Raina Paul

Pediatric severe sepsis in U.S. children's hospitals.

Objectives: To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies. Design: Observational cohort study from 2004 to 2012. Setting: Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database. Patients: Children 18 years old or younger. Measurements and Main Results: We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9th edition, Clinical Modification–based coding strategies: 1) combinations of International Classification of Diseases, 9th edition, Clinical Modification codes for infection plus organ dysfunction (combination code cohort); 2) International Classification of Diseases, 9th edition, Clinical Modification codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and ICU length of stay, and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified 176,124 hospitalizations (3.1% of all hospitalizations), whereas the sepsis code cohort identified 25,236 hospitalizations (0.45%), a seven-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p < 0.001 for trend in each cohort). Length of stay (hospital and ICU) and costs decreased in both cohorts over the study period (p < 0.001). Overall, hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2% [95% CI, 20.7–21.8] vs 8.2% [95% CI, 8.0–8.3]). Over the 9-year study period, there was an absolute reduction in mortality of 10.9% (p < 0.001) in the sepsis code cohort and 3.8% (p < 0.001) in the combination code cohort. Conclusions: Prevalence of pediatric severe sepsis increased in the studied U.S. children’s hospitals over the past 9 years, whereas resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to seven-fold depending on the strategy used for case ascertainment.

Adherence to PALS Sepsis Guidelines and Hospital Length of Stay

BACKGROUND AND OBJECTIVES: Few studies have evaluated sepsis guideline adherence in a tertiary pediatric emergency department setting. We sought to evaluate (1) adherence to 2006 Pediatric Advanced Life Support guidelines for severe sepsis and septic shock (SS), (2) barriers to adherence, and (3) hospital length of stay (LOS) contingent on guideline adherence. METHODS: Prospective cohort study of children presenting to a large urban academic pediatric emergency department with SS. Adherence to 5 algorithmic time-specific goals was reviewed: early recognition of SS, obtaining vascular access, administering intravenous fluids, delivery of vasopressors for fluid refractory shock, and antibiotic administration. Adherence to each time-defined goal and adherence to all 5 components as a bundle were reviewed. A detailed electronic medical record analysis evaluated adherence barriers. The association between guideline adherence and hospital LOS was evaluated by using multivariate negative binomial regression. RESULTS: A total of 126 patients had severe sepsis (14%) or septic shock (86%). The median age was 9 years (interquartile range, 3–16). There was a 37% and 35% adherence rate to fluid and inotrope guidelines, respectively. Nineteen percent adhered to the 5-component bundle. Patients who received 60 mL/kg of intravenous fluids within 60 minutes had a 57% shorter hospital LOS (P = .039) than children who did not. Complete bundle adherence resulted in a 57% shorter hospital LOS (P = .009). CONCLUSIONS: Overall adherence to Pediatric Advanced Life Support sepsis guidelines was low; however, when patients were managed within the guideline’s recommendations, patients had significantly shorter duration of hospitalization.

Improving Adherence to PALS Septic Shock Guidelines

BACKGROUND AND OBJECTIVES: Few studies have demonstrated improvement in adherence to Pediatric Advanced Life Support guidelines for severe sepsis and septic shock. We sought to improve adherence to national guidelines for children with septic shock in a pediatric emergency department with poor guideline adherence. METHODS: Prospective cohort study of children presenting to a tertiary care pediatric emergency department with septic shock. Quality improvement (QI) interventions, including repeated plan-do-study-act cycles, were used to improve adherence to a 5-component sepsis bundle, including timely (1) recognition of septic shock, (2) vascular access, (3) administration of intravenous (IV) fluid, (4) antibiotics, and (5) vasoactive agents. The intervention focused on IV fluid delivery as a key driver impacting bundle adherence, and adherence was measured using statistical process control methodology. RESULTS: Two-hundred forty-two patients were included: 126 subjects before the intervention (November 2009 to March 2011), and 116 patients during the QI intervention (October 2011 to May 2013). We achieved 100% adherence for all metrics, including (1) administration of 60 mL/kg IV fluid within 60 minutes (increased from baseline adherence rate of 37%), (2) administration of vasoactive agents within 60 minutes (baseline rate of 35%), and (3) 5-component bundle adherence (baseline rate of 19%). Improvement was sustained over 9 months. The number of septic shock cases between each death from this condition increased after implementation of the QI intervention. CONCLUSIONS: Using QI methodology, we have demonstrated improved adherence to national guidelines for severe sepsis and septic shock.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

Objectives: The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine “Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.” Design: Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006–2014). The PubMed/Medline/Embase literature (2006–14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. Measurements and Main Results: The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. Conclusions: The major new recommendation in the 2014 update is consideration of institution—specific use of 1) a “recognition bundle” containing a trigger tool for rapid identification of patients with septic shock, 2) a “resuscitation and stabilization bundle” to help adherence to best practice principles, and 3) a “performance bundle” to identify and overcome perceived barriers to the pursuit of best practice principles.

Identifying Pediatric Severe Sepsis and Septic Shock: Accuracy of Diagnosis Codes

OBJECTIVES To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN Multicenter retrospective study at 6 US childrens hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.

Teamwork and Collaboration

Teamwork and collaboration in quality improvement efforts are critically important to successful improvement work in the healthcare setting. Quality improvement teams have unique features and structure compared to many traditional clinical teams. Moreover, team members must have or develop specific skill sets and familiarity with formal methods of improvement science to be most effective. As in all teams, team dynamics will largely influence the productivity and success. Finally, collaboration with patients and families and their role on teams leading to coproduction of care is emphasized.

Improving the Quality of Pediatric Healthcare through Quality Improvement Collaboratives

Opinion statementPurpose of review This review summarizes the current need for Quality Improvement Collaboratives (QICs) and includes considerations specific to pediatric healthcare, such as low-frequency of outcomes and unique funding barriers. This review will consider nuances within measure formation and data collection within QICs, available models for structured formation of a QIC, components that are integral to a QICs success, as well as lessons learned and future directions.Recent findings The literature has demonstrated an increase in the number of pediatric QI collaboratives in recent years. These collaboratives have varied in size, duration, and composition of team members. While some QICs have included members at the organizational level, others have included more novel groups such as insurance companies. Novel methodologies have also been utilized such as N of 1 trials focused on continued interventions for one patient and provider dyad. Successful QICs include use of a steering committee or pre-planning group to guide measures development, use of robust QI methodology to implement small tests of change and continuous feedback of individual and aggregate data and transparency among benchmarking sites. Ideal QI methods for use within QICs have been vetted in prior collaboratives and include formal barriers assessments using driver diagrams, PDSA cycles and analyzing data and measures using run and statistical process control (SPC) charts to inform real-time change and interventions.Summary QICs are pivotal to closing the gap in delivery of evidence based practice while minimizing widespread unnecessary practice variation across multiple organizations using available QI methodologies and tools. Novel approaches to funding such as partnership with insurance companies and educational organizations can allow for more robust participation. Future research should broaden the scope of their measures to include patient centered outcomes.

The Spectrum of Pediatric Sepsis: “Septicemia” Misses Severe Cases

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