Roneet Lev, MD, FACEP
Executive Director, IEPC
With contribution from Dr. Les Berson

This story is heartbreaking — tragic for the patient and for the emergency group that lost its contract over a pediatric case gone wrong.

You be the judge…

December 2024 – A 14-month-old presented to the emergency department with intermittent fevers and reportedly “stiff neck.” The child appeared well-nourished, well-hydrated, afebrile (axillary), with a heart rate of 130, respiratory rate of 28, oxygen saturation of 99%, and in no distress. On examination, the neck was supple with no nuchal rigidity. The lungs were clear. The child was sitting on the mother’s lap eating Goldfish crackers.

A respiratory swab and urinalysis were negative, except for 1+ ketones in the urine. the patient was evaluated by a mid-level provider. The medical decision-making documented a viral illness; the diagnosis listed was “fever.” The child was discharged home without a physician review.

Thirty-six hours later, the child returned. (Don’t we all dread that? The patient always returns in the scary cases). This time, the child was lethargic and vomiting. The axillary temperature was 37°C, but rectally is was 38.5°C. Heart rate was 153, respiratory rate 22, and oxygen saturation 100%.

At this point, all the big guns were pulled: blood work, lumbar puncture, IV fluids, intubation, head CT, antibiotics, oxygen, consultation, and transfer to a pediatric hospital.

Abnormal labs showed:

• WBC: 1.4
• Hematocrit: 30.6
• Potassium: 3.2
• Anion gap: 20
• BUN: 18
• Creatinine: 0.5
• Lactic acid: 3.6

Chest X-ray showed no infection. CSF PCR was positive for Streptococcus pneumoniae meningitis.

The diagnosis: pneumococcal meningitis — consistent with lack of vaccination.

So what is the Quality Improvement lesson here?

• Should all infants have a rectal temperature taken in the ED?
• Should all children be evaluated by an attending physician before discharge?
• Should we start asking about vaccination status in febrile children?

Currently, EDs do not routinely inquire about vaccination status in pediatric patients. However, vaccination rates have declined — down 2-3% from pre-pandemic levels (2019) to 92.5% in kindergarten-aged children in 2024. For toddlers (age 3), the rate is even lower, around 72-73%.

Perhaps it’s time to add a new review-of-systems question: vaccine status — especially for young children presenting with fever.

This case was a sentinel event for the hospital. The emergency department was blamed, and the incident led the administration to terminate the ED group’s contract.