1. Quality improvement (QI) methodology improved adherence to national pediatric sepsis guidelines and was sustained during the study period.
2. After the QI intervention was implemented, there was an increase in cases of pediatric severe sepsis or septic shock between patient deaths from sepsis.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Early recognition and initiation of treatment for pediatric sepsis is key to preventing progression of disease and reducing mortality. Despite longstanding national and international guidelines (American Heart Association Pediatric Advanced Life Support [PALS], 2010; International Sepsis Consensus Conference, 2005), literature has shown limited adherence and multiple barriers to achieving these standards. This study analyzed adherence and outcomes in pediatric septic shock both before and after implementation of QI methodology. Early fluid resuscitation and vasoactive agents were the prime targets for improvement, though 100% adherence to all 5 components of the PALS bundle was eventually met and sustained during the study period. An increase in the mean cases between patient deaths for pediatric sepsis was also noted. This study is limited by lack of randomization and QI methodology tailored for this tertiary medical center. Nonetheless, results strongly suggest that targeted QI methodology can improve treatment adherence and reduce mortality for pediatric sepsis.
In-Depth [prospective cohort]: This study enrolled 242 patients with septic shock in a tertiary pediatric emergency department. A cohort of 126 pre-intervention patients with septic shock was enrolled from 2009-2011, while 116 were post-intervention from 2011-2013. Interventions included provider education, personalized feedback, order sets on electronic medical record (EMR), a lightning bolt on EMR that alerted all interdisciplinary providers to patient status, and a “shock clock” in resuscitation rooms to remind and track intervention efforts. Adherence to the 5-part bundle of PALS guidelines was measured – recognition in 5 minutes, vascular access in 5 minutes, antibiotics in 60 minutes, 60 mL/kg IV fluids in 60 minutes, vasoactive agents in 60 minutes – in addition to frequency of mortality from pediatric sepsis. Results showed marked improvement in the main targets of fluid resuscitation (37% pre-intervention to 100% post-intervention, P < 0.001) and initiation of vasoactive agents (35% to 100%, P < 0.001), though 100% adherence to all 5 components was met and sustained for the last 9 months of the study. The number of pediatric sepsis cases between each death from septic shock or severe sepsis increased over the study span.
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