spot during the structured interview. Neither nurse nor protocol picked up on this significant finding, and parents were reassured and advised to give paracetamol and ensure adequate fluid intake. After presentation to the hospital, one child turned out to have a viral illness, while the other had pneumococcal meningitis and required a prolonged hospital stay. The helplines have since addressed the issue by updating their protocol and providing further training for their nurses.
In both these cases an important sign, that is the bulging fontanelle, was missed, and parents were falsely reassured. In medical school, presentation of meningitis in children is well-rehearsed, including all rare and non-specific presentations, to ensure this disastrous condition is recognised early. I doubt that any doctor would have missed this sign. I would encourage all primary care trusts to review their out-of-hours service, and to review protocols and guidelines they hold on children presenting with non-specific febrile illness, and in particular, include this subtle but important sign. I would like to advocate a low threshold for babies and infants to be reviewed by a doctor in any case.
- © British Journal of General Practice, 2005.