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de Souza DC, Paul R, Mozun R, Sankar J, Jabornisky R, Lim E, Harley A, Al Amri S, Aljuaid M, Qian S, Schlapbach LJ, Argent A, Kissoon N. Quality improvement programmes in paediatric sepsis from a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:695-706. [PMID: 39142743 DOI: 10.1016/s2352-4642(24)00142-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 08/16/2024]
Abstract
Sepsis is a major contributor to poor child health outcomes around the world. The high morbidity, mortality, and societal cost associated with paediatric sepsis render it a global health priority, as summarised in Paper 1 of this Series. Sepsis is characterised by a dysregulated host response to infection that manifests as organ failure, and children are uniquely susceptible to sepsis, as discussed in Paper 2. The focus of this third Series paper is quality improvement in paediatric sepsis. The 2017 WHO resolution on sepsis outlined key aims to reduce the burden of sepsis. As of 2024, only a small number of countries have implemented systematic, paediatric-focused quality improvement programmes to raise sepsis awareness, enhance recognition of sepsis, promote timely treatment, and provide long-term support for paediatric sepsis survivors. We examine programme successes and systematic barriers to quality improvement targeting paediatric sepsis. We highlight the need for programme design to consider the entire patient journey, starting with prevention, caregiver awareness, recognition at home, education of the health-care workforce, development of health-care systems, and establishment of long-term family and survivor support extending beyond the intensive care unit. Building on lessons learnt from existing quality improvement programmes, we outline implementation strategies and measures to enable benchmarking. Ultimately, quality improvement on a global scale can only be accelerated through a global learning platform focusing on paediatric sepsis.
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Affiliation(s)
- Daniela C de Souza
- Latin American Sepsis Institute, São Paulo, Brazil; Pediatric Intensive Care Unit, Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil; Pediatric Intensive Care Unit, Hospital Sírio Libanês, São Paulo, Brazil.
| | - Raina Paul
- Children's Hospital of Orange County, Orange, CA, USA; Improving Pediatric Sepsis Outcomes Collaborative, Children's Hospital Association, Washington, DC, USA
| | - Rebeca Mozun
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jhuma Sankar
- All India Institute of Medical Sciences, New Delhi, India
| | - Roberto Jabornisky
- Universidad Nacional del Nordeste, Corrientes, Argentina; LARed Network, Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Emma Lim
- Department of Paediatric Infectious Diseases, Immunology and Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Harley
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia; Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Samirah Al Amri
- Nursing Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Maha Aljuaid
- Nursing Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Suyun Qian
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | | | - Niranjan Kissoon
- Global Child Health Department of Pediatrics and Emergency Medicine, British Columbia Women and Children's Hospital and the University of British Columbia, Vancouver, BC, Canada
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2
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Kandil SB, Lee S, Feinn RS, Murray TS. Younger Age and Female Gender Are Associated With Delayed Antibiotics in Pediatric Sepsis. J Pediatric Infect Dis Soc 2024; 13:434-438. [PMID: 38889196 DOI: 10.1093/jpids/piae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 06/17/2024] [Indexed: 06/20/2024]
Abstract
Sepsis is a leading cause of pediatric mortality and timely antibiotic administration has been shown to improve outcomes. In this retrospective review of a single center sepsis dataset, we identified younger age and female sex as more likely to have delays in antibiotics.
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Affiliation(s)
- Sarah B Kandil
- Yale New Haven Children's Hospital, Department of Pediatrics, New Haven, Connecticut, USA
- Yale University, School of Medicine, Deparmtment of Pediatrics, Section of Critical Care Medicine, New Haven, Connecticut, USA
| | - Seohyuk Lee
- Beth Israel Deaconess Medical Center, Department of Internal Medicine, Boston, Massachusetts, USA
| | - Richard S Feinn
- Quinnipiac University, Department of Medical Sciences, Hamden, Connecticut, USA
| | - Thomas S Murray
- Yale New Haven Children's Hospital, Department of Pediatrics, New Haven, Connecticut, USA
- Yale University, School of Medicine, Department of Pediatrics, Section of Infectious Disease, New Haven, Connecticut, USA
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3
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Paul R, Niedner M, Riggs R, Richardson T, DeSouza HG, Auletta JJ, Balamuth F, Campbell D, Depinet H, Hueschen L, Huskins WC, Kandil SB, Larsen G, Mack EH, Priebe GP, Rutman LE, Schafer M, Scott H, Silver P, Stalets EL, Wathen BA, Macias CG, Brilli RJ. Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics 2023; 152:e2022059938. [PMID: 37435672 DOI: 10.1542/peds.2022-059938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVES We sought to improve utilization of a sepsis care bundle and decrease 3- and 30- day sepsis-attributable mortality, as well as determine which care elements of a sepsis bundle are associated with improved outcomes. METHODS Children's Hospital Association formed a QI collaborative to Improve Pediatric Sepsis Outcomes (IPSO) (January 2017-March 2020 analyzed here). IPSO Suspected Sepsis (ISS) patients were those without organ dysfunction where the provider "intended to treat" sepsis. IPSO Critical Sepsis (ICS) patients approximated those with septic shock. Process (bundle adherence), outcome (mortality), and balancing measures were quantified over time using statistical process control. An original bundle (recognition method, fluid bolus < 20 min, antibiotics < 60 min) was retrospectively compared with varying bundle time-points, including a modified evidence-based care bundle, (recognition method, fluid bolus < 60 min, antibiotics < 180 min). We compared outcomes using Pearson χ-square and Kruskal Wallis tests and adjusted analysis. RESULTS Reported are 24 518 ISS and 12 821 ICS cases from 40 children's hospitals (January 2017-March 2020). Modified bundle compliance demonstrated special cause variation (40.1% to 45.8% in ISS; 52.3% to 57.4% in ICS). The ISS cohort's 30-day, sepsis-attributable mortality dropped from 1.4% to 0.9%, a 35.7% relative reduction over time (P < .001). In the ICS cohort, compliance with the original bundle was not associated with a decrease in 30-day sepsis-attributable mortality, whereas compliance with the modified bundle decreased mortality from 4.75% to 2.4% (P < .01). CONCLUSIONS Timely treatment of pediatric sepsis is associated with reduced mortality. A time-liberalized care bundle was associated with greater mortality reductions.
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Affiliation(s)
- Raina Paul
- Division of Emergency Medicine, Children's Hospital of Orange County, University of California Irvine, Orange California
| | | | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
| | | | | | - Jeffery J Auletta
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Frances Balamuth
- Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Holly Depinet
- Departments of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leslie Hueschen
- University of Missouri-Kansas City, Children's Mercy Hospital, Kansas City, Missouri
| | - W Charles Huskins
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota
| | - Sarah B Kandil
- Department of Pediatrics, Yale University School of Medicine, Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Gitte Larsen
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Elizabeth H Mack
- Medical University of South Carolina Children's Health, Charleston, South Carolina
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Lori E Rutman
- University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Melissa Schafer
- State University of New York Upstate Medical Center, Syracuse, New York
| | - Halden Scott
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Denver, Colorado
| | - Pete Silver
- Cohen Children's Medical Center of New York, Queens, New York
| | - Erika L Stalets
- Departments of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Charles G Macias
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Richard J Brilli
- Nationwide Children's Hospital, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbus, Ohio
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4
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Moorthy GS, Pung JS, Subramanian N, Theiling BJ, Sterrett EC. Causal Association of Physician-in-Triage with Improved Pediatric Sepsis Care: A Single-Center, Emergency Department Experience. Pediatr Qual Saf 2023; 8:e651. [PMID: 37250616 PMCID: PMC10219727 DOI: 10.1097/pq9.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/04/2023] [Indexed: 05/31/2023] Open
Abstract
Approximately 75,000 children are hospitalized for sepsis yearly in the United States, with 5%-20% mortality estimates. Outcomes are closely related to the timeliness of sepsis recognition and antibiotic administration. Methods A multidisciplinary sepsis task force formed in the Spring of 2020 aimed to assess and improve pediatric sepsis care in the pediatric emergency department (ED). The electronic medical record identified pediatric sepsis patients from September 2015 to July 2021. Data for time to sepsis recognition and antibiotic delivery were analyzed using statistical process control charts (X̄-S charts). We identified special cause variation, and Bradford-Hill Criteria guided multidisciplinary discussions to identify the most probable cause. Results In the fall of 2018, the average time from ED arrival to blood culture orders decreased by 1.1 hours, and the time from arrival to antibiotic administration decreased by 1.5 hours. After qualitative review, the task force hypothesized that initiation of attending-level pediatric physician-in-triage (P-PIT) as a part of ED triage was temporally associated with the observed improved sepsis care. P-PIT reduced the average time to the first provider exam by 14 minutes and introduced a process for physician evaluation before ED room assignment. Conclusions Timely assessment by an attending-level physician improves time to sepsis recognition and antibiotic delivery in children who present to the ED with sepsis. Implementing a P-PIT program with early attending-level physician evaluation is a potential strategy for other institutions.
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Affiliation(s)
- Ganga S. Moorthy
- From the Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
| | - Jordan S. Pung
- Division of Pediatric Critical Care, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
| | - Neel Subramanian
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
| | - B. Jason Theiling
- Department of Emergency Medicine, Duke University Medical Center; Durham, North Carolina
| | - Emily C. Sterrett
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
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5
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Macias CG, Remy KE, Barda AJ. Utilizing big data from electronic health records in pediatric clinical care. Pediatr Res 2023; 93:382-389. [PMID: 36434202 PMCID: PMC9702658 DOI: 10.1038/s41390-022-02343-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022]
Abstract
Big data has the capacity to transform both pediatric healthcare delivery and research, but its potential has yet to be fully realized. Curation of large multi-institutional datasets of high-quality data has allowed for significant advances in the timeliness of quality improvement efforts. Improved access to large datasets and computational power have also paved the way for the development of high-performing, data-driven decision support tools and precision medicine approaches. However, implementation of these approaches and tools into pediatric practice has been hindered by challenges in our ability to adequately capture the heterogeneity of the pediatric population as well as the nuanced complexities of pediatric diseases such as sepsis. Moreover, there are large gaps in knowledge and definitive evidence demonstrating the utility, usability, and effectiveness of these types of tools in pediatric practice, which presents significant challenges to provider willingness to leverage these solutions. The next wave of transformation for pediatric healthcare delivery and research through big data and sophisticated analytics will require focusing efforts on strategies to overcome cultural barriers to adoption and acceptance. IMPACT: Big data from EHRs can be used to drive improvement in pediatric clinical care. Clinical decision support, artificial intelligence, machine learning, and precision medicine can transform pediatric care using big data from the EHR. This article provides a review of barriers and enablers for the effective use of data analytics in pediatric clinical care using pediatric sepsis as a use case. The impact of this review is that it will inform influencers of pediatric care about the importance of current trends in data analytics and its use in improving outcomes of care through EHR-based strategies.
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Affiliation(s)
- Charles G. Macias
- grid.67105.350000 0001 2164 3847Department of Pediatrics, Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH USA
| | - Kenneth E. Remy
- grid.415629.d0000 0004 0418 9947Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University Hospital of Cleveland, Case Western University School of Medicine, Cleveland, OH USA
| | - Amie J. Barda
- grid.189504.10000 0004 1936 7558Department of Population and Quantitative Health Sciences, Case Western Reserve, University School of Medicine, Cleveland, OH USA
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Alturki A, Al-Eyadhy A, Alfayez A, Bendahmash A, Aljofan F, Alanzi F, Alsubaie H, Alabdulsalam M, Alayed T, Alofisan T, Alnajem A. Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience. Sci Rep 2022; 12:12436. [PMID: 35859000 PMCID: PMC9300636 DOI: 10.1038/s41598-022-16632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (p 0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (p 0.442). Considering the EAS initiation time as the "zero time", early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min, p < 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min, p 0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%, p 0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies.
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Affiliation(s)
- Abdullah Alturki
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
| | - Ayman Al-Eyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ali Alfayez
- Maternity and Children's Hospital, Alhasa, Saudi Arabia
| | - Abdulrahman Bendahmash
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad Aljofan
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fawaz Alanzi
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hadeel Alsubaie
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Moath Alabdulsalam
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Tareq Alayed
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Tariq Alofisan
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Afnan Alnajem
- Research Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Blythe R, Lister P, Seaton R, Harley A, Schlapbach LJ, McPhail S, Venkatesh B, Irwin A, Raman S. Patient and economic impact of implementing a paediatric sepsis pathway in emergency departments in Queensland, Australia. Sci Rep 2022; 12:10113. [PMID: 35710798 PMCID: PMC9203710 DOI: 10.1038/s41598-022-14226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/02/2022] [Indexed: 11/12/2022] Open
Abstract
We examined systems-level costs before and after the implementation of an emergency department paediatric sepsis screening, recognition and treatment pathway. Aggregated hospital admissions for all children aged < 18y with a diagnosis code of sepsis upon admission in Queensland, Australia were compared for 16 participating and 32 non-participating hospitals before and after pathway implementation. Monte Carlo simulation was used to generate uncertainty intervals. Policy impacts were estimated using difference-in-difference analysis comparing observed and expected results. We compared 1055 patient episodes before (77.6% in-pathway) and 1504 after (80.5% in-pathway) implementation. Reductions were likely for non-intensive length of stay (− 20.8 h [− 36.1, − 8.0]) but not intensive care (–9.4 h [− 24.4, 5.0]). Non-pathway utilisation was likely unchanged for interhospital transfers (+ 3.2% [− 5.0%, 11.4%]), non-intensive (− 4.5 h [− 19.0, 9.8]) and intensive (+ 7.7 h, [− 20.9, 37.7]) care length of stay. After difference-in-difference adjustment, estimated savings were 596 [277, 942] non-intensive and 172 [148, 222] intensive care days. The program was cost-saving in 63.4% of simulations, with a mean value of $97,019 [− $857,273, $1,654,925] over 24 months. A paediatric sepsis pathway in Queensland emergency departments was associated with potential reductions in hospital utilisation and costs.
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Affiliation(s)
- Robin Blythe
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD, 4059, Australia.
| | - Paula Lister
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,Paediatric Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, Australia
| | - Robert Seaton
- Department of Health, Clinical Excellence Queensland, Brisbane, QLD, Australia
| | - Amanda Harley
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Critical Care Nursing Management Team, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Steven McPhail
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD, 4059, Australia.,Digital Health and Informatics, Metro South Health, Brisbane, QLD, Australia
| | - Bala Venkatesh
- The George Institute for Global Health, Sydney, NSW, Australia.,Department of Intensive Care Medicine, Wesley Hospital, Brisbane, QLD, Australia.,The University of Queensland, Brisbane, QLD, Australia
| | - Adam Irwin
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Sainath Raman
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
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8
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Depinet H, Macias CG, Balamuth F, Lane RD, Luria J, Melendez E, Myers SR, Patel B, Richardson T, Zaniletti I, Paul R. Pediatric Septic Shock Collaborative Improves Emergency Department Sepsis Care in Children. Pediatrics 2022; 149:184791. [PMID: 35229124 DOI: 10.1542/peds.2020-007369] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The pediatric emergency department (ED)-based Pediatric Septic Shock Collaborative (PSSC) aimed to improve mortality and key care processes among children with presumed septic shock. METHODS This was a multicenter learning and improvement collaborative of 19 pediatric EDs from November 2013 to May 2016 with shared screening and patient identification recommendations, bundles of care, and educational materials. Process metrics included minutes to initial vital sign assessment and to first and third fluid bolus and antibiotic administration. Outcomes included 3- and 30-day all-cause in-hospital mortality, hospital and ICU lengths of stay, hours on increased ventilation (including new and increases from chronic baseline in invasive and noninvasive ventilation), and hours on vasoactive agent support. Analysis used statistical process control charts and included both the overall sample and an ICU subgroup. RESULTS Process improvements were noted in timely vital sign assessment and receipt of antibiotics in the overall group. Timely first bolus and antibiotics improved in the ICU subgroup. There was a decrease in 30-day all-cause in-hospital mortality in the overall sample. CONCLUSIONS A multicenter pediatric ED improvement collaborative showed improvement in key processes for early sepsis management and demonstrated that a bundled quality improvement-focused approach to sepsis management can be effective in improving care.
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Affiliation(s)
- Holly Depinet
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Charles G Macias
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roni D Lane
- Division of Emergency Medicine, Primary Children's Hospital and Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph Luria
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elliot Melendez
- Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Sage R Myers
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Binita Patel
- Section of Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | | | | | - Raina Paul
- Department of Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois
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9
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Dewan M. Use of Procalcitonin in Pediatric Sepsis is Low-Value Care. J Pediatric Infect Dis Soc 2022; 11:31-32. [PMID: 34338798 DOI: 10.1093/jpids/piab068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/11/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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10
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Eisenberg MA, Balamuth F. Pediatric sepsis screening in US hospitals. Pediatr Res 2022; 91:351-358. [PMID: 34417563 PMCID: PMC8378117 DOI: 10.1038/s41390-021-01708-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/28/2021] [Accepted: 08/04/2021] [Indexed: 11/09/2022]
Abstract
Sepsis is a major cause of morbidity and mortality in children. While adverse outcomes can be reduced through prompt initiation of sepsis protocols including fluid resuscitation and antibiotics, provision of these therapies relies on clinician recognition of sepsis. Recognition is challenging in children because early signs of shock such as tachycardia and tachypnea have low specificity while hypotension often does not occur until late in the clinical course. This narrative review highlights the important context that has led to the rapid growth of pediatric sepsis screening in the United States. In this review, we (1) describe different screening tools used in US emergency department, inpatient, and intensive care unit settings; (2) highlight details of the design, implementation, and evaluation of specific tools; (3) review the available data on the process of integrating sepsis screening into an overall sepsis quality improvement program and on the effect of these screening tools on patient outcomes; (4) discuss potential harms of sepsis screening including alarm fatigue; and (5) highlight several future directions in sepsis screening, such as novel tools that incorporate artificial intelligence and machine learning methods to augment sepsis identification with the ultimate goal of precision-based approaches to sepsis recognition and treatment. IMPACT: This narrative review highlights the context that has led to the rapid growth of pediatric sepsis screening nationally. Screening tools used in US emergency department, inpatient, and intensive care unit settings are described in terms of their design, implementation, and clinical performance. Limitations and potential harms of these tools are highlighted, as well as future directions that may lead to a more precision-based approach to sepsis recognition and treatment.
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Affiliation(s)
- Matthew A. Eisenberg
- grid.38142.3c000000041936754XDepartments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Fran Balamuth
- grid.25879.310000 0004 1936 8972Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
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11
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Queensland Pediatric Sepsis Breakthrough Collaborative: Multicenter Observational Study to Evaluate the Implementation of a Pediatric Sepsis Pathway Within the Emergency Department. Crit Care Explor 2021; 3:e0573. [PMID: 34765981 PMCID: PMC8577679 DOI: 10.1097/cce.0000000000000573] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. To evaluate the implementation of a pediatric sepsis pathway in the emergency department as part of a statewide quality improvement initiative in Queensland, Australia.
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12
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Harley A, Schlapbach LJ, Lister P, Massey D, Gilholm P, Johnston ANB. Knowledge translation following the implementation of a state-wide Paediatric Sepsis Pathway in the emergency department- a multi-centre survey study. BMC Health Serv Res 2021; 21:1161. [PMID: 34702256 PMCID: PMC8547904 DOI: 10.1186/s12913-021-07128-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
Background Several health care systems internationally have implemented protocolised sepsis recognition and treatment bundles for children to improve outcomes, as recommended by the Surviving Sepsis Campaign. Successful implementation of clinical pathways is challenging and dependent on nurse engagement. There is limited data on knowledge translation during implementation of sepsis quality improvement programs. Methods This cross-sectional, multicentre observational survey study evaluated knowledge and perceptions of Emergency Department nurses in relation to the recognition, escalation and management of paediatric sepsis following implementation of a sepsis pathway. The study was conducted between September 2019 and March 2020 across 14 Emergency Departments in Queensland, Australia. The primary outcome was a sepsis knowledge score. An exploratory factor analysis was conducted to identify factors impacting nurses’ perceptions of recognition, escalation and management of paediatric sepsis and their association with knowledge. Using a logistic mixed effects model we explored associations between knowledge, identified factors and other clinical, demographic and hospital site variables. Results In total, 676 nurses responded to the survey and 534 were included in the analysis. The median knowledge score was 57.1% (IQR = 46.7–66.7), with considerable variation observed between sites. The exploratory factor analysis identified five factors contributing to paediatric sepsis recognition, escalation and management, categorised as 1) knowledge and beliefs, 2) social influences, 3) beliefs about capability and skills delivering treatment, 4) beliefs about capability and behaviour and 5) environmental context. Nurses reported strong agreement with statements measuring four of the five factors, responding lowest to the factor pertaining to capability and skills delivering treatment for paediatric sepsis. The factors knowledge and beliefs, capability and skills, and environmental context were positively associated with a higher knowledge score. Years of paediatric experience and dedicated nurse funding for the sepsis quality improvement initiative were also associated with a higher knowledge score. Conclusion Translation of evidence to practice such as successful implementation of a sepsis care bundle, relies on effective education of staff and sustained uptake of protocols in daily practice. Our survey findings identify key elements associated with enhanced knowledge including dedicated funding for hospitals to target paediatric sepsis quality improvement projects. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07128-2.
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Affiliation(s)
- Amanda Harley
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia. .,Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, QLD, Brisbane, Australia. .,Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, QLD, Brisbane, Australia.,Pediatric and Neonatal Intensive Care Unit, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Paula Lister
- Paediatric Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.,School of Medicine, Griffith University, Brisbane, QLD, Australia
| | - Debbie Massey
- School of Nursing and Midwifery, Southern Cross University, Gold Coast, QLD, Australia
| | - Patricia Gilholm
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, QLD, Brisbane, Australia
| | - Amy N B Johnston
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia.,Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia
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13
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Schlapbach LJ, Reinhart K, Kissoon N. A pediatric perspective on World Sepsis Day in 2021: leveraging lessons from the pandemic to reduce the global pediatric sepsis burden? Am J Physiol Lung Cell Mol Physiol 2021; 321:L608-L613. [PMID: 34405733 PMCID: PMC8461799 DOI: 10.1152/ajplung.00331.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland and Queensland Children's Hospital, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Konrad Reinhart
- Intensive Care Unit, Charité Universitätsmedizin, Berlin, Germany
| | - Niranjan Kissoon
- Intensive Care Unit, Charité Universitätsmedizin, Berlin, Germany
- The Centre for International Child Health, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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14
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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15
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Paul R, Niedner M, Brilli R, Macias C, Riggs R, Balamuth F, Depinet H, Larsen G, Huskins C, Scott H, Lucasiewicz G, Schaffer M, DeSouza HG, Silver P, Richardson T, Hueschen L, Campbell D, Wathen B, Auletta JJ. Metric Development for the Multicenter Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics 2021; 147:peds.2020-017889. [PMID: 33795482 PMCID: PMC8131032 DOI: 10.1542/peds.2020-017889] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A 56 US hospital collaborative, Improving Pediatric Sepsis Outcomes, has developed variables, metrics and a data analysis plan to track quality improvement (QI)-based patient outcomes over time. Improving Pediatric Sepsis Outcomes expands on previous pediatric sepsis QI efforts by improving electronic data capture and uniformity across sites. METHODS An expert panel developed metrics and corresponding variables to assess improvements across the care delivery spectrum, including the emergency department, acute care units, hematology and oncology, and the ICU. Outcome, process, and balancing measures were represented. Variables and statistical process control charts were mapped to each metric, elucidating progress over time and informing plan-do-study-act cycles. Electronic health record (EHR) abstraction feasibility was prioritized. Time 0 was defined as time of earliest sepsis recognition (determined electronically), or as a clinically derived time 0 (manually abstracted), identifying earliest physiologic onset of sepsis. RESULTS Twenty-four evidence-based metrics reflected timely and appropriate interventions for a uniformly defined sepsis cohort. Metrics mapped to statistical process control charts with 44 final variables; 40 could be abstracted automatically from multiple EHRs. Variables, including high-risk conditions and bedside huddle time, were challenging to abstract (reported in <80% of encounters). Size or type of hospital, method of data abstraction, and previous QI collaboration participation did not influence hospitals' abilities to contribute data. To date, 90% of data have been submitted, representing 200 007 sepsis episodes. CONCLUSIONS A comprehensive data dictionary was developed for the largest pediatric sepsis QI collaborative, optimizing automation and ensuring sustainable reporting. These approaches can be used in other large-scale sepsis QI projects in which researchers seek to leverage EHR data abstraction.
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Affiliation(s)
- Raina Paul
- Division of Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois;
| | - Matthew Niedner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Richard Brilli
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Charles Macias
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Ruth Riggs
- Children’s Hospital Association, Lenexa, Kansas
| | - Frances Balamuth
- Department of Pediatrics, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Gitte Larsen
- Pediatric Critical Care, Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Charlie Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Halden Scott
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | | | - Melissa Schaffer
- Department of Pediatrics, Upstate Medical University, Syracuse, New York
| | | | - Pete Silver
- Department of Pediatrics, Zucker School of Medicine at Hofstra, Cohen Children’s Medical Center, East Garden City, New York
| | | | - Leslie Hueschen
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Missouri-Kansas City and Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Beth Wathen
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffery J. Auletta
- Divisions of Hematology, Oncology, and Blood and Marrow Transplant and Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
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16
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Ehwerhemuepha L, Heyming T, Marano R, Piroutek MJ, Arrieta AC, Lee K, Hayes J, Cappon J, Hoenk K, Feaster W. Development and validation of an early warning tool for sepsis and decompensation in children during emergency department triage. Sci Rep 2021; 11:8578. [PMID: 33883572 PMCID: PMC8060307 DOI: 10.1038/s41598-021-87595-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/30/2021] [Indexed: 11/09/2022] Open
Abstract
This study was designed to develop and validate an early warning system for sepsis based on a predictive model of critical decompensation. Data from the electronic medical records for 537,837 visits to a pediatric Emergency Department (ED) from March 2013 to December 2019 were collected. A multiclass stochastic gradient boosting model was built to identify early warning signs associated with death, severe sepsis, non-severe sepsis, and bacteremia. Model features included triage vital signs, previous diagnoses, medications, and healthcare utilizations within 6 months of the index ED visit. There were 483 patients who had severe sepsis and/or died, 1102 had non-severe sepsis, 1103 had positive bacteremia tests, and the remaining had none of the events. The most important predictors were age, heart rate, length of stay of previous hospitalizations, temperature, systolic blood pressure, and prior sepsis. The one-versus-all area under the receiver operator characteristic curve (AUROC) were 0.979 (0.967, 0.991), 0.990 (0.985, 0.995), 0.976 (0.972, 0.981), and 0.968 (0.962, 0.974) for death, severe sepsis, non-severe sepsis, and bacteremia without sepsis respectively. The multi-class macro average AUROC and area under the precision recall curve were 0.977 and 0.316 respectively. The study findings were used to develop an automated early warning decision tool for sepsis. Implementation of this model in pediatric EDs will allow sepsis-related critical decompensation to be predicted accurately after a few seconds of triage.
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Affiliation(s)
- Louis Ehwerhemuepha
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA.
| | - Theodore Heyming
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Rachel Marano
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Mary Jane Piroutek
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Antonio C Arrieta
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Kent Lee
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Jennifer Hayes
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - James Cappon
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Kamila Hoenk
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - William Feaster
- Children's Health of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
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17
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 170] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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18
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Eisenberg M, Freiman E, Capraro A, Madden K, Monuteaux MC, Hudgins J, Harper M. Comparison of Manual and Automated Sepsis Screening Tools in a Pediatric Emergency Department. Pediatrics 2021; 147:peds.2020-022590. [PMID: 33472987 DOI: 10.1542/peds.2020-022590] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To compare the performance and test characteristics of an automated sepsis screening tool with that of a manual sepsis screen in patients presenting to a pediatric emergency department (ED). METHODS We conducted a retrospective cohort study of encounters in a pediatric ED over a 2-year period. The automated sepsis screening algorithm replaced the manual sepsis screen 1 year into the study. A positive case was defined as development of severe sepsis or septic shock within 24 hours of disposition from the ED. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios with 95% confidence intervals (CIs) for each. RESULTS There were 122 221 ED encounters during the study period and 273 cases of severe sepsis. During year 1 of the study, the manual screen was performed in 8910 of 61 026 (14.6%) encounters, resulting in the following test characteristics: sensitivity of 64.6% (95% CI 54.2%-74.1%), specificity of 91.1% (95% CI 90.5%-91.7%), PPV of 7.3% (95% CI 6.3%-8.5%), and NPV of 99.6% (95% CI 99.5%-99.7%). During year 2 of the study, the automated screen was performed in 100% of 61 195 encounters, resulting in the following test characteristics: sensitivity of 84.6% (95% CI 77.4%-90.2%), specificity of 95.1% (95% CI 94.9%-95.2%), PPV of 3.7% (95% CI 3.4%-4%), and NPV of 99.9% (95% CI 99.9%-100%). CONCLUSIONS An automated sepsis screening algorithm had higher sensitivity and specificity than a widely used manual sepsis screen and was performed on 100% of patients in the ED, ensuring continuous sepsis surveillance throughout the ED stay.
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Affiliation(s)
- Matthew Eisenberg
- Division of Emergency Medicine, Department of Medicine and .,Departments of Pediatrics and
| | - Eli Freiman
- Division of Emergency Medicine, Department of Medicine and.,Departments of Pediatrics and
| | - Andrew Capraro
- Division of Emergency Medicine, Department of Medicine and.,Departments of Pediatrics and
| | - Kate Madden
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; and.,Anesthesiology, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Medicine and.,Departments of Pediatrics and
| | - Joel Hudgins
- Division of Emergency Medicine, Department of Medicine and.,Departments of Pediatrics and
| | - Marvin Harper
- Division of Emergency Medicine, Department of Medicine and.,Departments of Pediatrics and
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19
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Larsen GY, Brilli R, Macias CG, Niedner M, Auletta JJ, Balamuth F, Campbell D, Depinet H, Frizzola M, Hueschen L, Lowerre T, Mack E, Paul R, Razzaqi F, Schafer M, Scott HF, Silver P, Wathen B, Lukasiewicz G, Stuart J, Riggs R, Richardson T, Ward L, Huskins WC. Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes. Pediatrics 2021; 147:e20201434. [PMID: 33328337 PMCID: PMC7874527 DOI: 10.1542/peds.2020-1434] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/29/2022] Open
Abstract
Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.
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Affiliation(s)
- Gitte Y Larsen
- Pediatric Critical Care, Primary Children's Hospital and Department of Pediatrics, University of Utah, Salt Lake City, Utah;
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Matthew Niedner
- Pediatric Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Jeffery J Auletta
- Hematology, Oncology, and Blood and Marrow Transplant, and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Fran Balamuth
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deborah Campbell
- Infection Prevention and Quality, Kentucky Hospital Association, Louisville, Kentucky
| | - Holly Depinet
- Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meg Frizzola
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Leslie Hueschen
- Pediatric Emergency Medicine, Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Tracy Lowerre
- Acute Care Pediatric Unit, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth Mack
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Raina Paul
- Pediatric Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois
| | - Faisal Razzaqi
- Pediatric Hematology and Oncology, Valley Children's Hospital, Madera, California
| | - Melissa Schafer
- Department of Pediatrics, State University of New York Upstate Medical University and Upstate Golisano Children's Hospital, Syracuse, New York
| | - Halden F Scott
- Pediatric Emergency Medicine, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Pete Silver
- Cohen Children's Medical Center of New York and Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Queens, New York
| | - Beth Wathen
- Pediatric ICU, Children's Hospital Colorado, Aurora, Colorado
| | - Gloria Lukasiewicz
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Jayne Stuart
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Troy Richardson
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Lowrie Ward
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - W Charles Huskins
- Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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20
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Medeiros DNM, Mafra ACCN, Carcillo JA, Troster EJ. A Pediatric Sepsis Protocol Reduced Mortality and Dysfunctions in a Brazilian Public Hospital. Front Pediatr 2021; 9:757721. [PMID: 34869114 PMCID: PMC8633899 DOI: 10.3389/fped.2021.757721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Few studies in the literature discuss the benefits of compliance with sepsis bundles in hospitals in low- and middle-income countries, where resources are limited and mortality is high. Methods: This is a retrospective cohort study conducted at a public hospital in a low-income region in Brazil. We evaluated whether completion of a sepsis bundle is associated with reduced in-hospital mortality for sepsis, severe sepsis, and septic shock, as well as prevention of septic shock and organ dysfunction. Bundle compliance required the completion of three items: (1) obtaining blood count and culture, arterial or venous blood gases, and arterial or venous lactate levels; (2) antibiotic infusion within the first hour of diagnosis; and (3) infusion of 10-20 ml/kg saline solution within the first hour of diagnosis. Results: A total of 548 children with sepsis, severe sepsis, or septic shock who were treated at the emergency room from February 2008 to August of 2016 were included in the study. Of those, 371 patients were included in the protocol group and had a lower median length of stay (3 days vs. 11 days; p < 0.001), fewer organ dysfunctions during hospitalization (0 vs. 2, p < 0.001), and a lower probability of developing septic shock. According to a propensity score analysis, mortality was lower during the post-implementation period [2.75 vs. 15.4% (RR 95%IC 0.13 (0.06, 0.27); p < 0.001)]. Conclusions: A simple and low-cost protocol was feasible and yielded good results at a general hospital in a low-income region in Brazil. Protocol use resulted in decreased mortality and progression of dysfunctions and was associated with a reduced probability of developing septic shock.
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Affiliation(s)
| | | | | | - Eduardo Juan Troster
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
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21
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Cruz AT, Lane RD, Balamuth F, Aronson PL, Ashby DW, Neuman MI, Souganidis ES, Alpern ER, Schlapbach LJ. Updates on pediatric sepsis. J Am Coll Emerg Physicians Open 2020; 1:981-993. [PMID: 33145549 PMCID: PMC7593454 DOI: 10.1002/emp2.12173] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.
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Affiliation(s)
- Andrea T. Cruz
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Roni D. Lane
- Division of Pediatric Emergency Medicinethe University of Utah Primary Children's HospitalSalt Lake CityUtahUSA
| | - Fran Balamuth
- Division of Emergency MedicineDepartment of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Paul L. Aronson
- Section of Pediatric Emergency MedicineDepartments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - David W. Ashby
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Mark I. Neuman
- Division of Emergency MedicineDepartment of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Ellie S. Souganidis
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Elizabeth R. Alpern
- Division of Emergency MedicineDepartment of PediatricsAnn & Robert H. Lurie Children's HospitalFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Luregn J. Schlapbach
- Department of Intensive Care Medicine and Neonatologyand Children's Research CenterUniversity Children's Hospital of ZurichUniversity of ZurichZurichSwitzerland
- Paediatric Critical Care Research GroupThe University of Queensland and Queensland Children's HospitalBrisbaneQueenslandAustralia
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22
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Abstract
PURPOSE OF REVIEW Sepsis remains among the leading causes of childhood mortality worldwide. This review serves to highlight key areas of knowledge gain and ongoing controversies pertinent to sepsis in children. RECENT FINDINGS Several recent publications describe the epidemiology of paediatric sepsis, demonstrating the impact on child health in terms of mortality and morbidity, and the shortcomings of current paediatric sepsis definitions. Although emerging data support the importance of organ dysfunction as a hallmark of paediatric sepsis, the understanding of host susceptibility to sepsis and to sepsis severity remains very limited. Next-generation sequencing and host transcriptomics have the potential to provide new insights into the pathogenesis of sepsis and may enable personalized medicine approaches. Despite good observational data indicating benefit of sepsis recognition and treatment bundles, the evidence for the individual bundle components remains scarce, implying an urgent need for large trials. SUMMARY Recent studies have demonstrated distinct epidemiological patterns pertinent to age groups, healthcare settings, and comorbidities in the era post meningococcal epidemics. Although sepsis quality improvement initiatives have led to substantial outcome improvements, there is urgency for innovative trials to reduce uncertainty around the optimal approach for the recognition and treatment of sepsis in children.
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23
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Scott HF, Balamuth F, Alpern ER. The Legacy of Pediatric Sepsis State Legislation. Pediatrics 2020; 146:peds.2020-1525. [PMID: 32605993 PMCID: PMC7417071 DOI: 10.1542/peds.2020-1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Halden F. Scott
- Department of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado,Department of Children’s Hospital Colorado, Aurora, Colorado
| | - Fran Balamuth
- Department of Division of Pediatric Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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24
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Kollef MH, Burnham JP. Antibiotic Thresholds for Sepsis and Septic Shock. Clin Infect Dis 2020; 69:938-940. [PMID: 30535353 DOI: 10.1093/cid/ciy1035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/03/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
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25
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Impact of a Multidisciplinary Sepsis Initiative on Knowledge and Behavior in a Pediatric Center. Pediatr Qual Saf 2020; 5:e267. [PMID: 32426633 PMCID: PMC7190264 DOI: 10.1097/pq9.0000000000000267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/04/2020] [Indexed: 01/20/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objective: Our institution performed an educational initiative targeting previously identified barriers to pediatric sepsis recognition and treatment. We hypothesized that provider knowledge, attitude, and behavior would be improved 1 year after implementation. Methods: This was a prospective, observational study of a multi-faceted quality initiative introduced to providers in the Emergency Department, inpatient wards, and Pediatric Intensive Care Unit of a tertiary care children’s hospital. Educational platforms consisted of quarterly electronic sepsis “newsletters,” brightly colored posters highlighting protocol and screening strategies displayed throughout the hospital, and low-fidelity simulation sessions (drills) led by trained staff and incorporated into daily workflows. The content was driven by feedback from a baseline needs assessment of sepsis education. One year after implementation, the needs assessment was repeated. Results: Over 3 months, facilitators conducted 197 drills and captured a majority of nurses (89%), pediatrics residents (96%), and respiratory therapists (62%). By 6 months, 241 sessions had been completed. Approximately 55.4% of the 442 eligible staff participated in our post-intervention survey. Overall, knowledge of diagnostic criteria for pediatric sepsis and septic shock increased from pre-intervention levels (P = 0.015). Among post-implementation respondents, drill participants outperformed their colleagues (P = 0.001). A greater percentage of post-intervention respondents indicated comfort with sepsis recognition (P < 0.001), and fewer reported hesitating to bring sepsis concerns to their care team (P < 0.01). Conclusions: Our findings suggest that a multidisciplinary curriculum balancing active education—through brief, targeted simulation—and general awareness—through electronic resources and a poster campaign—can improve sepsis-related knowledge, attitude, and behavior among pediatric practitioners.
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26
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Hanson HR, Carlisle MA, Bensman RS, Byczkowski T, Depinet H, Terrell TC, Pitner H, Knox R, Goldstein SL, Basu RK. Early prediction of pediatric acute kidney injury from the emergency department: A pilot study. Am J Emerg Med 2020; 40:138-144. [PMID: 32024590 DOI: 10.1016/j.ajem.2020.01.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/15/2020] [Accepted: 01/26/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Identifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children. OBJECTIVE To derive and test performance of an "acute" RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers. METHODS Study of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24-72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed. RESULTS 118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86-0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69-99) and a negative predictive value of 99% (92-100) (versus sensitivity 59% (33-82) and NPV 93% (89-96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker. CONCLUSIONS This pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.
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Affiliation(s)
- Holly R Hanson
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America.
| | - Michael A Carlisle
- Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America.
| | - Rachel S Bensman
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America; Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America.
| | - Terri Byczkowski
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America.
| | - Holly Depinet
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America; Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America.
| | - Tara C Terrell
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
| | - Hilary Pitner
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
| | - Ryan Knox
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America.
| | - Stuart L Goldstein
- Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America; Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America.
| | - Rajit K Basu
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America.
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27
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Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach. Pediatr Qual Saf 2020; 5:e244. [PMID: 32766482 PMCID: PMC7056288 DOI: 10.1097/pq9.0000000000000244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022] Open
Abstract
Supplemental Digital Content is available in the text. Severe sepsis requires timely, resource-intensive resuscitation, a challenge when a sepsis diagnosis is not confirmed. The overall goals were to create a pediatric sepsis program that provided high-quality critical care in severe sepsis (Sepsis Stat), and, in possible sepsis, flexible evaluation and treatment that promoted stewardship (Sepsis Yellow). The primary aims were to decrease time to antibiotics and the intensive care unit requirement.
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28
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Barboza CL, Valete CO, da Silva AR. Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock. Indian J Crit Care Med 2020; 24:128-132. [PMID: 32205945 PMCID: PMC7075055 DOI: 10.5005/jp-journals-10071-23336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective The aim of this study was to measure the effects of a bundle of interventions in children admitted with severe sepsis or septic shock in the first hour after diagnosis on mortality. Materials and methods A retrospective study was conducted at a pediatric intensive care unit (PICU) between January 2014 and January 2016. Three interventions (intravenous [IV] antibiotic, fluid boluses, and vasopressor administration) applied in the first hour of severe sepsis or septic shock diagnosis were analyzed according to their adherence rates. The main outcome was mortality. Odds ratios were calculated. Results Of a total of 530 PICU admissions, 105 patients met the criteria for sepsis, 53 (50.5%) with severe sepsis and 52 (49.5%) with septic shock. Seventy-two (68.6%) patients received IV antibiotic within the first hour, 65 (61.9%) received IV fluid bolus, and 55 (53.3%) received a vasopressor drug. Fifty-two (49.5%) patients received concomitant IV antibiotics and fluid bolus. Blood cultures were collected before IV antibiotic administration in 87 (82.9%) out of 105 patients. Thirteen (12.4%) patients died, 1 with severe sepsis and 12 with septic shock. In a univariate analysis, the odds ratios for death and IV antibiotic were 6.39 (p value = 0.081, 95% CI = 0.795-51.465), 4.77 for fluid bolus between 21 and 40 mL/kg (p value = 0.013, 95% CI = 1.395-16.336), and 3.23 for vasopressor administration (p value < 0.0001, 95% CI = 1.734-6.018). In a multivariate analysis, the odds ratio of fluid bolus between 21 and 40 mL/kg was 42.66 (p value = 0.005, 95% CI = 3.117-583.841) and noradrenaline use was 23.93 (p value = 0.010, 95% CI = 2.124-269.750). Conclusion Adherence was observed for more than half of the single interventions as IV antibiotic, fluid resuscitation, and vasopressor administration in the first hour. The antibiotic administration alone was not associated with high mortality. Vasopressor administration was related to higher mortality but moderate fluid bolus was a protective factor associated with lower mortality. How to cite this article Barboza CL, Valete COS, da Silva ARA. Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock. Indian J Crit Care Med 2020;24(2):128-132.
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29
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Decreasing Time to Antibiotics for Patients with Sepsis in the Emergency Department. Pediatr Qual Saf 2019; 4:e173. [PMID: 31579872 PMCID: PMC6594778 DOI: 10.1097/pq9.0000000000000173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/02/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Sepsis is a significant cause of morbidity and mortality. Patients may present in a spectrum, from nonsevere sepsis through septic shock. Literature supports improvement in patient outcomes with timely care. This project describes an effort to improve delays in antibiotic administration in patients with sepsis spectrum disease presenting to a pediatric emergency department (PED). Objective: This project aimed to decrease time to antibiotics for patients with sepsis in the PED from 154 to <120 minutes within 2 years. Methods: Following the collection of baseline data, we assembled a multidisciplinary team. Specific interventions included staff education, the institution of a best practice alert with order set and standardized huddle response, and local stocking of antibiotics. We included all patients with orders for intravenous antibiotics and blood culture. Results: From April 2015 to April 2017, the PED demonstrated reduction in time to antibiotics from 154 to 114 minutes. The time from emergency department (ED) arrival to antibiotic order also improved, from 87 to 59 minutes. Conclusions: This initiative improved prioritization and efficiency of care of sepsis, and overall time to antibiotics in this population. The results of this project demonstrate the effectiveness of a multidisciplinary team working to improve an essential time-driven process.
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30
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Affiliation(s)
| | - Fran Balamuth
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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31
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Paul R. Recognition, Diagnostics, and Management of Pediatric Severe Sepsis and Septic Shock in the Emergency Department. Pediatr Clin North Am 2018; 65:1107-1118. [PMID: 30446051 DOI: 10.1016/j.pcl.2018.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Several new studies have emerged in recent years that have attempted to aid emergency department providers in recognizing and treating pediatric patients with severe sepsis and septic shock. National guidelines and supporting literature are unanimous in recommendations that early recognition and timely therapeutics are necessary for improved survival and decreased morbidity. The literature is less concrete in defining how emerging advances in the field can aid in time-sensitive care of these patients. This article summarizes the recent literature as it pertains to the initial presentation of severe sepsis and septic shock in the pediatric patient within the emergency department.
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Affiliation(s)
- Raina Paul
- Pediatric Emergency Department, Division of Emergency Medicine, Advocate Children's Hospital, 1700 Luther Lane, Park Ridge, IL 60068, USA.
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