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

Presentation

• 1/3-1/2ofpatientspresentviaEMS

• 2/3ofpatientspresenttoanED

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

PALS

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

Bundleadherence

Casesbetweendeaths

SaltLakeCity

• 1380Patientswithsepticshock(2007-2014)inED– QIinitiative• Bundle–Timelyantibiotics,– Intravenousfluids(IVF)forrapidreversalofperfusionabnormalitiesand/orhypotension

• Triagescreening

LaneRDetal.HighReliabilityPediatricSepticShockQualityImprovementInitiativeandDecreasingMortalityPediatrics.2016

Bundlecompliance

Daysbetweendeaths

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

CNMCDataPre-Implementation5/2015-5/2016Post-Implementation7/2016- Present

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

SepsisTriggerAlgorithm

SepsisTriggerToolCriteria

PotentialSepsisAlert

SepsisAlertTriggerFrequency

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

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IndividualFeedback

RNSepsisEducation

EHRAlert&Powerplan

FeedbackForm

ImprovementTimeline

Next Steps

Sepsis trigger characteristics to display on alert notification

Backtoourpatient

• Feverwouldhavemandateduseoftool– (T102F)

• Examnotedmottlingofskin(1point)• VSHR143,RR22 (2points)

• Wouldhavetriggeredcloserevaluation

The Future?

• EDSepsisTeam– Decisionmaking:Launchingthepathway?

• PrehospitalAlert/treatment– Marylandprotocol(2016)

• Otherareasofthehospital(PICU,Heme Onc)– CHAcollaborative