Quality standard

Quality statement 2: Lumbar puncture

Quality statement 2: Lumbar puncture

Quality statement

People with suspected meningitis have lumbar puncture without neuroimaging unless they have a contraindication to lumbar puncture that requires neuroimaging. [New 2024]

Rationale

Lumbar puncture is the only test that can directly confirm a diagnosis of bacterial meningitis. Most people with suspected bacterial meningitis do not need neuroimaging before a lumbar puncture. This is only needed if the person has risk factors for an evolving space-occupying lesion, or symptoms or signs of raised intracranial pressure. Performing lumbar puncture without delay reduces the time in starting tailored antibiotic treatment, which in turn may reduce rates of mortality, neurological problems, hearing problems and functional impairment.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

a) Proportion of people with suspected bacterial meningitis who had lumbar puncture without prior neuroimaging.

Numerator – the number in the denominator who did not have neuroimaging before lumbar puncture.

Denominator – the number of people with suspected bacterial meningitis who had lumbar puncture.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records. NHS England's Emergency Care Data Set includes data on suspected and confirmed bacterial meningitis and meningococcal disease.

b) Proportion of people with suspected bacterial meningitis who had neuroimaging before lumbar puncture and had a documented clinical indication for neuroimaging.

Numerator – the number in the denominator who had a documented clinical indication for neuroimaging.

Denominator – the number of people with suspected bacterial meningitis who had neuroimaging before lumbar puncture.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records. NHS England's Emergency Care Data Set includes data on suspected and confirmed bacterial meningitis and meningococcal disease.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that systems are in place for people with suspected bacterial meningitis to have lumbar puncture without undergoing neuroimaging unless they have a contraindication to lumbar puncture that requires neuroimaging. This includes ensuring that clinicians are aware that lumbar puncture should not be delayed because of neuroimaging and knowing the circumstances in which neuroimaging may be required, such as signs of raised intracranial pressure.

Healthcare professionals (such as emergency department doctors, paediatricians and physicians working in other hospital departments) ensure that people with suspected bacterial meningitis have lumbar puncture without undergoing neuroimaging unless they have a contraindication to lumbar puncture that requires neuroimaging. They ensure that they are aware of the circumstances which would necessitate neuroimaging before lumbar puncture, such as signs of raised intracranial pressure.

Commissioners ensure that they commission services in which people with suspected bacterial meningitis do not have neuroimaging before lumbar puncture unless they have a contraindication to lumbar puncture that requires neuroimaging.

People with suspected bacterial meningitis have a lumbar puncture, where a needle is used to obtain fluid from the lower back to help diagnose whether they have bacterial meningitis, without having a scan of their brain (neuroimaging) unless this is clinically required.

Definitions of terms used in this quality statement

Contraindications to lumbar puncture that require neuroimaging

Neuroimaging should be performed before lumbar puncture if the person has:

  • risk factors for an evolving space-occupying lesion or

  • any of these symptoms or signs of raised intracranial pressure:

    • new focal neurological features (including seizures or posturing)

    • abnormal pupillary reactions

    • a Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness.

[Adapted from NICE's guideline on meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management, recommendations 1.4.7 and 1.4.12]