Pediatric Emergency Department Sepsis and Shock Early Intervention Protocol

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Pediatric Emergency Department Sepsis and Shock
Early Intervention Protocol
Richard Greenberg, MD Gitte Larsen, MD, MPH Nancy
Mecham APRN,FNP Tracy Hill, RN, MSN Primary
Childrens Medical Center University of Utah Salt
Lake City, Utah
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Disclosures

• The authors have no conflicts of interest to
  disclose
• The authors disclose that this presentation will
  not involve comments or discussion of products,
  drugs, or devices that are unapproved or off
  label, experimental, or of investigational use

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Natural History of Shock
Normal
Death
Hypovolemia (early compensated shock)
Irreversible Shock
Compensated Shock
Uncompensated Shock
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Background

• Shock inability of the body to provide
  nutrients, including oxygen and macromolecules,
  to the tissues and cells
• Many different causes, sepsis is one cause
• Sepsis (shock serious infection) major cause of
  morbidity and mortality in children
• 42,000 cases annually United States (U.S.)
• 10 mortality rate U.S.
• 7 all childhood deaths U.S. due to sepsis

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Background

• Adult Surviving Sepsis Campaign
• International consensus
• Evidence-based guidelines for care of sepsis
  patients
• Action plan to improve high rate of morbidity and
  mortality due to sepsis
• Few reports in literature about protocol
  implementation to aid in the identification and
  treatment of pediatric sepsis/shock

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Outline of Context

• To impact outcome from shock, intervention needs
  to begin as early as possible
• Early intervention for shock and sepsis improves
  morbidity and mortality
• Mortality risk doubles for each hour of
  uncorrected shock

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Outline of Context Setting

• Academic tertiary care practice
• Free standing pediatric, 253 bed hospital
• 45,000 Emergency Department (ED) visits annually

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Outline of Problem

• Analysis of pediatric morbidity and mortality at
  our hospital
• Missed opportunities of recognition and treatment
  of compensated and uncompensated shock
• 8-10 deaths potentially preventable

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Problem Assessment

• Retrospective review of sepsis and shock cases
  from 1999-2006
• Estimated overall mortality 8.6
• Two areas for improvement
• 1) Earlier recognition of sepsis/shock cases
• 2) Earlier and more aggressive treatment of these
  patients

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Problem Assessment

• Problem 1 Delayed recognition of sepsis and
  shock
• Action Plan Create ED sepsis/shock triage
  protocol
• Goal high sensitivity and specificity of
  identification criteria to assist ED triage nurse

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Problem Assessment

• Problem 2 Delayed and sub-optimal treatment of
  sepsis and shock cases
• Action Plan Create ED sepsis/shock treatment
  guideline
• Ensure earlier evaluation by ED team
• Ensure rapid, systematic, and evidenced based
  treatment in the ED

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Strategy for Change

• Hypothesis Developing a process improvement
  procedure to rapidly identify and treat
  sepsis/shock would improve outcome

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Strategy for Change

• Multidisciplinary team of health care providers
  developed ED triage protocol and ED treatment
  guideline
• Combined individual triage protocol and treatment
  guideline elements into sepsis/shock bundle

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Strategy for Change

• ED sepsis/shock triage protocol
• Pediatric Advanced Life Support (PALS)1 vital
  sign parameters
• Inclusion criteria
• ED sepsis/shock treatment guideline
• Pediatric sepsis and shock care guidelines2

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Strategy for Change

• Triage Protocol
• Criteria to identify patients with potential
  early sepsis or shock and triage as
  Resuscitation
• Once identified ? initiation of sepsis/shock
  treatment guideline

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Strategy for Change

• Sepsis/shock bundle has 6 elements
• Triaged Resuscitation
• ED Attending at bedside within 15 minutes
• Blood cultures drawn prior to antibiotics
• Antibiotics given within 3 hours
• Minimum 20 ml/kg IV fluid bolus in 1 hour
• Lactate level drawn in ED

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Roadblocks to Change

• General concern of increased work burden and use
  of limited resources for patients without
  sepsis/shock
• Healthcare provider belief that they were already
  able to identify sepsis/shock cases
• I can tell if the child doesnt look well
• ED physician opinion that no problem existed with
  current treatment of sepsis/shock

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Mechanism for Change

• Two week pilot study
• Project feasibility
• Estimate number patients meeting inclusion
  criteria at triage
• Survey staff concerns
• Educate staff that a problem exists

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Mechanism for Change

• Pilot study results demonstrated study
  feasibility and a small increase in work load
• Educate staff (e.g. role of lactate in sepsis)
• Train staff re implementation
• Multiple training courses for healthcare
  providers
• Address staff concerns
• Discussed data re possible extra workload
• Importance of early recognition of sepsis/shock

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Mechanism for Change

• Individual Feedback
• Education and discussion
• For failure to triage patients who met criteria
• For missed elements of the treatment guideline
• Warning possible disciplinary action from
  hospital administration for non-compliance

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Measurement of Improvement

• Monthly review of ED patients with final hospital
  discharge diagnosis of sepsis/shock
• Monitored compliance ED triage protocol
• Monitored compliance sepsis/shock bundle 6
  individual elements and bundle as a whole
• Patient outcomes tracked
• Mortality, length of stay (LOS), and cost

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Results

• 65 patients sepsis/shock over 11 months
• 31/65 (48) male
• Mean age 7.9 years (range 0-25 years)
• Protocol criteria identified 64/65 (98.5)
  sepsis/shock patients
• 394 patients triaged into protocol
• Total ED census 39,095 (394/39,095 1.0)

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Results

• PICU LOS mean 2.8 days (median 1.5 days)
• Hospital LOS mean 9.4 days (median 5.0 days)
• U.S national average mean 31 days
• Total cost mean 29,084 USD
• U.S. national average mean 47,050 USD

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Effects of Change

• Mortality rate prior to protocol 8.6

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Lessons Learned

• Staff involvement ? improved compliance
• Implementation and design of protocol
• Specific education
• Timely feedback regarding outcomes
• Future Projects
• Advocate greater and earlier involvement of staff
  regarding project specifics that they can
  influence

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Message to Others

• We report successful implementation of an ED
  protocol for pediatric sepsis and shock
• Potential to improve patient outcomes
• Mortality 10.5 (4/38) ? 0 (0/27)
• Overall mortality 6.2
• Highly sensitive (98.5) identification pediatric
  sepsis/shock
• Low overall increase in work burden

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The End