Improving the quality of Pediatric Sepsis Care
Transcript of Improving the quality of Pediatric Sepsis Care
Improving the quality of Pediatric Sepsis Care
December9,2016
KathleenBrown,MDJeannePettinichi,MSN,RN
LearningObjectives
1. Describecurrentguidelinesforinitialmanagement
ofpediatricsepsis
2. Describequalityimprovementstrategiesfor
improvingpediatricsepsiscareintheED
3. Discussthecomponentsofapediatricsepsis
screeningtoolforearlyidentificationofsepsis.
March292012
• 9yoM,cutsarmingym->developsmyalgias,vomiting,fever
• EDdiagnoseswithgastroenteritis,receivesZofranandIVF,discharged
• Examnotedmottlingofskin– DischargeVitals:HR143,RR22,T102(noBPreported)
– CBCdrawnatthattimeshowedWBC14.7 (39%N,53%bands)butpatientdischargedbeforeresulted
Ourcase
• BacktoEDthefollowingdayinsepticshock,admittedtoICU– Bloodcultures:GroupAStreptococcus– Dateofinitialpresentation– March29– Dateofdeath- April1
CouldthishappeninmyED?
• >40,000USpediatricseveresepsiscases/year
• ~20,000pediatricsepticshock/year
• MortalityinUS4-10%forseveresepsisandsepticshock• Previouslywellchildren~4%• Highriskorchronicallyill7-
10%
• Sepsisorrelatedissuescauses7-9%ofallpediatricdeaths
ReviewofDefinitions
• Sepsis is life-threateningorgandysfunctionduetoadysregulatedhostresponsetoinfection*
• Sepsis:SIRS+Infection(suspectedorproven)
• SIRS(Needatleast2of4,onemustbeWBCorTemperature)• CoreTemp>38.5˚Cor<36˚C• Tachycardiaforage(orbradycardia if<1year)• Tachypneaforage• WBCelevatedordepressed
*VincentJ,AngusDC.TheThirdInternationalConsensusDefinitionsforSepsisandSepticShock(Sepsis-3).JAMA. 2016;315(8):801-810
GoldsteinB,\etal.InternationalConsensusConferenceonPediatricSepsis.Pediatr CritCareMed.2005;6(1):2.2005
Goldstein: Pediatric SIRS
Agegroup
Heartrate(beats/minute) Respiratoryrate(breaths/minute)
Leukocytecount(leukocytesx103/mm3)
Systolicbloodpressure(mmHg)Tachycardia Bradycardia
Newborn(0daysto1week)
>180 <100 >50 >34 <59
Neonate(1weekto1month)
>180 <100 >40 >19.5or<5 <79
Infant (1monthto1year)
>180 <90 >34 >17.5or<5 <75
Toddlerandpreschool(>1to5years)
>140 NA >22 >15.5or<6 <74
Schoolage(>5to12years) >130 NA >18 >13.5or<4.5 <83
Adolescent(>12to<18years)
>110 NA >14 >11or<4.5 <90
SurvivingSepsisCampaign
• “GRADES”recommendations– Includes“pediatricconsiderations”
• LargeQIinitiative– Bundles– Datacollection
DellingerRPetal.SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock,2012IntensiveCareMed2013
http://www.survivingsepsis.org/About-SSC/Pages/default.aspx
The Basics
• Earlyrecognition
• Timely/adequatefluidresuscitation– TimelyIVacess– Reversalofperfusionabnormalitiesasendpoint
• Earlyantibiotics
• Timelypressors
Howarewedoing?
• 3studiesattertiarycarechildren’shospitals– (Houston,SaltlakeCityandBoston)
• Poorcompliancewithadherencetoguidelines– Barrierstocompliancerecognized
• InitialQIeffortsreported
CruzAT,PerryAM,WilliamsEA,etal.Implementationofgoal-directedtherapyforchildrenwithsuspectedsepsisintheemergencydepartment.Pediatrics.2011;127(3).LarsenGY,Mecham N,GreenbergR,etal.Anemergencydepartmentsepticshockprotocolandcareguidelineforchildreninitiatedattriage.Pediatrics.2011;127(6).PaulR,Neuman MI,Monuteaux MC,MelendezE.AdherencetoPALSsepsisguidelinesandhospitallengthofstay.Pediatrics.2012;130
Boston
• 126subjectsbeforetheintervention– (November2009toMarch2011)
• 116patientsduringtheQIintervention– (October2011toMay2013)
• 5-componentbundle(baselinerateof19%)– Recognitionin5min– Vascularaccessin5min– Antibioticsin60min– 60/kgin60mins– Pressors in60mins
PaulRetal,ImprovingAdherencetoPALSSepticShockGuidelines.Pediatrics, 2014
SaltLakeCity
• 1380Patientswithsepticshock(2007-2014)inED– QIinitiative• Bundle–Timelyantibiotics,– Intravenousfluids(IVF)forrapidreversalofperfusionabnormalitiesand/orhypotension
• Triagescreening
LaneRDetal.HighReliabilityPediatricSepticShockQualityImprovementInitiativeandDecreasingMortalityPediatrics.2016
EarlyrecognitionScreeningtool:PCH(paperbased)
2013 2014
Sensitivity%(95%CI) 97(95–99) 100(100–100)a
Specificity%(95%CI) 98(98–98)b 97(97–98)b
PPV%(95%CI) 24(21–27) 15(13–17)
NPV%(95%CI) 100(100–100)b 100(100–100)b
Meanfalsepositiverate=80%
Earlyrecognition:CHOPelectronic
Balamuth Fetal.ComparisonofTwoSepsisRecognitionMethodsinaPediatricEmergencyDepartment Acad Emerg Med.2015Nov;22(11):1298–1306.
TheEDPediatricSepticShockCollaborative
• SponsoredbytheAmericanAcademyofPediatrics(AAP)• >40ED’s• QIstudydesignwithrapidcyclechanges– 1yearofretrospectivedata5yearsprospective– Allsitesmustinstituteascreeningtoolandtreatmentprotocol
– Noscreeningortreatmentmandates• BUTaskedtostayasclosetosuggestedscreeningmechanismaspossible• TreatmentbasedonbestpracticeguidelinesperPALS/SurvivingSepsis
QualityImprovementStrategies
• Increasingcompliancewithsepsisqualityindicators• Multidisciplinaryteamcollaboration• Education- introduceguidelinesintoclinicalpractice• Protocoldevelopmentandimplementation• Datacollection• Feedback– tofacilitatecontinuousimprovement• Ongoingeducation
Education
SepsisTraining1. Onlineeducationalcourse(1hour)- withpreandposttest
andat3months– AllStaff2. Clinicalsepsiscasestudyscenariosincludinghands-on
demonstrationofpush-pullIVFadministration,IOplacement,vasopressordripcalculationandadministration.
3. Sepsisalerttrainingwithdecisionsupportexplanation&nursingdocumentationrequirements
4. Sepsisalertprocesssteps
PDSAInterventions
1. Summer2014§ HandsonEducation
2. May2015§ Automatedscreeningalgorithm&EHRalert§ Powerplan§ Onlineeducationaltool
3. July2015§ Simplificationofscreeningalgorithm
4. May2016§ WeeklyIndividualFeedback
5. July2016§ Pre-assignedSepsisTeam
6. August2016§ Re-educationandreinvigorationofsepsisinitiative
7. October2016§ FeedbackForm§ Huddlereminders/ChargeNursecommunication
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Bolus1_Median
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SepsisTeam/Re-education
IndividualFeedback
RNSepsisEducation
EHRAlert&Powerplan
FeedbackForm
ImprovementTimeline
Backtoourpatient
• Feverwouldhavemandateduseoftool– (T102F)
• Examnotedmottlingofskin(1point)• VSHR143,RR22 (2points)
• Wouldhavetriggeredcloserevaluation