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Causal Association of Physician-in-Triage with Improved Pediatric Sepsis Care: A Single-Center, Emergency Department
Ganga S Moorthy1, Jordan S Pung2, Neel Subramanian3
1From the Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina.
Insights
Early physician evaluation in the emergency department significantly reduced sepsis recognition and antibiotic delivery times in children. Implementing a physician-in-triage program is a key strategy for improving pediatric sepsis care.
Area of Science:
- Pediatric Emergency Medicine
- Sepsis Management
- Healthcare Quality Improvement
Background:
- Pediatric sepsis affects approximately 75,000 children annually in the US, with significant mortality rates.
- Timeliness of sepsis recognition and antibiotic administration are critical for improving patient outcomes.
- Existing care pathways require optimization for rapid sepsis identification and treatment in pediatric emergency departments.
Purpose of the Study:
- To assess and enhance the quality of pediatric sepsis care within a pediatric emergency department.
- To identify factors influencing the timeliness of sepsis recognition and antibiotic delivery.
- To evaluate the impact of a multidisciplinary sepsis task force initiative.
Main Methods:
- Utilized electronic medical records to identify pediatric sepsis patients from September 2015 to July 2021.
- Analyzed time-to-event data (sepsis recognition, antibiotic delivery) using statistical process control charts (X̄-S charts).
- Employed Bradford-Hill Criteria to guide multidisciplinary discussions for cause identification after observing special cause variation.
Main Results:
- Observed a significant decrease in time from ED arrival to blood culture orders (1.1 hours) and antibiotic administration (1.5 hours) starting in Fall 2018.
- Hypothesized that the initiation of attending-level pediatric physician-in-triage (P-PIT) was associated with improved sepsis care metrics.
- P-PIT reduced average time to the first provider exam by 14 minutes, enabling earlier physician evaluation before room assignment.
Conclusions:
- Early assessment by an attending-level physician demonstrably improves sepsis recognition and antibiotic delivery times in pediatric emergency settings.
- Implementing a physician-in-triage program with early attending physician involvement is a recommended strategy for other institutions to enhance pediatric sepsis care.
Abstract:
Approximately 75,000 children are hospitalized for sepsis yearly in the United States, with 5%-20% mortality estimates. Outcomes are closely related to the timeliness of sepsis recognition and antibiotic administration.
Methods:
A multidisciplinary sepsis task force formed in the Spring of 2020 aimed to assess and improve pediatric sepsis care in the pediatric emergency department (ED). The electronic medical record identified pediatric sepsis patients from September 2015 to July 2021. Data for time to sepsis recognition and antibiotic delivery were analyzed using statistical process control charts (X̄-S charts). We identified special cause variation, and Bradford-Hill Criteria guided multidisciplinary discussions to identify the most probable cause.
Results:
In the fall of 2018, the average time from ED arrival to blood culture orders decreased by 1.1 hours, and the time from arrival to antibiotic administration decreased by 1.5 hours. After qualitative review, the task force hypothesized that initiation of attending-level pediatric physician-in-triage (P-PIT) as a part of ED triage was temporally associated with the observed improved sepsis care. P-PIT reduced the average time to the first provider exam by 14 minutes and introduced a process for physician evaluation before ED room assignment.
Conclusions:
Timely assessment by an attending-level physician improves time to sepsis recognition and antibiotic delivery in children who present to the ED with sepsis. Implementing a P-PIT program with early attending-level physician evaluation is a potential strategy for other institutions.
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