Ought 'standard care' be the 'standard of care'? A study of the time to administration of antibiotics in children with meningitis.
OBJECTIVE
To determine the time from triage in an emergency department until administration of parenteral antibiotics in children with bacterial meningitis.


METHODS
Retrospective review of medical records and survey of medical subspecialists in infectious diseases and emergency medicine.


METHODS
Emergency departments of two university-affiliated pediatric hospitals.


METHODS
All children with bacterial meningitis identified in medical records from 1987 to 1989 (N = 93).


METHODS
For each child, the time from presentation to the emergency department until administration of antibiotics (AB time) was determined; when possible, time from triage to contact with a physician, from triage to lumbar puncture, and from lumbar puncture to administration of antibiotics was measured. We then surveyed specialists in both pediatric infectious diseases (n = 23) and pediatric emergency medicine (n = 54) as to their beliefs about AB time in children with meningitis.


METHODS
Mann-Whitney Rank Sum Test and Kruskal-Wallis Test.


RESULTS
Median AB time was 2.0 hours (interquartile range, 1.25 to 3.33 hours). Only one (1%) of 93 children received antibiotics within 30 minutes of presentation. Median time from triage until contact with a physician was 0.45 hour. Median time from lumbar puncture until antibiotics administration was about 0.5 hour. The estimates of median AB time differed significantly between emergency medicine (0.93 hour) and infectious disease (1.45 hours) experts, and estimates from both differed significantly from the median AB time (2.0 hours) actually observed.


CONCLUSIONS
These data reveal that the usual and customary practice (ie, standard medical care) by qualified physicians may differ from opinions of standard medical care promulgated by medical experts. Even among experts there is a wide range of (mistaken) opinions about standard medical care. Insofar as jurors in medical malpractice cases are instructed to consider what physicians "ordinarily do in similar circumstances," a data-based definition of "standard" medical care should supplant anecdotal testimony by individual expert witnesses.
Meadow
W L
WL
Department of Pediatrics, Wyler Children's Hospital, Chicago, Ill 60637.
Lantos
J
J
Tanz
R R
RR
Mendez
D
D
Unger
R
R
Wallskog
P
P
D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D002641:Chicago / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols / Q000592:standards*; D004635:Emergency Medicine / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007262:Infusions, Intravenous; D008485:Medical Audit; D008511:Medicine; D016920:Meningitis, Bacterial / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D010372:Pediatrics / Q000592:standards; D010820:Physicians / Q000523:psychology; D011787:Quality of Health Care; D012189:Retrospective Studies; D013038:Specialization; D013129:Spinal Puncture; D013997:Time Factors; D014218:Triage
D000900:Anti-Bacterial Agents