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Improving adherence to PALS septic shock guidelines
Raina Paul1, Elliot Melendez2, Anne Stack3
1Department of Emergency Medicine, Pediatric Section, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina; and raina.paul@childrens.harvard.edu.
Insights
Pediatric Advanced Life Support guidelines adherence for septic shock improved significantly using quality improvement methods. This led to sustained improvements in care and better outcomes for critically ill children.
Area of Science:
- Pediatric Emergency Medicine
- Critical Care
- Quality Improvement Science
Background:
- Severe sepsis and septic shock in children require adherence to strict treatment guidelines.
- Previous studies show poor adherence to Pediatric Advanced Life Support guidelines for pediatric septic shock.
- This study addressed a pediatric emergency department with documented low adherence rates.
Purpose of the Study:
- To improve adherence to national guidelines for pediatric septic shock.
- To implement and evaluate quality improvement interventions.
- To focus on intravenous fluid delivery as a critical factor in sepsis management.
Main Methods:
- Prospective cohort study design.
- Implementation of quality improvement (QI) interventions using plan-do-study-act cycles.
- Statistical process control methodology to measure adherence to a 5-component sepsis bundle.
Main Results:
- Achieved 100% adherence to all 5 sepsis bundle components, including timely IV fluid and vasoactive agent administration.
- Baseline adherence rates for key metrics were low (e.g., 37% for IV fluids, 35% for vasoactive agents, 19% for the overall bundle).
- Improvements were sustained over 9 months, with an increased ratio of septic shock cases to deaths.
Conclusions:
- Quality improvement methodology effectively enhanced adherence to Pediatric Advanced Life Support guidelines for pediatric septic shock.
- The interventions demonstrated sustained improvements in critical care delivery.
- This approach offers a viable strategy for improving sepsis management in pediatric emergency settings.
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.
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