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Implementation of goal-directed therapy for children with suspected sepsis in the emergency department
Andrea T Cruz1, Andrew M Perry, Eric A Williams
1Department of Pediatrics, Sections of Emergency Medicine and Infectious Diseases, Baylor College of Medicine, 6621 Fannin St, Suite A210, MC 1-1481, Houston, TX 77030, USA. acruz@bcm.edu
Insights
Implementing a new emergency department protocol significantly improved the recognition and treatment of pediatric septic shock, reducing delays in critical interventions like fluid resuscitation and antibiotics.
Area of Science:
- Pediatric Emergency Medicine
- Critical Care
- Healthcare Systems Improvement
Background:
- Suboptimal care for pediatric septic shock is characterized by delayed recognition and insufficient fluid resuscitation.
- Systemic issues in sepsis recognition and management were identified through root-cause analyses and morbidity and mortality conferences.
Purpose of the Study:
- To implement an emergency department (ED) protocol for prompt recognition of septic shock.
- To enhance adherence to national treatment guidelines for pediatric sepsis.
Main Methods:
- Physician collaboration to identify barriers and develop solutions for sepsis management.
- Implementation of a computerized triage system with alerts for abnormal vital signs.
- Establishment of a dedicated resuscitation room for high-risk pediatric patients.
- Augmentation of staffing in nursing, respiratory therapy, and pharmacy.
- Standardized administration of fluids, laboratory studies, and antibiotics.
- Utilized a graphical flow sheet for continuous monitoring and documentation of interventions.
Main Results:
- The protocol led to a significant decrease in the median time from triage to first fluid bolus (56 to 22 minutes).
- Median time from triage to first antibiotics was substantially reduced (130 to 38 minutes).
- The study included 191 encounters in 167 pediatric patients with suspected sepsis.
Conclusions:
- The implemented protocol facilitated earlier recognition of pediatric septic shock.
- Significant reductions in the time to critical, time-sensitive interventions were achieved.
- The protocol led to a decrease in treatment variation for pediatric septic shock.
Background:
Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation.
Objective:
To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines.
Patients And Methods:
Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions.
Results:
To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001).
Conclusions:
The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.
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