Ought 'standard care' be the 'standard of care'? A study of the time to administration of antibiotics in children with meningitis
W. L. Meadow, J. Lantos, R. R. Tanz, D. Mendez, R. Unger and P. Wallskog
Department of Pediatrics, Wyler Children's Hospital, Chicago, Ill 60637.
OBJECTIVE--To determine the time from triage in an emergency department
until administration of parenteral antibiotics in children with bacterial
meningitis. RESEARCH DESIGN--Retrospective review of medical records and
survey of medical subspecialists in infectious diseases and emergency
medicine. SETTING--Emergency departments of two university-affiliated
pediatric hospitals. PARTICIPANTS--All children with bacterial meningitis
identified in medical records from 1987 to 1989 (N = 93). MEASUREMENTS--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. STATISTICAL ANALYSES--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.
