Improving the quality of Pediatric Sepsis Care
December9,2016
KathleenBrown,MDJeannePettinichi,MSN,RN
LearningObjectives
1. Describecurrentguidelinesforinitialmanagement
ofpediatricsepsis
2. Describequalityimprovementstrategiesfor
improvingpediatricsepsiscareintheED
3. Discussthecomponentsofapediatricsepsis
screeningtoolforearlyidentificationofsepsis.
March292012
• 9yoM,cutsarmingym->developsmyalgias,vomiting,fever
• EDdiagnoseswithgastroenteritis,receivesZofranandIVF,discharged
• Examnotedmottlingofskin– DischargeVitals:HR143,RR22,T102(noBPreported)
– CBCdrawnatthattimeshowedWBC14.7 (39%N,53%bands)butpatientdischargedbeforeresulted
Ourcase
• BacktoEDthefollowingdayinsepticshock,admittedtoICU– Bloodcultures:GroupAStreptococcus– Dateofinitialpresentation– March29– Dateofdeath- April1
CouldthishappeninmyED?
• >40,000USpediatricseveresepsiscases/year
• ~20,000pediatricsepticshock/year
• MortalityinUS4-10%forseveresepsisandsepticshock• Previouslywellchildren~4%• Highriskorchronicallyill7-
10%
• Sepsisorrelatedissuescauses7-9%ofallpediatricdeaths
ReviewofDefinitions
• Sepsis is life-threateningorgandysfunctionduetoadysregulatedhostresponsetoinfection*
• Sepsis:SIRS+Infection(suspectedorproven)
• SIRS(Needatleast2of4,onemustbeWBCorTemperature)• CoreTemp>38.5˚Cor<36˚C• Tachycardiaforage(orbradycardia if<1year)• Tachypneaforage• WBCelevatedordepressed
*VincentJ,AngusDC.TheThirdInternationalConsensusDefinitionsforSepsisandSepticShock(Sepsis-3).JAMA. 2016;315(8):801-810
GoldsteinB,\etal.InternationalConsensusConferenceonPediatricSepsis.Pediatr CritCareMed.2005;6(1):2.2005
Goldstein: Pediatric SIRS
Agegroup
Heartrate(beats/minute) Respiratoryrate(breaths/minute)
Leukocytecount(leukocytesx103/mm3)
Systolicbloodpressure(mmHg)Tachycardia Bradycardia
Newborn(0daysto1week)
>180 <100 >50 >34 <59
Neonate(1weekto1month)
>180 <100 >40 >19.5or<5 <79
Infant (1monthto1year)
>180 <90 >34 >17.5or<5 <75
Toddlerandpreschool(>1to5years)
>140 NA >22 >15.5or<6 <74
Schoolage(>5to12years) >130 NA >18 >13.5or<4.5 <83
Adolescent(>12to<18years)
>110 NA >14 >11or<4.5 <90
SurvivingSepsisCampaign
• “GRADES”recommendations– Includes“pediatricconsiderations”
• LargeQIinitiative– Bundles– Datacollection
DellingerRPetal.SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock,2012IntensiveCareMed2013
http://www.survivingsepsis.org/About-SSC/Pages/default.aspx
The Basics
• Earlyrecognition
• Timely/adequatefluidresuscitation– TimelyIVacess– Reversalofperfusionabnormalitiesasendpoint
• Earlyantibiotics
• Timelypressors
Howarewedoing?
• 3studiesattertiarycarechildren’shospitals– (Houston,SaltlakeCityandBoston)
• Poorcompliancewithadherencetoguidelines– Barrierstocompliancerecognized
• InitialQIeffortsreported
CruzAT,PerryAM,WilliamsEA,etal.Implementationofgoal-directedtherapyforchildrenwithsuspectedsepsisintheemergencydepartment.Pediatrics.2011;127(3).LarsenGY,Mecham N,GreenbergR,etal.Anemergencydepartmentsepticshockprotocolandcareguidelineforchildreninitiatedattriage.Pediatrics.2011;127(6).PaulR,Neuman MI,Monuteaux MC,MelendezE.AdherencetoPALSsepsisguidelinesandhospitallengthofstay.Pediatrics.2012;130
Boston
• 126subjectsbeforetheintervention– (November2009toMarch2011)
• 116patientsduringtheQIintervention– (October2011toMay2013)
• 5-componentbundle(baselinerateof19%)– Recognitionin5min– Vascularaccessin5min– Antibioticsin60min– 60/kgin60mins– Pressors in60mins
PaulRetal,ImprovingAdherencetoPALSSepticShockGuidelines.Pediatrics, 2014
SaltLakeCity
• 1380Patientswithsepticshock(2007-2014)inED– QIinitiative• Bundle–Timelyantibiotics,– Intravenousfluids(IVF)forrapidreversalofperfusionabnormalitiesand/orhypotension
• Triagescreening
LaneRDetal.HighReliabilityPediatricSepticShockQualityImprovementInitiativeandDecreasingMortalityPediatrics.2016
EarlyrecognitionScreeningtool:PCH(paperbased)
2013 2014
Sensitivity%(95%CI) 97(95–99) 100(100–100)a
Specificity%(95%CI) 98(98–98)b 97(97–98)b
PPV%(95%CI) 24(21–27) 15(13–17)
NPV%(95%CI) 100(100–100)b 100(100–100)b
Meanfalsepositiverate=80%
Earlyrecognition:CHOPelectronic
Balamuth Fetal.ComparisonofTwoSepsisRecognitionMethodsinaPediatricEmergencyDepartment Acad Emerg Med.2015Nov;22(11):1298–1306.
TheEDPediatricSepticShockCollaborative
• SponsoredbytheAmericanAcademyofPediatrics(AAP)• >40ED’s• QIstudydesignwithrapidcyclechanges– 1yearofretrospectivedata5yearsprospective– Allsitesmustinstituteascreeningtoolandtreatmentprotocol
– Noscreeningortreatmentmandates• BUTaskedtostayasclosetosuggestedscreeningmechanismaspossible• TreatmentbasedonbestpracticeguidelinesperPALS/SurvivingSepsis
QualityImprovementStrategies
• Increasingcompliancewithsepsisqualityindicators• Multidisciplinaryteamcollaboration• Education- introduceguidelinesintoclinicalpractice• Protocoldevelopmentandimplementation• Datacollection• Feedback– tofacilitatecontinuousimprovement• Ongoingeducation
Education
SepsisTraining1. Onlineeducationalcourse(1hour)- withpreandposttest
andat3months– AllStaff2. Clinicalsepsiscasestudyscenariosincludinghands-on
demonstrationofpush-pullIVFadministration,IOplacement,vasopressordripcalculationandadministration.
3. Sepsisalerttrainingwithdecisionsupportexplanation&nursingdocumentationrequirements
4. Sepsisalertprocesssteps
PDSAInterventions
1. Summer2014§ HandsonEducation
2. May2015§ Automatedscreeningalgorithm&EHRalert§ Powerplan§ Onlineeducationaltool
3. July2015§ Simplificationofscreeningalgorithm
4. May2016§ WeeklyIndividualFeedback
5. July2016§ Pre-assignedSepsisTeam
6. August2016§ Re-educationandreinvigorationofsepsisinitiative
7. October2016§ FeedbackForm§ Huddlereminders/ChargeNursecommunication
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Bolus1_Median
Antibiotic_Median
SepsisTeam/Re-education
IndividualFeedback
RNSepsisEducation
EHRAlert&Powerplan
FeedbackForm
ImprovementTimeline
Backtoourpatient
• Feverwouldhavemandateduseoftool– (T102F)
• Examnotedmottlingofskin(1point)• VSHR143,RR22 (2points)
• Wouldhavetriggeredcloserevaluation
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