Improving Recognition of Pediatric Severe Sepsis in the Emergency Department

Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department | Annals of Emergency Medicine

Methods: This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.

Conclusion: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert–negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

Full reference: Balamuth, F. et al. (2017) Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign–Based Electronic Alert and Bedside Clinician Identification. Annals of Emergency Medicine. Published online: 2 June 2017

Sepsis care in UK Emergency Departments is improving

Sepsis care is improving but treatment needs to be faster, according to a new audit by the Royal College of Emergency Medicine.

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Image source: http://www.rcem.ac.uk

The report published this month audited 13,129 adults presenting to 196 Emergency Departments (EDs), and was endorsed by the Sepsis Trust.  It shows an improvement in the proportion of patients receiving the best care for severe sepsis and septic shock, but that improvements are needed to make treatment available faster.

The audit is designed to drive clinical practice forward by helping clinicians examine the work they do day-to-day and benchmark against their peers, and to recognise excellence.  There is much good practice occurring and RCEM believes that this audit is an important component in sharing this and ensuring patient safety.

The report finds that there has been a steady improvement in the ‘Sepsis-Six’, an initial resuscitation bundle designed to offer basic interventions within the first hour of arriving at an ED. However, despite seeing improvements in care, the report finds that RCEM standards are not yet being met by all EDs.

Full report:  Severe Sepsis and Septic Shock. Clinical Audit 2016/17

Validity of the Manchester Triage System in patients with sepsis presenting at the ED

Gräff, I. et al. Emergency Medicine Journal. Published Online: 19 December 2016

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Background: The Manchester Triage System (MTS) does not have a specific presentational flow chart for sepsis. The goal of this investigation was to determine adequacy of acuity assignment for patients with sepsis presenting at the ED and triaged using the MTS.

 

Conclusions: The MTS has some weaknesses regarding priority levels in emergency patients with septic illness. Overall, target key symptoms (discriminators) which aim at identifying systemic infection and ascertaining vital parameters are insufficiently considered.

Read the full abstract here

Clinical Practice: Using a Best Evidence Sepsis Scoring Tool to Identify and Manage Pediatric Patients With Severe Sepsis in the Emergency Department

Calhoun, C. et al. (2016) Journal of Pediatric Nursing. 31(5) pp. 560-561

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Severe sepsis and septic shock are leading causes of pediatric morbidity and mortality, resulting in prolonged hospitalization and increased healthcare costs. 1,2 Delays in recognition of sepsis, vascular access, and administration of fluids and antibiotics are major barriers within pediatric emergency departments (ED). 3,4 Severe sepsis is defined as symptoms suspicious of infection plus signs of organ dysfunction or tissue hypoperfusion. 5 A sepsis trigger tool at triage can identify vital sign abnormalities of severe sepsis, alert ED resources, and rapidly begin the sepsis protocol. 3 Annually, almost 100,000 pediatric patients present to the ED with signs of severe sepsis. 6.

Using the concept of “PIRO” (predisposition, infection, response, and organ dysfunction), the sepsis tool was adapted to identify pediatric patients at risk for sepsis with signs of infection, age-related abnormal vital signs, and signs of organ dysfunction.

With 5 or greater score (maximum score of 16), a “sepsis alert” was paged. A multidisciplinary team was mobilized: ED nurse, ED paramedic, physician, respiratory therapist, and child life specialist. Using a nurse-initiated pathway, patient was placed on cardiac apnea monitor, pulse oximeter, and oxygen, vital sign monitoring was begun, intravenous (IV) line insertion with lab work was obtained, and weight-based IV fluid bolus was initiated with antibiotics anticipated. Sepsis scores were repeated after interventions or with status changes. An ED sepsis committee was formed to audit charts and educate staff on the sepsis tool.

From January 2014 through April 2015, median times for triage-to-IV fluid bolus improved from 65 to 51 min and triage-to-antibiotic times improved from 137 to 80 min.

With early recognition and treatment of sepsis, ED experienced improved patient mortality rates, shorter hospital stays, and decreased hospital costs. The successes of multidisciplinary interventions, effective communication, increased awareness, and staff compliance have led to decreases in triage-to-bolus and triage-to-antibiotic times. The tool was accurate in identifying severe sepsis; the admission rate for positive sepsis alerts was 60%.

Read the abstract here

A prospective quality improvement study in the emergency department targeting paediatric sepsis

Long, E. et al. Archives of Disease in Childhood. Published Online: 31st March 2016

Objective: Quality improvement sepsis initiatives in the paediatric emergency department have been associated with improved processes, but an unclear effect on patient outcome. We aimed to evaluate and improve emergency department sepsis processes and track subsequent changes in patient outcome.

Study design: A prospective observational cohort study in the emergency department of The Royal Children’s Hospital, Melbourne. Participants were children aged 0–18 years of age meeting predefined criteria for the diagnosis of sepsis. The following shortcomings in management were identified and targeted in a sepsis intervention: administration of antibiotics and blood sampling for a venous gas at the time of intravenous cannulation, and rapid administration of all fluid resuscitation therapy. The primary outcome measure was hospital length of stay.

Results: 102 patients were enrolled pre-intervention, 113 post-intervention. Median time from intravenous cannula insertion to antibiotic administration decreased from 55 min (IQR 27–90 min) pre-intervention to 19 min (IQR 10–32 min) post-intervention (p≤0.01). Venous blood gas at time of first intravenous cannula insertion was performed in 60% of patients pre-intervention vs 79% post-intervention (p≤0.01). Fluids were administered using manual push-pull or pressure-bag methods in 31% of patients pre-intervention and 84% of patients post-intervention (p≤0.01). Median hospital length of stay decreased from 96 h (IQR 64–198 h) pre-intervention to 80 h (IQR 53–167 h) post-intervention (p=0.02). This effect persisted when corrected for unequally distributed confounders between pre-intervention and post-intervention groups (uncorrected HR: 1.36, 95% CI 1.04 to 1.80, p=0.02; corrected HR: 1.34, 95% CI 1.01 to 1.80, p=0.04).

Conclusions: Use of quality improvement methodologies to improve the management of paediatric sepsis in the emergency department was associated with a reduction in hospital length of stay.

Read the full article here