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Use of a Sepsis Score can help teams identify early indicators of sepsis and improve the time to notification of a clinical provider, which can also improve the time to therapeutic management. The EC Pediatric Sepsis Evaluation Clinical Pathway is a guide for use of the Sepsis Score in the emergency center (EC).
Severe Sepsis: Sepsis with signs and symptoms of organ hypoperfusion or dysfunction including cardiovascular dysfunction, respiratory distress, or multiorgan dysfunction in 2 or more organ systems. Septic Shock: Sepsis with cardiovascular dysfunction that persists despite fluid resuscitation (40ml/kg isotonic fluid).
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Within 1 hour of initial recognition of septic shock, the following six steps should be performed: (1) obtain intravenous/intraosseous access; (2) collect blood culture; (3) start empiric broad-spectrum antibiotics; (4) measure lactate; (5) administer fluid bolus if shock persists; and (6) start vasoactive agents if shock persists.54
- Kam Lun Hon, Karen Ka Yan Leung, Felix Oberender, Felix Oberender, Alexander Kc Leung
- 2021
- Conflict of Interest
- Agenda
- Learning Objectives
- Background
- Adults
- Children
- Creating a Pediatric Sepsis Detection Algorithm
- Project Goal
- Partnering with the Vendor
- Challenges
- Neurologic Dysfunction
- Defining gold standard sepsis cohort
- Algorithm Performance
- Implementation into Clinical Workflows
- +SIRS/SEPSIS ALERT
- What’s next
- EMR Team
- Questions
Statistical and project management support for this study were provided by an electronic medical record vendor Drs. Madden and Eisenberg received no financial support and have no other disclosures or conflicts of interest
Background Creating a pediatric sepsis detection algorithm Algorithm performance Implementation into clinical workflows Future directions
Recognize the process used to develop and evaluate the pediatric sepsis algorithm at Boston Children’s Hospital Describe the range of operating characteristics of the pediatric sepsis algorithm based on different changes to the algorithm Identify the strategy for inserting the algorithm into clinical workflows Discuss the plans to iterate on the al...
Pediatric vs. adult sepsis Quality improvement efforts in pediatric sepsis
Sepsis identification tools based on one set of criteria Organ dysfunction included in sepsis definition Hypotension an earlier sign
Vital sign & lab criteria differ based on age groups Tools must incorporate many different age-based cutoffs Organ dysfunction a later sign Hypotension occurs late Paul,
Algorithm creation Defining sepsis “gold standard”
Develop an automated sepsis screening tool to alert clinicians of children at risk of severe sepsis Earlier detection Prevent missed cases more rapid intervention
Vendor had pre-existing adult sepsis screening tool Not designed for use in children Vendor team Performance improvement strategists Statisticians BCH team Critical care and emergency medicine physicians
Difficult to distinguish sepsis from vital signs/labs alone Most detection tools have low specificity High risk of alarm fatigue Sepsis and severe sepsis are not easily defined Gold standard needed to evaluate tool performance Diagnosis codes inaccurate
Mental Status identified as Decreased, Irritability, Confusion, inappropriate crying or drowsiness, poor interaction with parents, lethargy, diminished arousability, or obtunded (ALTERED_MENTAL_STATUS_CLIN, IRRITABILITY_CLIN, CONFUSION_CLIN, LETHARGY_CLIN, CRYING_EXCESSIVE_OR_INAPPROPRIATE_CLIN, DROWSINESS_CLIN, OBTUNDED_CLIN)
No single test defines sepsis ICD codes are inaccurate Defined gold standard by clinician “intention to treat” severe sepsis Also adopted by IPSO sepsis collaborative
Performance of the initial algorithm Iterations to improve performance Final performance characteristics
Current state Implementation in the emergency department
Alert goes to attending, trainee and RN assigned on tracking board No assignment Any RN with “relationship”
Continued cycles of improvement Adding to the model to further improve PPV Risk of infection History of chemo order, indwelling lines Suspected infection Microbial test or antimicrobial given Changes in vital signs What’s next Complete ED implementation and evaluate Prospective study ongoing Outcomes: missed cases, timeliness of interventions, ICU ...
Jeff Christianson, PhD Abbey Logan, Strategist Justin Kimbrell, Sr. Strategist
Contact Info: matthew.eisenberg@childrens.harvard.edu kate.madden@childrens.harvard.edu Please complete online session evaluation
- 1MB
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Rapid identification and treatment of pediatric patients ≥ 60 days presenting in septic shock. Create a team-oriented approach to efficient and timely evaluation and work-up. Early and aggressive treatment to stabilize hemodynamic status and reverse shock.
septic shock increases over a continuum. Early signs and symptoms of septic shock are a result of the body’s compensatory mechanisms while late signs are indicative of decompensation. Assess for the early indications of shock along with the signs below: Widened pulse pressure due to decreased diastolic pressures
early and accurate diagnosis of sepsis a challenge. For example, common symptoms such as fast heart rate and fast breathing may indicate a child is afraid or anxious. However, sepsis also can be overlooked in children because low blood pressure (a sign of septic shock) may not occur until very late in the illness.
