1
|
Corboy J, Denicolo K, Jones RC, Simon NJE, Adler M, Trainor J, Steinmann R, Jain P, Stephen R, Alpern E. Impact of a Coordinated Sepsis Response on Time to Treatment in a Pediatric Emergency Department. Hosp Pediatr 2024; 14:272-280. [PMID: 38449428 DOI: 10.1542/hpeds.2023-007203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Sepsis is responsible for 75 000 pediatric hospitalizations annually, with an associated mortality rate estimated between 11% and 19%. Evidence supports the use of timely fluid resuscitation and antibiotics to decrease morbidity and mortality. Our emergency department did not meet the timeliness goals for fluid and antibiotic administration suggested by the 2012 Surviving Sepsis Campaign. METHODS In November 2018, we implemented a sepsis response team utilizing a scripted communication tool and a dedicated sepsis supply cart to address timeliness barriers. Performance was evaluated using statistical process control charts. We conducted observations to evaluate adherence to the new process. Our aim was to meet the Surviving Sepsis Campaign's timeliness goals for first fluid and antibiotic administration (20 and 60 minutes, respectively) within 8 months of our intervention. RESULTS We observed sustained decreases in mean time to fluids. We also observed a shift in the proportion of patients receiving fluids within 20 minutes. No shifts were observed for timely antibiotic administration. CONCLUSIONS The implementation of a dedicated emergency department sepsis response team with designated roles and responsibilities, directed communication, and easily accessible supplies can lead to improvements in the timeliness of fluid administration in the pediatric population.
Collapse
Affiliation(s)
- Jaqueline Corboy
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics (Emergency Medicine), Feinberg School of Medicine, Northwestern School of Medicine, Chicago, Illinois
| | - Kimberly Denicolo
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Roderick C Jones
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Mark Adler
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics (Emergency Medicine), Feinberg School of Medicine, Northwestern School of Medicine, Chicago, Illinois
| | - Jennifer Trainor
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics (Emergency Medicine), Feinberg School of Medicine, Northwestern School of Medicine, Chicago, Illinois
| | - Rebecca Steinmann
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Priya Jain
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics (Emergency Medicine), Feinberg School of Medicine, Northwestern School of Medicine, Chicago, Illinois
| | - Rebecca Stephen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics (Emergency Medicine), Feinberg School of Medicine, Northwestern School of Medicine, Chicago, Illinois
| | - Elizabeth Alpern
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics (Emergency Medicine), Feinberg School of Medicine, Northwestern School of Medicine, Chicago, Illinois
| |
Collapse
|
2
|
Baker AH, Mazandi VM, Norton JS, Melendez E. Emergency Department Sepsis Triage Scoring Tool Elements Associated With Hypotension Within 24 Hours in Children With Fever and Tachycardia. Pediatr Emerg Care 2024:00006565-990000000-00416. [PMID: 38471759 DOI: 10.1097/pec.0000000000003153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE Pediatric sepsis screening is becoming the standard of care for children presenting to the emergency department (ED) and has been shown to improve recognition of severe sepsis, but it is unknown if these screening tools can predict progression of disease. The objective of this study was to determine if any elements of a sepsis triage trigger tool were predictive of progression to hypotensive shock in children presenting to the ED with fever and tachycardia. METHODS This study is a retrospective case-control study of children ≤18 years presenting to an ED with fever and tachycardia, comparing those who went on to develop hypotensive shock in the subsequent 24 hours (case) to those who did not (control). Primary outcome was the proportion of encounters where the patient had specific abnormal vital signs or clinical signs as components of the sepsis triage score. The secondary outcomes were the proportion of encounters where the patient had a sepsis risk factor. RESULTS During the study period, there were 94 patients who met case criteria and 186 controls selected. In the adjusted multivariable model, the 2 components of the sepsis triage score that were more common in case patients were the presence of severe cerebral palsy (adjusted odds ratio, 9.4 [3.7, 23.9]) and abnormal capillary refill at triage (adjusted odds ratio, 3.1 [1.4, 6.9]). CONCLUSIONS Among children who present to a pediatric ED with fever and tachycardia, those with prolonged capillary refill at triage or severe cerebral palsy were more likely to progress to decompensated septic shock, despite routine ED care.
Collapse
Affiliation(s)
| | | | - Jackson S Norton
- Division of Medical Critical Care, Boston Children's Hospital, Boston, MA
| | - Elliot Melendez
- Division of Pediatric Critical Care, Connecticut Children's Medical Center, Hartford, CT
| |
Collapse
|
3
|
Webb LV, Evans J, Smith V, Pettibone E, Tofil J, Hicks JF, Green S, Nassel A, Loberger JM. Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis. Crit Care Explor 2024; 6:e1056. [PMID: 38415020 PMCID: PMC10896474 DOI: 10.1097/cce.0000000000001056] [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] [Indexed: 02/29/2024] Open
Abstract
IMPORTANCE Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. OBJECTIVE This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). DESIGN SETTING AND PARTICIPANTS This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). RESULTS A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). CONCLUSIONS AND RELEVANCE Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.
Collapse
Affiliation(s)
- Lece V Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Jakob Evans
- Department of Pediatrics, Pediatrics Residency Program, University of Alabama at Birmingham, Birmingham, AL
| | - Veronica Smith
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Elisabeth Pettibone
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Jessica Floyd Hicks
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Sherry Green
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Ariann Nassel
- Lister Hill Center for Health Policy, School of Public Health, University of Alabama at Birmingham, AL
| | - Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
4
|
Shukla M, Carcone A, Mooney M, Kannikeswaran N, Ellis DA. Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework. J Asthma 2024; 61:184-193. [PMID: 37688796 PMCID: PMC10922072 DOI: 10.1080/02770903.2023.2257318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/16/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. METHODS The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. RESULTS Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. CONCLUSIONS Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.
Collapse
Affiliation(s)
| | - April Carcone
- Family Medicine, Wayne State University, Detroit, MI, USA
| | | | | | | |
Collapse
|
5
|
Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics 2024; 153:e2023062967. [PMID: 38084084 PMCID: PMC11058732 DOI: 10.1542/peds.2023-062967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 01/02/2024] Open
Abstract
Sepsis and septic shock are major causes of morbidity, mortality, and health care costs for children worldwide, including >3 million deaths annually and, among survivors, risk for new or worsening functional impairments, including reduced quality of life, new respiratory, nutritional, or technological assistance, and recurrent severe infections. Advances in understanding sepsis pathophysiology highlight a need to update the definition and diagnostic criteria for pediatric sepsis and septic shock, whereas new data support an increasing role for automated screening algorithms and biomarker combinations to assist earlier recognition. Once sepsis or septic shock is suspected, attention to prompt initiation of broad-spectrum empiric antimicrobial therapy, fluid resuscitation, and vasoactive medications remain key components to initial management with several new and ongoing studies offering new insights into how to optimize this approach. Ultimately, a key goal is for screening to encompass as many children as possible at risk for sepsis and trigger early treatment without increasing unnecessary broad-spectrum antibiotics and preventable hospitalizations. Although the role for adjunctive treatment with corticosteroids and other metabolic therapies remains incompletely defined, ongoing studies will soon offer updated guidance for optimal use. Finally, we are increasingly moving toward an era in which precision therapeutics will bring novel strategies to improve outcomes, especially for the subset of children with sepsis-induced multiple organ dysfunction syndrome and sepsis subphenotypes for whom antibiotics, fluid, vasoactive medications, and supportive care remain insufficient.
Collapse
Affiliation(s)
- Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, DE, USA
- Departments of Pediatrics & Pathology, Anatomy, and Cell Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
6
|
Liang H, Carey KA, Jani P, Gilbert ER, Afshar M, Sanchez-Pinto LN, Churpek MM, Mayampurath A. Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit. Front Pediatr 2023; 11:1284672. [PMID: 38188917 PMCID: PMC10768058 DOI: 10.3389/fped.2023.1284672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the association between critical events (CEs), i.e., MV or VI events, within the first 48 h of PICU transfer from the ward or emergency department (ED) and in-hospital mortality. Methods We conducted a retrospective study of a cohort of PICU transfers from the ward or the ED at two tertiary-care academic hospitals. We determined the association between mortality and occurrence of CEs within 48 h of PICU transfer after adjusting for age, gender, hospital, and prior comorbidities. Results Experiencing a CE within 48 h of PICU transfer was associated with an increased risk of mortality [OR 12.40 (95% CI: 8.12-19.23, P < 0.05)]. The increased risk of mortality was highest in the first 12 h [OR 11.32 (95% CI: 7.51-17.15, P < 0.05)] but persisted in the 12-48 h time interval [OR 2.84 (95% CI: 1.40-5.22, P < 0.05)]. Varying levels of risk were observed when considering ED or ward transfers only, when considering different age groups, and when considering individual 12-h time intervals. Discussion We demonstrate that occurrence of a CE within 48 h of PICU transfer was associated with mortality after adjusting for confounders. Studies focusing on the impact of quality improvement efforts may benefit from using CEs within 48 h of PICU transfer as an additional evaluation metric, provided these events could have been influenced by the initiative.
Collapse
Affiliation(s)
- Huan Liang
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
| | - Kyle A. Carey
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Priti Jani
- Department of Pediatrics, University of Chicago, Chicago, IL, United States
| | - Emily R. Gilbert
- Department of Medicine, Loyola University Medical Center, Maywood, IL, United States
| | - Majid Afshar
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - L. Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Matthew M. Churpek
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Anoop Mayampurath
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| |
Collapse
|
7
|
Mwanza ZV, White BS, Britton PN, McCaskill ME. Timing of antibiotics in febrile children meeting sepsis criteria at a paediatric emergency department. Emerg Med Australas 2023; 35:855-861. [PMID: 37501504 DOI: 10.1111/1742-6723.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 06/28/2023] [Accepted: 07/02/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Delay in antibiotic administration in paediatric sepsis is associated with increased mortality and prolonged organ dysfunction. This pre-intervention study evaluated performance in paediatric sepsis management. METHODS Retrospective cohort study of febrile children admitted through the ED at The Children's Hospital at Westmead, Sydney, between 1 May and 31 July 2017. Participants were children aged 29 days to 60 months excluding children with simple febrile seizures, neonates and children who had received intravenous antibiotics elsewhere. We assessed the timing of antibiotic administration in children meeting local sepsis guidelines. We conducted a survey of clinicians in ED in 2018 to describe contributing factors. RESULTS There were 160 febrile children admitted and 144 presentations were included in the analysis. Male 53% (n = 76); median age 20.1 months (interquartile range [IQR] 3.9-37 months). Thirty-seven (26%) febrile children met local sepsis criteria. The median time from triage to first dose of intravenous antibiotic was 109 min (IQR 62-183 min). Delay (>60 min) occurred in 26 (76%) children. Reported reasons contributing to delay included high patient load, long waiting times, difficult intravenous access, delayed prescribing, inadequate staffing and difficulty distinguishing between a viral infection and serious bacterial infection. CONCLUSION There was frequent delay in administering antibiotics in children meeting local sepsis criteria, more commonly in young infants. Reasons contributing to delay were specific to young children along with departmental factors that will require addressing through targeted quality improvement interventions.
Collapse
Affiliation(s)
- Zondiwe V Mwanza
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brent S White
- School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Philip N Britton
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mary E McCaskill
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Stephen RJ, Lucey K, Carroll MS, Hoge J, Maciorowski K, Jones RC, O'Connell M, Schwab C, Rojas J, Sanchez Pinto LN. Sepsis Prediction in Hospitalized Children: Clinical Decision Support Design and Deployment. Hosp Pediatr 2023; 13:751-759. [PMID: 37599646 DOI: 10.1542/hpeds.2023-007218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Following development and validation of a sepsis prediction model described in a companion article, we aimed to use quality improvement and safety methodology to guide the design and deployment of clinical decision support (CDS) tools and clinician workflows to improve pediatric sepsis recognition in the inpatient setting. METHODS CDS tools and sepsis huddle workflows were created to implement an electronic health record-based sepsis prediction model. These were proactively analyzed and refined using simulation and safety science principles before implementation and were introduced across inpatient units during 2020-2021. Huddle compliance, alerts per non-ICU patient days, and days between sepsis-attributable emergent transfers were monitored. Rapid Plan-Do-Study-Act (PDSA) cycles based on user feedback and weekly metric data informed improvement throughout implementation. RESULTS There were 264 sepsis alerts on 173 patients with an 89% bedside huddle completion rate and 10 alerts per 1000 non-ICU patient days per month. There was no special cause variation in the metric days between sepsis-attributable emergent transfers. CONCLUSIONS An automated electronic health record-based sepsis prediction model, CDS tools, and sepsis huddle workflows were implemented on inpatient units with a relatively low rate of interruptive alerts and high compliance with bedside huddles. Use of CDS best practices, simulation, safety tools, and quality improvement principles led to high utilization of the sepsis screening process.
Collapse
Affiliation(s)
- Rebecca J Stephen
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
| | - Kate Lucey
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
| | - Michael S Carroll
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Data Analytics and Reporting
| | | | | | | | | | | | | | - L Nelson Sanchez Pinto
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Division of Critical Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| |
Collapse
|
9
|
Stephen RJ, Carroll MS, Hoge J, Maciorowski K, Jones RC, Lucey K, O'Connell M, Schwab C, Rojas J, Sanchez-Pinto LN. Sepsis Prediction in Hospitalized Children: Model Development and Validation. Hosp Pediatr 2023; 13:760-767. [PMID: 37599645 DOI: 10.1542/hpeds.2022-006964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Early recognition and treatment of pediatric sepsis remain mainstay approaches to improve outcomes. Although most children with sepsis are diagnosed in the emergency department, some are admitted with unrecognized sepsis or develop sepsis while hospitalized. Our objective was to develop and validate a prediction model of pediatric sepsis to improve recognition in the inpatient setting. METHODS Patients with sepsis were identified using intention-to-treat criteria. Encounters from 2012 to 2018 were used as a derivation to train a prediction model using variables from an existing model. A 2-tier threshold was determined using a precision-recall curve: an "Alert" tier with high positive predictive value to prompt bedside evaluation and an "Aware" tier with high sensitivity to increase situational awareness. The model was prospectively validated in the electronic health record in silent mode during 2019. RESULTS A total of 55 980 encounters and 793 (1.4%) episodes of sepsis were used for derivation and prospective validation. The final model consisted of 13 variables with an area under the curve of 0.96 (95% confidence interval 0.95-0.97) in the validation set. The Aware tier had 100% sensitivity and the Alert tier had a positive predictive value of 14% (number needed to alert of 7) in the validation set. CONCLUSIONS We derived and prospectively validated a 2-tiered prediction model of inpatient pediatric sepsis designed to have a high sensitivity Aware threshold to enable situational awareness and a low number needed to Alert threshold to minimize false alerts. Our model was embedded in our electronic health record and implemented as clinical decision support, which is presented in a companion article.
Collapse
Affiliation(s)
- Rebecca J Stephen
- Department of Pediatrics, Northwestern Feinberg School of Medicine
- Divisions of Hospital-Based Medicine
- Center for Quality and Safety
| | - Michael S Carroll
- Department of Pediatrics, Northwestern Feinberg School of Medicine
- Data Analytics and Reporting
| | | | | | | | - Kate Lucey
- Department of Pediatrics, Northwestern Feinberg School of Medicine
- Divisions of Hospital-Based Medicine
- Center for Quality and Safety
| | - Megan O'Connell
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Carly Schwab
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jillian Rojas
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | |
Collapse
|
10
|
Kadish CB, Lloyd JK, Adelgais KM, Ward CE, Lo CB, Truelove A, Leonard JC. Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment. PREHOSP EMERG CARE 2023; 27:775-785. [PMID: 37141419 DOI: 10.1080/10903127.2023.2210217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/10/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND PURPOSE Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting. METHODS This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change. RESULTS Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information. CONCLUSION This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.
Collapse
Affiliation(s)
- Chelsea B Kadish
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Julia K Lloyd
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kathleen M Adelgais
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Caleb E Ward
- Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Charmaine B Lo
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Annie Truelove
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Kohlmaier B, Leitner M, Hagedoorn NN, Borensztajn DM, von Both U, Carrol ED, Emonts M, van der Flier M, de Groot R, Herberg J, Levin M, Lim E, Maconochie IK, Martinon-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Tan CD, Tsolia M, Vermont CL, Zachariasse JM, Zavadska D, Moll HA, Zenz W. European study confirms the combination of fever and petechial rash as an important warning sign for childhood sepsis and meningitis. Acta Paediatr 2023; 112:1058-1066. [PMID: 36866956 DOI: 10.1111/apa.16740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/03/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
AIM This study investigated febrile children with petechial rashes who presented to European emergency departments (EDs) and investigated the role that mechanical causes played in diagnoses. METHODS Consecutive patients with fever presenting to EDs in 11 European emergency departments in 2017-2018 were enrolled. The cause and focus of infection were identified and a detailed analysis was performed on children with petechial rashes. The results are presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS We found that 453/34010 (1.3%) febrile children had petechial rashes. The focus of the infection included sepsis (10/453, 2.2%) and meningitis (14/453, 3.1%). Children with a petechial rash were more likely than other febrile children to have sepsis or meningitis (OR 8.5, 95% CI 5.3-13.1) and bacterial infections (OR 1.4, 95% CI 1.0-1.8) as well as need for immediate life-saving interventions (OR 6.6, 95% CI 4.4-9.5) and intensive care unit admissions (OR 6.5, 95% CI 3.0-12.5). CONCLUSION The combination of fever and petechial rash is still an important warning sign for childhood sepsis and meningitis. Ruling out coughing and/or vomiting was insufficient to safely identify low-risk patients.
Collapse
Affiliation(s)
- Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Manuel Leitner
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Nienke N Hagedoorn
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dorine M Borensztajn
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
- German Centre for Infection Research, DZIF, Munich, Germany
| | - Enitan D Carrol
- Institute of Infection, Veterinary and Ecological Sciences Liverpool, University of Liverpool, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Marieke Emonts
- Great North Children's Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Michiel van der Flier
- Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, RadboudUMC, Nijmegen, The Netherlands
- Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ronald de Groot
- Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, RadboudUMC, Nijmegen, The Netherlands
| | - Jethro Herberg
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
| | - Emma Lim
- Great North Children's Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ian K Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, London, UK
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Paediatrics Research group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud G Nijman
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
| | - Marko Pokorn
- University Medical Centre Ljubljana, Department of Infectious Diseases and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Paediatrics Research group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Chantal D Tan
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maria Tsolia
- Second Department of Paediatrics, P. and A. Kyriakou Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Clementien L Vermont
- Department of Paediatric Infectious Diseases and Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dace Zavadska
- Department of Paediatrics, Children Clinical University Hospital, Rīga Stradiņa Universitāte, Riga, Latvia
| | - Henriette A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | | |
Collapse
|
13
|
Optimizing Recognition and Management of Patients at Risk for Infection-Related Decompensation Through Team-Based Decision Making. J Healthc Qual 2023; 45:59-68. [PMID: 36041070 PMCID: PMC9977419 DOI: 10.1097/jhq.0000000000000363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pediatric sepsis is a leading cause of death among children. Electronic alert systems may improve early recognition but do not consistently result in timely interventions given the multitude of clinical presentations, lack of treatment consensus, standardized order sets, and inadequate interdisciplinary team-based communication. We conducted a quality improvement project to improve timely critical treatment of patients at risk for infection-related decompensation (IRD) through team-based communication and standardized treatment workflow. METHODS We evaluated children at risk for IRD as evidenced by the activation of an electronic alert system (Children at High Risk Alert Tool [CAHR-AT]) in the emergency department. Outcomes were assessed after multiple improvements including CAHR-AT implementation, clinical coassessment, visual cues for situational awareness, huddles, and standardized order sets. RESULTS With visual cue activation, initial huddle compliance increased from 7.8% to 65.3% ( p < .001). Children receiving antibiotics by 3 hours postactivation increased from 37.9% pre-CAHR-AT to 50.7% posthuddle implementation ( p < .0001); patients who received a fluid bolus by 3 hours post-CAHR activation increased from 49.0% to 55.2% ( p = .001). CONCLUSIONS Implementing a well-validated electronic alert tool did not improve quality measures of timely treatment for high-risk patients until combined with team-based communication, standardized reassessment, and treatment workflow.
Collapse
|
14
|
Gilholm P, Gibbons K, Lister P, Harley A, Irwin A, Raman S, Rice M, Schlapbach LJ. Validation of a paediatric sepsis screening tool to identify children with sepsis in the emergency department: a statewide prospective cohort study in Queensland, Australia. BMJ Open 2023; 13:e061431. [PMID: 36604132 PMCID: PMC9827183 DOI: 10.1136/bmjopen-2022-061431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE The Surviving Sepsis Campaign guidelines recommend the implementation of systematic screening for sepsis. We aimed to validate a paediatric sepsis screening tool and derive a simplified screening tool. DESIGN Prospective multicentre study conducted between August 2018 and December 2019. We assessed the performance of the paediatric sepsis screening tool using stepwise multiple logistic regression analyses with 10-fold cross-validation and evaluated the final model at defined risk thresholds. SETTING Twelve emergency departments (EDs) in Queensland, Australia. PARTICIPANTS 3473 children screened for sepsis, of which 523 (15.1%) were diagnosed with sepsis. INTERVENTIONS A 32-item paediatric sepsis screening tool including rapidly available information from triage, risk factors and targeted physical examination. PRIMARY OUTCOME MEASURE Senior medical officer-diagnosed sepsis combined with the administration of intravenous antibiotics in the ED. RESULTS The 32-item paediatric sepsis screening tool had good predictive performance (area under the receiver operating characteristic curve (AUC) 0.80, 95% CI 0.78 to 0.82). A simplified tool containing 16 of 32 criteria had comparable performance and retained an AUC of 0.80 (95% CI 0.78 to 0.82). To reach a sensitivity of 90% (95% CI 87% to 92%), the final model achieved a specificity of 51% (95% CI 49% to 53%). Sensitivity analyses using the outcomes of sepsis-associated organ dysfunction (AUC 0.84, 95% CI 0.81 to 0.87) and septic shock (AUC 0.84, 95% CI 0.81 to 0.88) confirmed the main results. CONCLUSIONS A simplified paediatric sepsis screening tool performed well to identify children with sepsis in the ED. Implementation of sepsis screening tools may improve the timely recognition and treatment of sepsis.
Collapse
Affiliation(s)
- Patricia Gilholm
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Paula Lister
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Paediatric Critical Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Amanda Harley
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Queensland Paediatric Sepsis Program, Brisbane, Queensland, Australia
| | - Adam Irwin
- Queensland Paediatric Sepsis Program, Brisbane, Queensland, Australia
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Queensland Paediatric Sepsis Program, Brisbane, Queensland, Australia
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Michael Rice
- Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
15
|
Miller H, Tseng A, Lowerre T, Schefft M, Muñoz J, Pedigo S, Silverman J. Improving Time to Stat Intravenous Antibiotic Administration: An 8-Year Quality Initiative. Hosp Pediatr 2023; 13:88-94. [PMID: 36545766 DOI: 10.1542/hpeds.2021-006422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Prompt antibiotics have been shown to improve outcomes in pediatric sepsis, which continues to be a leading cause of death in children. We describe the quality improvement (QI) efforts of a single academic children's hospital to improve antibiotic timeliness. METHODS Using the electronic health record, we report time from order to the administration of stat intravenous (IV) antibiotics from 2012 to 2020 using statistical process control charts. We describe QI interventions initiated over the study period. These include the formation of a Pediatric Sepsis Committee, routine use of automated dispensing machines for stat IV antibiotics, creation of sepsis order sets, manual and automated sepsis screening implementation, participation in national sepsis QI collaboratives, creation of difficult intravenous access guidelines, and an automated notification system for charge nurses. As a balancing measure, we assessed stat IV antibiotic use normalized to total emergency department visits and inpatient days. RESULTS Multiple quality improvement interventions were initiated and sustained under the direction of the hospital Pediatric Sepsis Committee. We improved our stat IV antibiotics given within 1 hour of order from 33% in 2012 to 77% in 2019 and maintained this through the end of the study period in July 2020. CONCLUSIONS By using a multipronged quality improvement approach, we demonstrated consistent and sustained improvement in the timely administration of stat IV antibiotics over an 8-year period at our institution. Further study is needed to assess whether this is associated with reduced length of stay or improved survival in children with sepsis.
Collapse
Affiliation(s)
- Hannah Miller
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Ashlie Tseng
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Tracy Lowerre
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Matthew Schefft
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Jose Muñoz
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | | | - Jonathan Silverman
- Division of Pediatric Emergency Medicine.,Department of Emergency Medicine, Virginia Commonwealth University Health Systems, Richmond, Virginia
| |
Collapse
|
16
|
Toews JR, Leonard JC, Shi J, Lloyd JK. Implementation of an Automated Sepsis Screening Tool in a Children's Hospital Emergency Department: A Cost Analysis. J Pediatr 2022; 250:38-44.e1. [PMID: 35772510 DOI: 10.1016/j.jpeds.2022.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 06/09/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters. STUDY DESIGN This retrospective cohort study used propensity score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters. RESULTS The overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657). CONCLUSIONS The median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.
Collapse
Affiliation(s)
- Jason R Toews
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH; Division of Emergency Medicine, Dayton Children's Hospital, Dayton, OH
| | - Julie C Leonard
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Junxin Shi
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Julia K Lloyd
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH.
| |
Collapse
|
17
|
Faisal M, Mohammed M, Richardson D, Fiori M, Beatson K. Development and validation of automated computer-aided risk scores to predict in-hospital mortality for emergency medical admissions with COVID-19: a retrospective cohort development and validation study. BMJ Open 2022; 12:e050274. [PMID: 36041761 PMCID: PMC9437732 DOI: 10.1136/bmjopen-2021-050274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES There are no established mortality risk equations specifically for unplanned emergency medical admissions which include patients with SARS-19 (COVID-19). We aim to develop and validate a computer-aided risk score (CARMc19) for predicting mortality risk by combining COVID-19 status, the first electronically recorded blood test results and the National Early Warning Score (NEWS2). DESIGN Logistic regression model development and validation study. SETTING Two acute hospitals (York Hospital-model development data; Scarborough Hospital-external validation data). PARTICIPANTS Adult (aged ≥16 years) medical admissions discharged over a 24-month period with electronic NEWS and blood test results recorded on admission. We used logistic regression modelling to predict the risk of in-hospital mortality using two models: (1) CARMc19_N: age+sex+NEWS2 including subcomponents+COVID19; (2) CARMc19_NB: CARMc19_N in conjunction with seven blood test results and acute kidney injury score. Model performance was evaluated according to discrimination (c-statistic), calibration (graphically) and clinical usefulness at NEWS2 thresholds of 4+, 5+, 6+. RESULTS The risk of in-hospital mortality following emergency medical admission was similar in development and validation datasets (8.4% vs 8.2%). The c-statistics for predicting mortality for CARMc19_NB is better than CARMc19_N in the validation dataset (CARMc19_NB=0.88 (95% CI 0.86 to 0.90) vs CARMc19_N=0.86 (95% CI 0.83 to 0.88)). Both models had good calibration (CARMc19_NB=1.01 (95% CI 0.88 to 1.14) and CARMc19_N:0.95 (95% CI 0.83 to 1.06)). At all NEWS2 thresholds (4+, 5+, 6+) model, CARMc19_NB had better sensitivity and similar specificity. CONCLUSIONS We have developed a validated CARMc19 scores with good performance characteristics for predicting the risk of in-hospital mortality. Since the CARMc19 scores place no additional data collection burden on clinicians, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.
Collapse
Affiliation(s)
- Muhammad Faisal
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Bradford, UK
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre (YHPSTRC), Bradford, UK
| | - Mohammed Mohammed
- Faculty of Health Studies, University of Bradford, Bradford, UK
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Donald Richardson
- Department of Renal Medicine, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Massimo Fiori
- Department of Information Technology, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Kevin Beatson
- Department of Information Technology, York Teaching Hospitals NHS Foundation Trust, York, UK
| |
Collapse
|
18
|
Witting CS, Simon NJE, Lorenz D, Murphy JS, Nelson J, Lehnig K, Alpern ER. Sepsis Electronic Decision Support Screen in High-Risk Patients Across Age Groups in a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1479-e1484. [PMID: 35383693 DOI: 10.1097/pec.0000000000002709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to compare the performance of a pediatric decision support algorithm to detect severe sepsis between high-risk pediatric and adult patients in a pediatric emergency department (PED). METHODS This is a retrospective cohort study of patients presenting from March 2017 to February 2018 to a tertiary care PED. Patients were identified as high risk for sepsis based on a priori defined criteria and were considered adult if 18 years or older. The 2-step decision support algorithm consists of (1) an electronic health record best-practice alert (BPA) with age-adjusted vital sign ranges, and (2) physician screen. The difference in test characteristics of the intervention for the detection of severe sepsis between pediatric and adult patients was assessed at 0.05 statistical significance. RESULTS The 2358 enrolled subjects included 2125 children (90.1%) and 233 adults (9.9%). The median ages for children and adults were 3.8 (interquartile range, 1.2-8.6) and 20.1 (interquartile range, 18.2-22.0) years, respectively. In adults, compared with children, the BPA alone had significantly higher sensitivity (0.83 [95% confidence interval {CI}, 0.74-0.89] vs 0.72 [95% CI, 0.69-0.75]; P = 0.02) and lower specificity (0.11 [95% CI, 0.07-0.19] vs 0.48 [95% CI, 0.45-0.51; P < 0.001). With the addition of provider screen, sensitivity and specificity were comparable across age groups, with a lower negative predictive value in adults compared with children (0.66 [95% CI, 0.58-0.74] vs 0.77 [95% CI, 0.75-0.79]; P = 0.005). CONCLUSIONS The BPA was less specific in adults compared with children. With the addition of provider screen, specificity improved; however, the lower negative predictive value suggests that providers may be less likely to suspect sepsis even after automated screen in adult patients. This study invites further research aimed at improving screening algorithms, particularly across the diverse age spectrum presenting to a PED.
Collapse
Affiliation(s)
| | - Norma-Jean E Simon
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Doug Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Julia S Murphy
- From the Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jill Nelson
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Katherine Lehnig
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | | |
Collapse
|
19
|
Souganidis ES, Patel B, Sampayo EM. Physician-Specific Utilization of an Electronic Best Practice Alert for Pediatric Sepsis in the Emergency Department. Pediatr Emerg Care 2022; 38:e1417-e1422. [PMID: 35696307 DOI: 10.1097/pec.0000000000002778] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early recognition of sepsis remains a critical goal in the pediatric emergency department (ED). Although this has led to the development of best practice alerts (BPAs) to facilitate screening and bundled care, research on how individual physicians interact with sepsis alerts and protocols is limited. This study aims to identify common reasons for acceptance and rejection of a sepsis BPA by pediatric emergency medicine (PEM) physicians and understand how the BPA affects physician management of patients with suspected sepsis. METHODS This is a qualitative study of PEM physicians in a quaternary-care children's hospital. Data were collected through semistructured interviews and analyzed through an iterative coding process until thematic saturation was achieved. Member checking was completed to ensure trustworthiness. Thematic analysis of PEM physicians' rejection reasons in the electronic health record was used to categorize their responses and calculate each theme's frequency. RESULTS Twenty-two physicians participated in this study. Seven physicians (32%) relied solely on patient characteristics when deciding to accept the BPA, whereas the remaining physicians considered nonpatient factors specific to the ED environment, individualized practice patterns, and BPA design. Eleven principal reasons for BPA rejection were derived from 1406 electronic health record responses, with clinical appearance not consistent with shock being the most common. Physicians identified the BPA's configuration and incomplete understanding of the BPA as the biggest barriers to utilization and provided strategies to improve the BPA screening process and streamline sepsis care. Physicians emphasized the need for further BPA education for physicians and triage staff and improved transparency of the alert. CONCLUSIONS Physicians consider patient and nonpatient factors when responding to the BPA. Improved BPA functionality combined with measures to enhance screening, optimize sepsis management, and educate ED providers on the BPA may increase satisfaction with the alert and promote more effective utilization when it fires.
Collapse
Affiliation(s)
- Ellie S Souganidis
- From the Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | | | | |
Collapse
|
20
|
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] [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.
Collapse
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
| |
Collapse
|
21
|
Yan AP, Zipursky AR, Capraro A, Harper M, Eisenberg M. Pediatric Emergency Department Sepsis Screening Tool Accuracy During the COVID-19 Pandemic. Pediatrics 2022; 150:186991. [PMID: 35502122 DOI: 10.1542/peds.2022-057492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Automated sepsis alerts in pediatric emergency departments (EDs) can identify patients at risk for sepsis, allowing for earlier intervention with appropriate therapies. The impact of the COVID-19 pandemic on the performance of pediatric sepsis alerts is unknown. METHODS We performed a retrospective cohort study of 59 335 ED visits before the pandemic and 51 990 ED visits during the pandemic in an ED with an automated sepsis alert based on systemic inflammatory response syndrome criteria. The sensitivity, specificity, negative predictive value, and positive predictive value of the sepsis algorithm were compared between the prepandemic and pandemic phases and between COVID-19-negative and COVID-19-positive patients during the pandemic phase. RESULTS The proportion of ED visits triggering a sepsis alert was 7.0% (n = 4180) before and 6.1% (n = 3199) during the pandemic. The number of sepsis alerts triggered per diagnosed case of hypotensive septic shock was 24 in both periods. There was no difference in the sensitivity (74.1% vs 72.5%), specificity (93.2% vs 94.0%), positive predictive value (4.1% vs 4.1%), or negative predictive value (99.9% vs 99.9%) of the sepsis alerts between these periods. The alerts had a lower sensitivity (60% vs 73.3%) and specificity (87.3% vs 94.2%) for COVID-19-positive versus COVID-19-negative patients. CONCLUSIONS The sepsis alert algorithm evaluated in this study did not result in excess notifications and maintained adequate performance during the COVID-19 pandemic in the pediatric ED setting.
Collapse
Affiliation(s)
- Adam P Yan
- Division of Hematology and Oncology, Boston Children's Hospitaland Harvard Medical School, Boston, Massachusetts.,Divisions of Hematology and Oncology
| | - Amy R Zipursky
- Emergency Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.,Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Capraro
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marvin Harper
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthew Eisenberg
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
22
|
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.
Collapse
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
| | | |
Collapse
|
23
|
Stella P, Haines E, Aphinyanaphongs Y. Prediction of Resuscitation for Pediatric Sepsis from Data Available at Triage. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:1129-1138. [PMID: 35308977 PMCID: PMC8861694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Pediatric sepsis imposes a significant burden of morbidity and mortality among children. While the speedy application of existing supportive care measures can substantially improve outcomes, further improvements in delivering that care require tools that go beyond recognizing sepsis and towards predicting its development. Machine learning techniques have great potential as predictive tools, but their application to pediatric sepsis has been stymied by several factors, particularly the relative rarity of its occurrence. We propose an alternate approach which focuses on predicting the provision of resuscitative care, rather than sepsis diagnoses or criteria themselves. Using three years of Emergency Department data from a large academic medical center, we developed a boosted tree model that predicts resuscitation within 6 hours of triage, and significantly outperforms existing rule-based sepsis alerts.
Collapse
Affiliation(s)
- Peter Stella
- Department of Pediatrics, NYU Grossman School of Medicine, New York
| | - Elizabeth Haines
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York
| | | |
Collapse
|
24
|
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
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Souganidis E, Abbadessa MK, Ku B, Minich C, Lavelle J, Zorc J, Balamuth F. Analysis of Missed Sepsis Patients in a Pediatric Emergency Department With a Vital Sign-Based Electronic Sepsis Alert. Pediatr Emerg Care 2022; 38:e1-e4. [PMID: 33003131 DOI: 10.1097/pec.0000000000002207] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED). METHODS Retrospective cohort study in a tertiary care children's hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications. RESULTS There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients. CONCLUSIONS In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.
Collapse
Affiliation(s)
- Ellie Souganidis
- From the Division of Pediatric Emergency Medicine, Texas Children's Hospital, Houston, TX
| | | | - Brandon Ku
- Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Christian Minich
- Division of Emergency Medicine, Children's Hospital of Philadelphia
| | | | | | | |
Collapse
|
27
|
Hutchinson CL, Curtis K, McCloughen A, Fethney J, Wiseman G, Hutchinson L. Clinician perspectives on reasons for, implications and management of unplanned patient returns to the Emergency Department: A descriptive study. Int Emerg Nurs 2021; 60:101125. [PMID: 34953437 DOI: 10.1016/j.ienj.2021.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Unplanned return visits to the emergency department (ED) have been associated with adverse outcomes and may reflect the quality of care delivered. Several studies speculate the reasons for return and suggest clinician behaviour as potentially influencing a patient's decision to return to the ED. There is little research about this issue from the clinician's perspective, which is necessary to inform future practice improvement. METHODS A descriptive cross sectional design was employed to ascertain perspectives on identification and management of return visits occurring within 48 hours of discharge. An electronic survey was distributed to all medical, nursing, and clerical staff at one ED. Descriptive statistics were used for quantitative data and content analysis was performed on textual data. Results were categorised as barriers or facilitators, then mapped to the Theoretical Domains Framework. RESULTS A response rate of 59.7% (n=86/144) was achieved. Staff reported increased levels of concern for this patient group but not all staff were aware of the policy for managing return patients (40.7%). Five barriers and three facilitators were identified that mapped to eight influencers of behaviour including knowledge, memory and environmental factors. CONCLUSION Overall, staff were aware of return patients but lacked familiarity with policy and processes to identify and commence relevant protocols. Further review of current practice as well as the patient perspective is required before any intervention to improve practice is developed.
Collapse
Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Glen Wiseman
- Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia
| | - Laura Hutchinson
- Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia
| |
Collapse
|
28
|
Ackermann K, Baker J, Festa M, McMullan B, Westbrook J, Li L. Computerized Clinical Decision Support Systems for Early Detection of Sepsis Among Pediatric, Neonatal, and Maternal Inpatients: A Scoping Review (Preprint). JMIR Med Inform 2021; 10:e35061. [PMID: 35522467 PMCID: PMC9123549 DOI: 10.2196/35061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/27/2022] [Accepted: 03/19/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Khalia Ackermann
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Jannah Baker
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Marino Festa
- Kids Critical Care Research, Department of Paediatric Intensive Care, Children's Hospital at Westmead, Sydney, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| |
Collapse
|
29
|
Eisenberg M, Puder M, Hudgins J. Prediction of the Development of Severe Sepsis Among Children With Intestinal Failure and Fever Presenting to the Emergency Department. Pediatr Emerg Care 2021; 37:e1366-e1372. [PMID: 32149998 DOI: 10.1097/pec.0000000000002048] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Children with intestinal failure (IF) and fever are frequently bacteremic, but risk factors for development of sepsis in this population are not well delineated. Our objective was to determine what clinical factors available on arrival to the emergency department (ED), including commonly used vital sign thresholds, predicted the subsequent development of severe sepsis in children with IF and fever. STUDY DESIGN This was a retrospective cohort study of children younger than 21 years with IF presenting to a tertiary care ED between 2010 and 2016 with fever who did not have hypotensive septic shock on arrival. The primary outcome was development of severe sepsis within 24 hours of ED arrival, as defined by consensus criteria. We identified predictors of severe sepsis using both univariate and multivariate models and calculated the test characteristics of 3 different sets of vital sign criteria in determining risk of severe sepsis. RESULTS In 26 (9.4%) of 278 encounters, the patient developed severe sepsis within 24 hours of arrival to the ED; 3 were excluded due to hypotensive shock on arrival. Predictors of severe sepsis included history of intestinal pseudo-obstruction (odds ratio, 8.2; 95% confidence interval, 2.3-30.2) and higher initial temperature (odds ratio, 1.7; 95% confidence interval, 1.2-2.3). The 3 sets of vital sign criteria had widely varying sensitivity and specificity in identifying development of severe sepsis. CONCLUSIONS History of intestinal pseudo-obstruction and higher fever predicted increased risk of severe sepsis among children with IF and fever presenting to an ED. No single set of vital sign criteria had both high sensitivity and specificity for this diagnosis.
Collapse
|
30
|
Sepanski RJ, Zaritsky AL, Godambe SA. Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool. Diagnosis (Berl) 2021; 8:458-468. [PMID: 32755968 DOI: 10.1515/dx-2020-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/04/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Electronic alert systems to identify potential sepsis in children presenting to the emergency department (ED) often either alert too frequently or fail to detect earlier stages of decompensation where timely treatment might prevent serious outcomes. METHODS We created a predictive tool that continuously monitors our hospital's electronic health record during ED visits. The tool incorporates new standards for normal/abnormal vital signs based on data from ∼1.2 million children at 169 hospitals. Eighty-two gold standard (GS) sepsis cases arising within 48 h were identified through retrospective chart review of cases sampled from 35,586 ED visits during 2012 and 2014-2015. An additional 1,027 cases with high severity of illness (SOI) based on 3 M's All Patient Refined - Diagnosis-Related Groups (APR-DRG) were identified from these and 26,026 additional visits during 2017. An iterative process assigned weights to main factors and interactions significantly associated with GS cases, creating an overall "score" that maximized the sensitivity for GS cases and positive predictive value for high SOI outcomes. RESULTS Tool implementation began August 2017; subsequent improvements resulted in 77% sensitivity for identifying GS sepsis within 48 h, 22.5% positive predictive value for major/extreme SOI outcomes, and 2% overall firing rate of ED patients. The incidence of high-severity outcomes increased rapidly with tool score. Admitted alert positive patients were hospitalized nearly twice as long as alert negative patients. CONCLUSIONS Our ED-based electronic tool combines high sensitivity in predicting GS sepsis, high predictive value for physiologic decompensation, and a low firing rate. The tool can help optimize critical treatments for these high-risk children.
Collapse
Affiliation(s)
- Robert J Sepanski
- Department of Quality and Safety, Children's Hospital of The King's Daughters, Norfolk, VA, USA.,Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - Arno L Zaritsky
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - Sandip A Godambe
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, USA
| |
Collapse
|
31
|
Nomura O, Ihara T, Morikawa Y, Sakakibara H, Horikoshi Y, Inoue N. Predictor of Early Administration of Antibiotics and a Volume Resuscitation for Young Infants with Septic Shock. Antibiotics (Basel) 2021; 10:1414. [PMID: 34827352 PMCID: PMC8615069 DOI: 10.3390/antibiotics10111414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
(1) Background: It is critical to administer antibiotics and fluid bolus within 1 h of recognizing sepsis in pediatric patients. This study aimed to identify the predictor of the successful completion of a 1-h sepsis bundle for infants with suspected sepsis. (2) Methods: This is an observational study using a prospective registry including febrile young infants (aged < 90 days) who visited a pediatric emergency department with a core body temperature of 38.0 °C or higher and 36.0 °C or lower. Univariate and logistic regression analyses were conducted to determine the predictor (s) of successful sepsis bundle completion. (3) Results: Of the 323 registered patients, 118 patients with suspected sepsis were analyzed, and 38 patients (32.2%) received a bundle-compliant treatment. Among potential variables, such as age, sex, and vital sign parameters, the logistic regression analysis showed that heart rate (odds ratio: OR 1.02; 95% confidence interval: 1.00-1.04) is a significant predictor of the completion of a 1-h sepsis bundle. (4) Conclusions: We found that tachycardia facilitated the sepsis recognition and promoted the successful completion of a 1-h sepsis bundle for young infants with suspected septic shock and a possible indicator for improving the quality of the team-based sepsis management.
Collapse
Affiliation(s)
- Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki 036-8562, Japan
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, Tokyo 183-8561, Japan;
| | - Takateru Ihara
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, Tokyo 183-8561, Japan;
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, Tokyo 183-8561, Japan;
| | - Hiroshi Sakakibara
- Division of General Pediatrics, Department of Pediatrics, Tokyo Metropolitan Children’s Medical Center, Tokyo 183-8561, Japan;
| | - Yuho Horikoshi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children’s Medical Center, Tokyo 183-8561, Japan;
| | - Nobuaki Inoue
- Department of Human Resources and Development, National Center for Global Health and Medicine, Tokyo 162-8655, Japan;
| |
Collapse
|
32
|
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.
Collapse
|
33
|
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.
Collapse
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
| |
Collapse
|
34
|
Pediatric sepsis survival in pediatric and general emergency departments. Am J Emerg Med 2021; 51:53-57. [PMID: 34673476 DOI: 10.1016/j.ajem.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Understanding differences in mortality rate secondary to sepsis between pediatric and general emergency departments (EDs) would help identify strategies to improve pediatric sepsis care. We aimed to determine if pediatric sepsis mortality differs between pediatric and general EDs. METHODS We performed a nationally representative, retrospective cohort study using the 2008-2017 Nationwide Emergency Department Sample (NEDS) to examine visits by patients less than 19 years old with a diagnostic code of severe sepsis or septic shock. We generated national estimates of study outcomes using NEDS survey weights. We compared pediatric to general EDs on the outcomes of ED mortality and hospital mortality. We determined adjusted mortality risk using logistic regression, controlling for age, gender, complex care code, and geographic region. RESULTS There were 54,129 weighted pediatric ED visits during the study period with a diagnosis code of severe sepsis or septic shock. Of these visits, 285 died in the ED (0.58%) and 5065 died during their hospital stay (9.8%). Mortality risk prior to ED disposition in pediatric and general EDs was 0.31% and 0.72%, respectively (adjusted odds ratio (aOR), 95% confidence interval (CI): 0.36 (0.14-0.93)). Mortality risk prior to hospital discharge in pediatric and general EDs was 7.5% and 10.9%, respectively (aOR, 95% CI: 0.55 (0.41-0.72)). CONCLUSIONS In a nationally representative sample, pediatric mortality from severe sepsis or septic shock was lower in pediatric EDs than in general EDs. Identifying features of pediatric ED care associated with improved sepsis mortality could translate into improved survival for children wherever they present with sepsis.
Collapse
|
35
|
Arriaga-Pizano LA, Gonzalez-Olvera MA, Ferat-Osorio EA, Escobar J, Hernandez-Perez AL, Revilla-Monsalve C, Lopez-Macias C, León-Pedroza JI, Cabrera-Rivera GL, Guadarrama-Aranda U, Leder R, Gallardo-Hernandez AG. Accurate diagnosis of sepsis using a neural network: Pilot study using routine clinical variables. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 210:106366. [PMID: 34500141 DOI: 10.1016/j.cmpb.2021.106366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/17/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Sepsis is a severe infection that increases mortality risk and is one if the main causes of death in intensive care units. Accurate detection is key to successful interventions, but diagnosis of sepsis is complicated because the initial signs and symptoms are not specific. Biomarkers that have been proposed have low specificity and sensitivity, are expensive, and not available in every hospital. In this study, we propose the use of artificial intelligence in the form of a neural network to diagnose sepsis using only common laboratory tests and vital signs that are routine and widely available. METHODS A retrospective, cross sectional cohort of 113 patients from an intensive care unit, each with 48 routinely evaluated vital signs and biochemical parameters was used to train, validate and test a neural network with 48 inputs, 10 neurons in a single hidden layer and one output. The sensitivity and specificity of the neural network as a point sampled diagnostic test was calculated. RESULTS All but one case were correctly diagnosed by the neural network, with 91% sensitivity and 100% specificity in the validation data set, and 100% sensitivity and specificity in the test data set. CONCLUSIONS The designed neural network system can identify patients with sepsis, with minimal resources using standard laboratory tests widely available in most health care facilities. This should reduce the burden on the medical staff of a difficult diagnosis and should improve outcomes for patients with sepsis.
Collapse
Affiliation(s)
- Lourdes Andrea Arriaga-Pizano
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Marcos Angel Gonzalez-Olvera
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Eduardo Antonio Ferat-Osorio
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Jesica Escobar
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Ana Luisa Hernandez-Perez
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Cristina Revilla-Monsalve
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Constatino Lopez-Macias
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - José Israel León-Pedroza
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Graciela Libier Cabrera-Rivera
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Uriel Guadarrama-Aranda
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | - Ron Leder
- Instituto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXI, Hospital de cardiología, Mexico 0672, DF, Mexico
| | | |
Collapse
|
36
|
Faisal M, Mohammed MA, Richardson D, Steyerberg EW, Fiori M, Beatson K. Predictive accuracy of enhanced versions of the on-admission National Early Warning Score in estimating the risk of COVID-19 for unplanned admission to hospital: a retrospective development and validation study. BMC Health Serv Res 2021; 21:957. [PMID: 34511131 PMCID: PMC8435351 DOI: 10.1186/s12913-021-06951-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/27/2021] [Indexed: 08/24/2023] Open
Abstract
Background The novel coronavirus SARS-19 produces ‘COVID-19’ in patients with symptoms. COVID-19 patients admitted to the hospital require early assessment and care including isolation. The National Early Warning Score (NEWS) and its updated version NEWS2 is a simple physiological scoring system used in hospitals, which may be useful in the early identification of COVID-19 patients. We investigate the performance of multiple enhanced NEWS2 models in predicting the risk of COVID-19. Methods Our cohort included unplanned adult medical admissions discharged over 3 months (11 March 2020 to 13 June 2020 ) from two hospitals (YH for model development; SH for external model validation). We used logistic regression to build multiple prediction models for the risk of COVID-19 using the first electronically recorded NEWS2 within ± 24 hours of admission. Model M0’ included NEWS2; model M1’ included NEWS2 + age + sex, and model M2’ extends model M1’ with subcomponents of NEWS2 (including diastolic blood pressure + oxygen flow rate + oxygen scale). Model performance was evaluated according to discrimination (c statistic), calibration (graphically), and clinical usefulness at NEWS2 ≥ 5. Results The prevalence of COVID-19 was higher in SH (11.0 %=277/2520) than YH (8.7 %=343/3924) with a higher first NEWS2 scores ( SH 3.2 vs YH 2.8) but similar in-hospital mortality (SH 8.4 % vs YH 8.2 %). The c-statistics for predicting the risk of COVID-19 for models M0’,M1’,M2’ in the development dataset were: M0’: 0.71 (95 %CI 0.68–0.74); M1’: 0.67 (95 %CI 0.64–0.70) and M2’: 0.78 (95 %CI 0.75–0.80)). For the validation datasets the c-statistics were: M0’ 0.65 (95 %CI 0.61–0.68); M1’: 0.67 (95 %CI 0.64–0.70) and M2’: 0.72 (95 %CI 0.69–0.75) ). The calibration slope was similar across all models but Model M2’ had the highest sensitivity (M0’ 44 % (95 %CI 38-50 %); M1’ 53 % (95 %CI 47-59 %) and M2’: 57 % (95 %CI 51-63 %)) and specificity (M0’ 75 % (95 %CI 73-77 %); M1’ 72 % (95 %CI 70-74 %) and M2’: 76 % (95 %CI 74-78 %)) for the validation dataset at NEWS2 ≥ 5. Conclusions Model M2’ appears to be reasonably accurate for predicting the risk of COVID-19. It may be clinically useful as an early warning system at the time of admission especially to triage large numbers of unplanned hospital admissions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06951-x.
Collapse
Affiliation(s)
- Muhammad Faisal
- Faculty of Health Studies, University of Bradford, Bradford, UK.,Bradford Institute for Health Research , Bradford, UK.,NIHR Yorkshire and Humber Patient Safety Translational Research Centre (YHPSTRC), Bradford, UK.,Wolfson Centre for Applied Health Research, Bradford, UK
| | - Mohammed Amin Mohammed
- Faculty of Health Studies, University of Bradford, Bradford, UK. .,The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, Kingston House, B70 9LD, West Bromwich, UK.
| | - Donald Richardson
- Department of Renal Medicine, York Teaching Hospitals NHS Foundation Trust, York, England, UK
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands
| | - Massimo Fiori
- York Teaching Hospitals NHS Foundation Trust, York, England, UK
| | - Kevin Beatson
- York Teaching Hospitals NHS Foundation Trust, York, England, UK
| |
Collapse
|
37
|
Application of the Improving Pediatric Sepsis Outcomes Definition for Pediatric Sepsis to Nationally Representative Emergency Department Data. Pediatr Qual Saf 2021; 6:e468. [PMID: 35018312 PMCID: PMC8741269 DOI: 10.1097/pq9.0000000000000468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 04/21/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. To compare encounter estimates and demographics of pediatric patients (<18 years) meeting modified Improving Pediatric Sepsis Outcomes (IPSO) criteria for sepsis to cohorts obtained using other criteria for pediatric sepsis from administrative datasets.
Collapse
|
38
|
Huddles and their effectiveness at the frontlines of clinical care: a scoping review. J Gen Intern Med 2021; 36:2772-2783. [PMID: 33559062 PMCID: PMC8390736 DOI: 10.1007/s11606-021-06632-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research. METHODS A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts. RESULTS Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%). DISCUSSION Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes. STUDY REGISTRATION This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).
Collapse
|
39
|
Eisenberg MA, Freiman E, Capraro A, Madden K, Monuteaux MC, Hudgins J, Harper M. Outcomes of Patients with Sepsis in a Pediatric Emergency Department after Automated Sepsis Screening. J Pediatr 2021; 235:239-245.e4. [PMID: 33798508 DOI: 10.1016/j.jpeds.2021.03.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the effect of an automated sepsis screening tool on treatment and outcomes of severe sepsis in a pediatric emergency department (ED). STUDY DESIGN Retrospective cohort study of encounters of patients with severe sepsis in a pediatric ED with a high volume of pediatric sepsis cases over a 2-year period. The automated sepsis screening algorithm replaced a manual screen 1 year into the study. The primary outcome was the proportion of patients treated for sepsis while in the ED. Secondary outcomes were time from ED arrival to first intravenous (IV) antibiotic and first IV fluid bolus, volume of fluid administered in the ED, 30-day mortality, intensive care unit-free days, and hospital-free days. RESULTS In year 1 of the study, 8910 of 61 026 (14.6%) of encounters had a manual sepsis screen; 137 patients met criteria for severe sepsis. In year 2, 100% of 61 195 encounters had an automated sepsis screen and there were 136 cases of severe sepsis. There was a higher proportion of patients with severe sepsis who had an active malignancy and indwelling central venous catheter in year 2. There were no differences in the proportion of patients treated for sepsis in the ED, time to first IV antibiotic or first IV fluid bolus, fluid volume delivered in the ED, hospital-free days, intensive care unit-free days, or 30-day mortality after implementation of the automated screening algorithm. CONCLUSIONS An automated sepsis screening algorithm introduced into an academic pediatric ED with a high volume of sepsis cases did not lead to improvements in treatment or outcomes of severe sepsis in this study.
Collapse
Affiliation(s)
- Matthew A Eisenberg
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Eli Freiman
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Andrew Capraro
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kate Madden
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Joel Hudgins
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Marvin Harper
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
40
|
Multidisciplinary Kaizen Event to Improve Adherence to a Sepsis Clinical Care Guideline. Pediatr Qual Saf 2021; 6:e435. [PMID: 34235357 PMCID: PMC8225368 DOI: 10.1097/pq9.0000000000000435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 01/21/2021] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Since 2015, the Ann and Robert H. Lurie Children’s Hospital Emergency Department (ED) has improved the recognition and treatment of pediatric sepsis and septic shock. Despite existing clinical care guidelines, the ED had not yet achieved the Surviving Sepsis Campaign timeliness goals for fluid and antibiotic administration. Methods: The team conducted a multidisciplinary Kaizen event to evaluate clinical workflows and identify opportunities to improve sepsis care adherence. Using rigorous quality improvement methodology, frontline providers mapped workflows to identify barriers and prioritize emerging solutions. Results: Thirty-seven staff members across 17 disciplines participated. Nurses and physicians identified communication gaps at pathway initiation. Access to supplies, inadequate task delegation, and a lack of urgency for a subset of pathway patients delayed treatment. Prioritized interventions included scripted communication tools, a delineated response plan, and standardized reassessment processes. Revisions to the key driver diagram were made after the improvement event, guiding future plan-do-study-act cycles. Conclusions: Frontline provider participation in the Kaizen event uncovered barriers to care and identified the root causes of ineffective communication and system process inefficiencies. Engaging key stakeholders from multiple care areas in a candid context was a novel approach to process improvement within our department. The Kaizen methodology is fundamental to developing sustainable quality improvement practices, creating momentum for a continuous improvement culture to engrain quality improvement in practice. The success of Kaizen will shape the format of future ED improvement projects.
Collapse
|
41
|
Gibbs KD, Shi Y, Sanders N, Bodnar A, Brown T, Shah MD, Hess LM. Evaluation of a Sepsis Alert in the Pediatric Acute Care Setting. Appl Clin Inform 2021; 12:469-478. [PMID: 34041734 DOI: 10.1055/s-0041-1730027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Severe sepsis can cause significant morbidity and mortality in pediatric patients. Early recognition and treatment are vital to improving patient outcomes. OBJECTIVE The study aimed to evaluate the impact of a best practice alert in improving recognition of sepsis and timely treatment to improve mortality in the pediatric acute care setting. METHODS A multidisciplinary team adapted a sepsis alert from the emergency room setting to facilitate identification of sepsis in acute care pediatric inpatient areas. The sepsis alert included clinical decision support to aid in timely treatment, prompting the use of intravenous fluid boluses, and antibiotic administration. We compared sepsis-attributable mortality, time to fluid and antibiotic administration, proportion of patients who required transfer to a higher level of care, and antibiotic days for the year prior to the sepsis alert (2017) to the postimplementation phase (2019). RESULTS We had 79 cases of severe sepsis in 2017 and 154 cases in 2019. Of these, we found an absolute reduction in both 3-day sepsis-attributable mortality (2.53 vs. 0%) and 30-day mortality (3.8 vs. 1.3%) when comparing the pre- and postintervention groups. Though our analysis was underpowered due to small sample size, we also identified reductions in median time to fluid and antibiotic administration, proportion of patients who were transferred to the intensive care unit, and no observable increase in antibiotic days. CONCLUSION Electronic sepsis alerts may assist in improving recognition of sepsis and support timely antibiotic and fluid administration in pediatric acute care settings.
Collapse
Affiliation(s)
- Karen DiValerio Gibbs
- Texas Children's Hospital and the University of Texas Health Science Center, Houston Cizik School of Nursing, Houston, Texas, United States
| | - Yan Shi
- Texas Children's Hospital, Houston, Texas, United States
| | - Nicole Sanders
- Texas Children's Hospital, Houston, Texas, United States
| | - Anthony Bodnar
- Texas Children's Hospital, Houston, Texas, United States
| | - Terri Brown
- Texas Children's Hospital, Houston, Texas, United States
| | - Mona D Shah
- Genentech, South San Francisco, California, United States
| | - Lauren M Hess
- Texas Children's Hospital, Houston, Texas, United States.,Section of Pediatric Hospital Medicine, Baylor College of Medicine, Houston, Texas, United States
| |
Collapse
|
42
|
Weiss SL, Fitzgerald JC, Balamuth F. Let Us Not Forget Early Mortality in Pediatric Sepsis. Pediatr Crit Care Med 2021; 22:434-436. [PMID: 33790212 PMCID: PMC8023721 DOI: 10.1097/pcc.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
43
|
Baker AH, Monuteaux MC, Madden K, Capraro AJ, Harper MB, Eisenberg M. Effect of a Sepsis Screening Algorithm on Care of Children with False-Positive Sepsis Alerts. J Pediatr 2021; 231:193-199.e1. [PMID: 33358842 DOI: 10.1016/j.jpeds.2020.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/17/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine if implementation of an automated sepsis screening algorithm with low positive predictive value led to inappropriate resource utilization in emergency department (ED) patients as evidenced by an increased proportion of children with false-positive sepsis screens receiving intravenous (IV) antibiotics. STUDY DESIGN Retrospective cohort study comparing children <18 years of age presenting to an ED who triggered a false-positive sepsis alert during 2 different 5-month time periods: a silent alert period when alerts were generated but not visible to clinicians and an active alert period when alerts were visible. Primary outcome was the proportion of patients who received IV antibiotics. Secondary outcomes included proportion receiving IV fluid boluses, proportion admitted to the hospital, and ED length of stay (LOS). RESULTS Of 1457 patients, 1277 triggered a false-positive sepsis alert in the silent and active alert periods, respectively. In multivariable models, there were no changes in the proportion administered IV antibiotics (27.0% vs 27.6%, aOR 1.1 [0.9,1.3]) or IV fluid boluses (29.7% vs 29.1%, aOR 1.0 [0.8,1.2]). Differences in ED LOS and proportion admitted to the hospital were not significant when controlling for similar changes seen across all ED encounters. CONCLUSIONS An automated sepsis screening algorithm did not lead to changes in the proportion receiving IV antibiotics or IV fluid boluses, department LOS, or the proportion admitted to the hospital for patients with false-positive sepsis alerts.
Collapse
Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Kate Madden
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Harvard Medical School, Boston, MA
| | - Andrew J Capraro
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Marvin B Harper
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Matthew Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
44
|
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.
Collapse
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
| |
Collapse
|
45
|
Abstract
Sepsis, in particular severe sepsis, is a major cause of morbidity and mortality in pediatrics. It is most likely to affect very young children and children with significant medical comorbidities. The definition of sepsis in pediatrics is currently rapidly evolving but the best treatment for children with severe sepsis remains early goal directed therapy with intravenous fluids and antibiotics. It is therefore important for any pediatric urgent care providers to be able to recognize and treat patients with severe sepsis. It is also important for pediatric urgent care providers to be aware of certain groups of patients who have an increased risk of mortality when they develop sepsis. This article summarizes the current understanding of pediatric sepsis and then focuses on the management of these patients in the pediatric urgent care setting, with special attention paid to groups at higher risks of negative outcomes.
Collapse
Affiliation(s)
- Benjamin Klick
- USADirector of Resident Education, Children's Hospital of the King's Daughters Urgent Care Division, Assistant Professor of Pediatrics, Eastern Virginia Medical School.
| | - Theresa Guins
- Director, CSG Division of Urgent Care, Medical Director, CHKD Urgent Care Services, Director, EVMS/CSG PA Urgent Care Fellowship, Associate Professor of Pediatrics, Eastern Virginia Medical School USA.
| |
Collapse
|
46
|
Hegamyer E, Smith N, Thompson AD, Depiero AD. Treatment of suspected sepsis and septic shock in children with chronic disease seen in the pediatric emergency department. Am J Emerg Med 2021; 44:56-61. [PMID: 33581601 DOI: 10.1016/j.ajem.2021.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Research demonstrates that timely recognition and treatment of sepsis can significantly improve pediatric patient outcomes, especially regarding time to intravenous fluid (IVF) and antibiotic administration. Further research suggests that underlying chronic disease in a septic pediatric patient puts them at higher risk for poor outcomes. OBJECTIVE To compare treatment time for suspected sepsis and septic shock in pediatric patients with chronic disease versus those without chronic disease seen in the Pediatric Emergency Department (PED). METHODS We reviewed patient data from a pediatric sepsis outcomes dataset collected at two tertiary care pediatric hospital sites from January 2017-December 2018. Patients were stratified into two groups: those with and without chronic disease, defined as any patient with at least one of eight chronic health conditions. INCLUSION CRITERIA patients seen in the PED ultimately diagnosed with sepsis or septic shock, patient age 0 to 20 years and time zero for identification of sepsis in the PED. EXCLUSION CRITERIA time zero unavailable, inability to determine time of first IVF or antibiotic administration or patient death within the PED. Primary analysis included comparison of time zero to first IVF and antibiotic administration between each group. RESULTS 312 patients met inclusion criteria. 169 individuals had chronic disease and 143 did not. Median time to antibiotics in those with chronic disease was 41.9 min versus 43.0 min in patients without chronic disease (p = 0.181). Time to first IVF in those with chronic disease was 22.0 min versus 12.0 min in those without (p = 0.010). Those with an indwelling line/catheter (n = 40) received IVF slower than those without (n = 272), with no significant difference in time to antibiotic administration by indwelling catheter status (p = 0.063). There were no significant differences in the mode of identification of suspected sepsis or septic shock between those with versus without chronic disease (p = 0.27). CONCLUSIONS Study findings suggest pediatric patients with chronic disease with suspected sepsis or septic shock in the PED have a slower time to IVF administration but equivocal use of sepsis recognition tools compared to patients without chronic disease.
Collapse
Affiliation(s)
- Emily Hegamyer
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Nadine Smith
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Amy D Thompson
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Andrew D Depiero
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| |
Collapse
|
47
|
Scott HF, Colborn KL, Sevick CJ, Bajaj L, Deakyne Davies SJ, Fairclough D, Kissoon N, Kempe A. Development and Validation of a Model to Predict Pediatric Septic Shock Using Data Known 2 Hours After Hospital Arrival. Pediatr Crit Care Med 2021; 22:16-26. [PMID: 33060422 PMCID: PMC7790844 DOI: 10.1097/pcc.0000000000002589] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To use Electronic Health Record (EHR) data from the first two hours of care to derive and validate a model to predict hypotensive septic shock in children with infection. Design: Derivation-validation study using an existing registry Setting: Six emergency care sites within a regional pediatric healthcare system. Three datasets of unique visits were designated: Patients: Patients in whom clinicians were concerned about serious infection from 60 days-17 years were included; those with septic shock in the first two hours were excluded. There were 2318 included visits; 197 developed septic shock (8.5%). Interventions: Lasso with tenfold cross-validation was used for variable selection; logistic regression was then used to construct a model from those variables in the training set. Variables were derived from EHR data known in the first two hours, including vital signs, medical history, demographics, laboratory information. Test characteristics at two thresholds were evaluated: 1) optimizing sensitivity and specificity, 2) set to 90% sensitivity. Measurements and Main Results: Septic shock was defined as systolic hypotension and vasoactive use or ≥30 ml/kg isotonic crystalloid administration in the first 24 hours. A model was created using twenty predictors, with an area under the receiver operating curve in the training set of 0.85 (0.82-0.88); 0.83 [0.78-0.89] in the temporal test set; 0.83 [0.60-1.00] in the geographic test set. Sensitivity and specificity varied based on cutpoint; when sensitivity in the training set was set to 90% (83%, 94%), specificity was 62% (60%, 65%). Conclusions: This model predicted risk of septic shock in children with suspected infection 2 hours after arrival, a critical timepoint for emergent treatment and transfer decisions. Varied cutpoints could be used to customize sensitivity to clinical context.
Collapse
Affiliation(s)
- Halden F. Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Kathryn L. Colborn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Carter J. Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
- Center for Clinical Effectiveness, Children’s Hospital Colorado, Aurora CO, United States
| | | | - Diane Fairclough
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Niranjan Kissoon
- British Columbia Children’s Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
| |
Collapse
|
48
|
Disparities in paediatric sepsis outcomes in the USA. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 5:92-93. [PMID: 33333070 DOI: 10.1016/s2352-4642(20)30389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/22/2022]
|
49
|
Harrison WN, Workman JK, Bonafide CP, Lockwood JM. Surviving Sepsis Screening: The Unintended Consequences of Continuous Surveillance. Hosp Pediatr 2020; 10:e14-e17. [PMID: 33184126 DOI: 10.1542/hpeds.2020-002121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Wade N Harrison
- Pediatric Residency Program and Divisions of Pediatric Inpatient Medicine and .,Division of Hospital Pediatrics, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer K Workman
- Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Justin M Lockwood
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| |
Collapse
|
50
|
Valentino K, Campos GJ, Acker KA, Dolan P. Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department. J Pediatr Health Care 2020; 34:522-534. [PMID: 32709522 DOI: 10.1016/j.pedhc.2020.05.005] [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: 03/14/2020] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department. METHOD A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed. RESULTS Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved. DISCUSSION Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.
Collapse
|