Post on 22-Dec-2015
PEDIATRIC SEPTIC SHOCK COLLABORATIVE
Educational Content (Sepsis, Septic Shock, & QI Primer)
Goals• Review the impact of sepsis on patient outcomes
• Define the sepsis disease spectrum
• Review the evidenced based guidelines for the management of severe sepsis/septic shock
• Outline quality improvement strategies for change
IMPACT OF SEPSIS ON PATIENT OUTCOMESEducational Content
Epidemiology• Over 18 million cases worldwide each year
• The annual incidence in the US of severe sepsis is approximately 3.0 cases per 1,000
• Sepsis kills approximately 1,400 people worldwide EVERYDAY
Epidemiology-Pediatric • Sepsis is a leading cause of illness & death among U.S. children• > 42,000 cases annually (4th leading cause behind asthma,
appendicitis, and poisonings)• 5-10% overall mortality (0-5% healthy children; 10% if
underlying medical conditions)
• 7-9 % of all childhood deaths are due to sepsis (more common than cancer)
Watson Am J Respir Crit Care Med 2003 167:695-701Kutko Pediatr Crit Care Med 2003; 4:333-337Carcillo Crit Care Med 2002 30(6):1365-1378
Conditions Associated with High Hospital Resource Use
Condition Mean Cost Mean LOS
Severe Sepsis ~$40,600 31 days
IRDS ~$35,000 25 days
Spinal cord injury ~$25,000 16 days
Prematurity ~$24,000 22 days
Heart valve disease ~$23,000 9 days
Watson RS et al, Am J Respir CCM 2003
Sepsis Disease Spectrum
Presentation of sepsis reflects a spectrum
SIRS Sepsis Severe Sepsis
Septic Shock
Definitions• Systemic Inflammatory Response Syndrome (SIRS): 2 of 4 criteria • Temp <36 or >38.5• HR >2 SD above normal for age (or bradycardia if <1
year old*)• RR > 2 SD above normal for age• Abnormal WBC or > 10% immature neutrophils
• Sepsis: SIRS with suspected or confirmed infection
• Severe sepsis: Sepsis + organ dysfunction or failure
Goldstein Pediatr Crit Care Med 2005 6(1):2-8
Definitions• Septic shock= Hypothermia or hyperthermia and signs of cardiovascular organ dysfunction including• Altered or decreased mental status (inconsolable irritability, lack of
interaction with parents and inability to be aroused)
• Capillary refill ≥3sec (cold shock) or flash capillary refill (warm shock)
• Diminished (cold shock) or bounding peripheral pulses (warm shock)
• Mottled cool extremities (cold shock)
• Decreased urine output <1 mL/kg/hr
• Hypotension
Carcillo Crit Care Med 2002
30(6):1365-1378
2 Major Types of Septic Shock
•Cold Shock• Cold extremities
• Capillary refill ≥ 3 sec
• Myocardial Dysfunction
• Low CI and high SVRI
• Sick heart with significant vasoconstriction to maintain perfusion to organs
•Warm Shock• Warm extremities
• Flash capillary refill
• Vasomotor Paralysis
• High CI and low SVRI
• Hyperdynamic heart with vasodilation
Definitions
• Compensated shock: • Systolic blood pressure within normal range with signs and symptoms of inadequate perfusion
• Children more often present in compensated shock
• Decompensated shock: • Signs of shock associated with systolic hypotension
Further Definitions• Fluid-refractory shock:
• Shock despite 60 cc/kg in 1st hour
• Dopamine-resistant shock: • Shock despite adequate fluid resuscitation and 10
mcg/kg/min
• Catecholamine-resistant shock: • Shock despite epinephrine or norepinephrine
• Refractory shock:• Shock despite goal-directed use of inotropic agents,
vasopressors, vasodilators, and maintenance of metabolic and hormonal homeostasis
Carcillo Crit Care Med 2002
30(6):1365-1378
Sepsis: A Disease Continuum•Patients with life-threatening infection often present with fever and excessive, persistent tachycardia
•Tachycardia, tachypnea, and signs of worsening perfusion precede hypotension
•Hypotension is a late, ominous sign in pediatrics•Often followed by cardiopulmonary collapse
•Stopping progression to hypotension (decompensated shock) via early aggressive interventions improves outcomes
THE EVIDENCEEducational Content
Han et al., Pediatrics 112: 2003
p < .001
p < .001
Each hour of delay associated with 50%
increased odds of mortality
Rivers et al., NEJM 2001
Adult Mortality Reduced by 15% with Early Goal Directed Therapy
For every 6 adults with
septic shock who are treated
effectively, 1 death is
prevented
Early Rapid Fluid Resuscitation in Pediatric Septic Shock is Associated with Improved
Outcomes
Oliveira et al, Ped Emergency Care 24:2008
Time-sensitive Fluid-sensitive
% M
ort
alit
y
Every hour delay in receiving effective antibiotics is associated with a 7.6% decrease in survival in
adults with septic shock
Kumar et al, Crit Care Med 34: 2006
EVIDENCED BASED GUIDELINESEducational Content
Pediatric Septic Shock Guidelines
• Early aggressive fluid resuscitation (up to 60 cc/kg in the first 15 minutes)• Proportionally larger quantities of fluid in children
• Initial volume resuscitation commonly requires 40-60 cc/kg but can be as much as 200 cc/kg in the 1st hour
• Reassess between boluses for signs of volume overload—hepatomegaly, rales, gallops
• Vasoactive agents for fluid refractory shock• Can be given through peripheral IV until central access is
obtained• Initiate dopamine for fluid-refractory shock• Initiate norepinephrine (warm shock) or epinephrine (cold shock)
for fluid-dopamine-refractory shock• Remember short half life therefore rapid titrations are needed
• Hydrocortisone for adrenal insufficiency• Identify need for invasive cardiovascular monitoring for fluid-
refractory shock Carcillo Crit Care Med 2002 30(6):1365-1378
Pediatric Septic Shock Guideline
• Therapeutic goals include:• Capillary refill time ≤ 2 seconds
• Normal pulses with no differential between peripheral and central pulses
• Warm extremities
• Urine output > 1 cc/kg/hr
• Normal mental status
• Normal blood pressure for age
ACCM Guidelines: 60 cc/kg in 15 minutes
PALS Guidelines: 60 cc/kg in 60 minutes
The PSSCClinical
Pathway
0-20 min
TRIAGE TRIGGER TOOLHigh Risk Conditions
Vital Signs
Signs of Perfusion
TRIAGE TRIGGER TOOL
Identify as at risk for sepsis if:1. Hypotension or2. Meets 3/8 criteria or3. Meets 2/8 criteria if high-
risk
0-20 min
20-60 min
>60 min
Intubation and Septic Shock• Low threshold for ET intubation even without primary
respiratory failure• Up to 40% of cardiac output may be devoted to work of breathing;
this can be unloaded
• Atropine, ketamine preferred agents for sedation
• Caution with etomidate
PEDIATRIC SEPTIC SHOCK COLLABORATIVE
Educational Content (Quality Improvement Primer)
QI BASICS
• Create a mission statement• Identify specific aims• Identify measures• Gather key stakeholders• Needs assessment• Rapid cycle change
Plan-Do-Study-Act
EXAMPLE OF QI INITIATIVEQuality Improvement Primer
Mission Statement• To improve the care of children with severe sepsis and septic shock in a pediatric emergency medicine department
Modified from Pediatric Advanced Life Support Manual. American Heart Association. 2006.
Recognize altered mental status and poor perfusion
Establish vascular access and begin resuscitation
Recognize altered mental status and poor perfusion
Establish vascular access and begin resuscitation
1st hour: Push repeated 20 mL/kg IVF up to 3
Administer antibiotics STAT
1st hour: Push repeated 20 mL/kg IVF up to 3
Administer antibiotics STAT
Fluid responsive (i.e. normalization of BP and/or perfusion)?
Fluid responsive (i.e. normalization of BP and/or perfusion)?
Begin vasoactive drug therapy and titrate to correct hypotension / poor perfusionBegin vasoactive drug therapy and titrate to correct hypotension / poor perfusion
Consider ICU monitoring
Consider ICU monitoring
Background
1st hour
noyes
5 min
5 min
60 min
60 min
60 min
PALS (2006)
Needs Assessment
0
10
20
30
40
50
60
70
80
90
100
PALS Intervention
% Adherence
Fluid adherence
n= 29(mean # days)
Fluid non-adherence
n= 98(mean # days)
% decrease P value
HospitalLOS
8.0 11.2 57% 0.039
ICU LOS 5.5 7.2 42% 0.024
Total algorithm adherence
n= 15(mean # days)
Total algorithm non-adherence
n= 112(mean # days)
% decrease P value
HospitalLOS
6.8 10.9 57% 0.009
ICU LOS 5.5 6.8 59% 0.035
Needs Assessment
Aim Statement
• Increase adherence to the Pediatric Advanced Life Support Guidelines
• for severe sepsis and septic shock in the Children’s Hospital Boston Emergency department
• from 19% overall adherence to the 5 component bundle to > 90% adherence
• within one year
Secondary Aims• COMPONENTS OF THE BUNDLE:• Improve recognition: > 90 % of patients are recognized within
5 minutes of meeting definition of SS
• Improve attainment of vascular access: (peripheral, intraosseous or central): >90% of patients have access within 5 minutes of meeting definition of SS
• Improve delivery of fluid: > 90% of patients have 60 ml/kg of isotonic fluid delivered within 60 minutes of meeting definition of SS
• Improve delivery of antibiotics: >90% of patients have antibiotics delivered within 60 minutes of meeting definition of SS
• Improve delivery of vasoactive agents: > 90% of patients have a vasoactive agent begun at 60 minutes of meeting definition of SS
Measures• Outcome Measures
• Mortality• Length of stay in ICU, hospital• Days on vasoactive agents• Multiorgan dysfunction syndrome
• Process Measures• Adherence to recognition, vascular access, IV fluid,
antibiotic and vasoactive agents
• Balancing Measures• ED length of stay• Increased respiratory support due to pulmonary
edema
Team Members
Frontline workers Physicians
NursingRespiratory
Nursing assistantsPharmacists
Middle Management
Statistical Support
Computer Support
Upper Level Management
Physician Leadership
Nursing Leadership
Hospital Leadership
Research Assistants
Pharmacy Head
60ml/kg within 60 minutes
EnvironmentMethods
PeopleEquipment
No IV access
Access tenuous
Hesitance to use IO
Waiting for IV team
Wrong fluid device used
Can’t find pressure bag
Don’t know to use pressure bag
Don’t know how to use pressure bag
Pharmacists difficult to get a hold of
People don’t know pharmacy number
CA’s cannot be reached
Holding for other procedures
CA phones numbers not uniformly posted, some don’t have phones
Need labels to sent labs
CA’s usually get labels but are busy holding for IV
MD’s are too busy with patient to put in orders
Poor knowledge of protocol
No educational sessions
No visible algorithms
No pocket cards for bedside reference
Many trainees to educate, many adult trainees
Too busy to recognize septic patients
Too many patients
Not enough MDS
No trigger system
No accountability/feedback Poor RN/MD
communication
Many trainees
MD’s don’t know who the nurses are
Inotropes in 60 min
60ml/kg in 60 min
Vascular Access in 5 min
Antibiotics in 60 min
Recognition in 5 min
0
5
10
15
20
25
30
35
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Frequency Percent
Cumulative Percentage
Needs Assessment: Pareto
Change Hypotheses• Educational sessions MDs• Educational sessions RNs
• Didactics• Net learning• Skills Day (pressure bags)
• Computer Orderset
• Visible algorithm • Posters• Pocket cards
• Clock
• Bedside Survey
Ongoing
October 12
September 26
September 21, October 2
October 16
October 27
October 19
October 10
October 6
Modified from Pediatric Advanced Life Support Manual. American Heart Association.
RECOGNIZEaltered mental status / poor perfusion
VASCULAR ACCESS
RECOGNIZEaltered mental status / poor perfusion
VASCULAR ACCESS
IV FLUIDS60 mL/kg
pressure bag if >10kg
ANTIBIOTICS
IV FLUIDS60 mL/kg
pressure bag if >10kg
ANTIBIOTICS
Fluid Responsive (normalization of BP and/or perfusion)?
Fluid Responsive (normalization of BP and/or perfusion)?
VASOACTIVE DRUGtitrate quickly to correct
hypotension / poor perfusion
VASOACTIVE DRUGtitrate quickly to correct
hypotension / poor perfusion
Admission for
monitoring
Admission for
monitoring
no yes
SEVERE SEPSIS AND SEPTIC SHOCK PROTOCOL
WITHIN
0:05 min
WITHIN
1:00 hr
AT
1:00 hr
ED Septic Shock Orderset
Personal Feedback
Hi, This email is to let you know that your patient AT (24 year old Asperger's, panhypopit, vomiting and diarrhea) met the criteria for septic shock. He had fever, tachycardia (SIRS) and hypotension. You met the recognition in 5 minute goal!You met the IV access in 5 minute goal!You met the 60cc/kg in 60 minute goal for IVFs!You met the antibiotics in 60 minute goal!You met the pressor initiation at 60 minute goal!
MEASURE: Run Chart
Lower Control Limit
Upper Control Limit
MEASURE: SPC Chart
Example SPC chart
Nov 0
9
Dec 0
9
Jan
10
Feb 1
0
Mar
10
Apr 1
0
May
10
Jun
10
Jul 1
0
Aug 1
0
Sep 1
0
Oct 1
0
Nov 1
0
Dec 1
0
Jan
11
Feb 1
1
Mar
11
11-O
ct
11-N
ov
11-D
ec
12-J
an
12-F
eb0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total Bundle Adherence Pre and Post Intervention
Mean Adherence
Institutional Adherence
Lower Control Limit
Upper Control Limit
Month
Percent Adherence
INTERVENTION
The Improvement Guide: 1996
Sepsis and Septic Shock• Early, timely goal directed therapy improves patient outcomes and mortality
• A systematic approach is necessary for a successful quality improvement project