Trying to Make Health Care Systems Work

Patient Presentation
A pediatrician received a telephone call on a Saturday from her sister who lived in another state.
An infant in the nieces/nephews’ daycare had been diagnosed with rapid-onset meningitis was not expected to live.
The sister was very worried about the infant and its family, and also concerned about her own children, so she had called her sister for support.
The daycare provider had heard about the infant through a friend of the family and had no direct contact with the family for more information.
The pediatrician recommended for her sister to contact her own pediatrician locally so the sister’s pediatrician could manage the problem locally as needed.
The pediatrician also told her sister to call the daycare provider to try to contact public health.
The daycare provider left messages with the local public health department but got no answer.
The sister’s pediatrician said that although meningococcal meningitis potentially was a cause, more information was necessary before beginning prophylactic antibiotics.

Over the next several days, the daycare provider found out more information from the friend of the infant’s family but because of HIPAA regulations, no information could be released directly to the daycare provider.
The daycare provider continued to try to contact the local public health department without success. The daycare provider was also not aware if the infant’s physician’s had contacted the local public health department.
On day 5 of admission, a culture grew Kingella kingae, but unfortunately the infant died later that evening.
When the pediatrician received this information from her sister, she checked the AAP’s RedBook® which did not recommend any antibiotic prophylaxis nor special instructions for the contacts.
The pediatrician was still concerned that the local public health department had not contacted the daycare provider.

Five days after the first child died, another toddler in the same daycare was admitted to a second hospital with a fever and rash.
The pediatrician’s sister was told that the diagnosis was a virus, but later the sister was told that the infection still required antibiotics.
One week after the second child was admitted, a third toddler was admitted to a third hospital with fever and severe leg pain.
The pediatrician told her sister that she was very worried about this situation because although the second child may have had a virus, Kingella kingae often causes osteoarthritis.
The pediatrician had her sister contact the sister’s pediatrician to see if this pediatrician could get the local health department to investigate.
Concurrently, the pediatrician also called the sister’s state health department who was surprised to be called by someone from out of state.

Within a few hours, the state health department contacted the local health department who began investigating immediately.
Along with advice from the Centers for Disease Control, the local health department determined that all of the children in the daycare needed prophylactic antibiotics because the third child with leg pain was very suspicious for Kingella kingae as a causative organism.
All the children in the daycare received amoxicillin and rifampin as prophylactic antibiotics.
The second and third children were doing well one week later.

Kingella kingae is a slow-growing, gram-negative organism that was previously classified as Moraxella kingae.
Kingella kingae is usually known for causing osteoarticular infections (particularly the femur) but also other invasive disease such as occult bacteremia, diskitis, endocarditis, meningitis, and pneumonia.
The organism colonizes the oropharynx and is known to spread within daycare settings usually without causing disease. Infections may occur with concomitant or preceding upper airway infections or stomatitis.
The organism can be isolated from many fluids and tissues and grows better in anaerobic conditions. It can also be difficult to isolate using standard media.
Blood cultures are frequently negative in children with osteoarthritis and Kingella kingae should be suspected with blood culture negative skeletal infections.
Penicillin is recommended for treatment of beta-lactam negative isolates. Other beta-lactam antibiotics are also effective.

Learning Point
Unfortunately the initial infant with Kingella kingae succumbed to this invasive organism.
The second child appears not to have had Kingella kingae but another illness that coincidentally occurred at that particular time.
The third child potentially may not have had the presumed leg infection if prophylaxis had been started earlier.
However, recommendations from the American Academy of Pediatric are not to give prophylaxis but to monitor closely after the first case which was done.
The public health department did determine that prophylaxis was needed after the third child with suspicious disease.
It appears that the Kingella kingae either burnt itself out or was stopped by the prophylactic antibiotics.

From a systems-based perspective, many problems occurred to complicate making the diagnosis, investigating, and treating contacts that could be considered for improvement:

  • Kingella kingae is slow growing and therefore takes time to isolate. It usually does not require prophylaxis for contacts and therefore the pediatrician was not as concerned about prophylaxis for this organism until after the 2nd and 3rd child presented.
    Should the pediatrician have called the state health department sooner?

  • The pediatrician and sister’s pediatrian were concerned about giving unnecessary prophylactic antibiotics for the contacts of the initial infant; meningococcus should not receive prophylaxis until the organism has been identified.
    Should the pediatrician or the sister’s pediatrician have pushed for prophylactic antibiotics sooner and if so at what point?

  • The infant with meningitis initially presented over the weekend when it can be more difficult to contact the regular health care providers working within and between health systems.
    How can off-hours contacts with healthcare providers be facilitated?

  • The pediatrician and the involved children were in different states thus the pediatrician did not know the local health care systems well enough to offer specific advice but only general advice to her sister and the daycare provider.
    What else could the pediatrician have done to learn more about the local health care systems to be able to give more specific advice?

  • The pediatrician did not have a personal or professional relationship with the initial infant and other children in the daycare and therefore could not obtain specific information, nor had a specific legal responsibility to act on their behalf.
    What defines a professional relationship with a patient? What if anything could the sister’s pediatrician who did have a professional relationship with the sister’s children potentially do if this pediatrician had been aware of the circumstances as they were evolving.

  • Information was being communicated between many different people including the pediatrician, pediatrician’s sister, daycare provider, infant’s family friend, other daycare families, healthcare teams for the second and third ill children, sister’s pediatrician, local health department, state health department, and the Centers for Disease Control.
    The information may or may not have been communicated accurately between all these people. How can accurate information be conveyed between and among laypersons and health care professionals?
    What could the pediatrician do to facilitate communication between all these people?

  • HIPAA regulations are privacy regulations and properly prevented information from being given to non-family members. The daycare provider could not receive direct information and therefore may not have been giving accurate information to the local health department.
    What are the exceptions in the HIPAA laws that allow private information to be shared for the public good?

  • The daycare provider as a layperson may not know how to make various healthcare systems work and therefore may have been contacting the wrong local health department or the wrong people within the health department.
    How can health systems be user-friendly and facilitate interactions?

  • Within the public health systems there are inconsistent divisions of responsibilities between the local and state levels in different states, so the pediatrician contacted the state level when the local level needed to be investigating.
    The state level did contact the local level and the investigation then began promptly after this contact.
    How could the pediatrician learn about how to work the health care system when she was not involved in that system and the systems she was aware of worked differently?

Questions for Further Discussion
1. How do you treat your own family members who ask for medical advice?
2. How would you have handled this situation differently from the pediatrician?
3. How do you define advocacy and when do you need to take action?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Meningitis and Bone Diseases
and at Pediatric Common Questions, Quick Answers for this topic: Bacterial Meningitis

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Moylett EH, Rossmann SN, Epps HR, Demmler GJ. Importance of Kingella kingae as a Pediatric Pathogen In the United States. Pediatr Infect Dis J. 2000 Mar;19(3):263-5.

Yagupsky P. Kingella kingae: From Medical Rarity to an Emergency Paediatric Pathogen.
Lancet Infect Dis. 2004 Jun;4(6):358-67. Available from the Internet at (cited 10/11/2007).

American Academy of Pediatrics. Kingella kingae infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;416.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    November 19, 2007