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A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned
Raina Paul1, Elliot Melendez1, Beth Wathen1
1Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine Northwestern University, Chicago, Ill.; Division of Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, Fla.; Children's Hospital Colorado, Pediatric Intensive Care Unit, Aurora, Colo.; Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah; Hasbro Children's Hospital, Alpert Medical School, Providence, R.I.; Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Dell Children's Medical Center, Austin, Tex.; Department of Pediatrics, Section of Emergency Medicine and The Center for Clinical Effectiveness, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex.; and The Center for Clinical Effectiveness, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex.
Insights
A quality improvement initiative improved early sepsis recognition and resuscitation in children but did not reduce overall mortality. Further standardization is needed for sepsis management to improve outcomes.
Area of Science:
- Pediatric critical care
- Quality improvement science
- Infectious disease management
Background:
- Sepsis is a significant cause of pediatric morbidity and mortality globally.
- Timely recognition and management of sepsis in emergency settings face several barriers.
- This study aimed to reduce pediatric sepsis mortality through a quality improvement collaborative.
Purpose of the Study:
- To implement and evaluate a quality improvement collaborative for pediatric sepsis.
- To improve the timely recognition and resuscitation of children with sepsis.
- To ultimately reduce mortality associated with pediatric sepsis.
Main Methods:
- A 1-year quality improvement collaborative involving 15 hospitals.
- Intervention focused on recognition, escalation, and the first hour of resuscitation for pediatric sepsis.
- Monthly learning sessions and data feedback facilitated rapid cycle improvement.
Main Results:
- Seven hospitals provided analyzable data for 1,173 pediatric patients.
- Improved initial clinical assessment (46% to 60%) and fluid bolus adherence (38% to 46%) were observed.
- No statistically significant reduction in 3- or 30-day mortality was found for sepsis or septic shock.
Conclusions:
- The quality improvement collaborative enhanced some sepsis care processes but did not decrease mortality.
- Standardization of sepsis definitions and care processes, including "time zero," is crucial for future efforts.
- Further research and national initiatives are needed to effectively combat pediatric sepsis mortality.
Background:
Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis.
Methods:
Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement.
Results:
Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality.
Conclusions:
A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a "time zero" for measuring the timeliness of treatment.
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