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Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative
Raina Paul1, Matthew Niedner2, Ruth Riggs3
1Division of Emergency Medicine, Children's Hospital of Orange County, University of California Irvine, Orange California.
Insights
A modified sepsis care bundle in children, allowing more time for fluids and antibiotics, significantly reduced sepsis-related deaths. This approach proved more effective than the original, stricter bundle in improving pediatric sepsis outcomes.
Area of Science:
- Pediatric critical care medicine
- Quality improvement initiatives
- Sepsis management
Background:
- Sepsis care bundles are crucial for improving outcomes in pediatric patients.
- Previous guidelines emphasized very rapid interventions, potentially creating challenges in real-world application.
- Optimizing the timing of sepsis care elements is essential for reducing mortality.
Purpose of the Study:
- To enhance the utilization of a pediatric sepsis care bundle.
- To decrease 3- and 30-day sepsis-attributable mortality.
- To identify specific care bundle elements associated with improved patient outcomes.
Main Methods:
- A quality improvement collaborative (Improve Pediatric Sepsis Outcomes) involving 40 children's hospitals from January 2017 to March 2020.
- Analysis of two cohorts: IPSO Suspected Sepsis (ISS) and IPSO Critical Sepsis (ICS).
- Comparison of an original bundle (recognition, fluids < 20 min, antibiotics < 60 min) with a modified, time-liberalized bundle (recognition, fluids < 60 min, antibiotics < 180 min).
Main Results:
- Over 24,518 ISS and 12,821 ICS cases were analyzed.
- Modified bundle compliance increased over time in both cohorts.
- In the ISS cohort, 30-day mortality decreased by 35.7% (1.4% to 0.9%).
- In the ICS cohort, the modified bundle was associated with a significant reduction in 30-day mortality (4.75% to 2.4%), unlike the original bundle.
Conclusions:
- Timely sepsis treatment is vital for reducing pediatric mortality.
- A time-liberalized sepsis care bundle demonstrated greater effectiveness in reducing sepsis-attributable mortality compared to a stricter, original bundle.
- The findings support the adoption of modified, evidence-based sepsis care bundles in pediatric settings.
Objectives:
We sought to improve utilization of a sepsis care bundle and decrease 3- and 30- day sepsis-attributable mortality, as well as determine which care elements of a sepsis bundle are associated with improved outcomes.
Methods:
Children's Hospital Association formed a QI collaborative to Improve Pediatric Sepsis Outcomes (IPSO) (January 2017-March 2020 analyzed here). IPSO Suspected Sepsis (ISS) patients were those without organ dysfunction where the provider "intended to treat" sepsis. IPSO Critical Sepsis (ICS) patients approximated those with septic shock. Process (bundle adherence), outcome (mortality), and balancing measures were quantified over time using statistical process control. An original bundle (recognition method, fluid bolus < 20 min, antibiotics < 60 min) was retrospectively compared with varying bundle time-points, including a modified evidence-based care bundle, (recognition method, fluid bolus < 60 min, antibiotics < 180 min). We compared outcomes using Pearson χ-square and Kruskal Wallis tests and adjusted analysis.
Results:
Reported are 24 518 ISS and 12 821 ICS cases from 40 children's hospitals (January 2017-March 2020). Modified bundle compliance demonstrated special cause variation (40.1% to 45.8% in ISS; 52.3% to 57.4% in ICS). The ISS cohort's 30-day, sepsis-attributable mortality dropped from 1.4% to 0.9%, a 35.7% relative reduction over time (P < .001). In the ICS cohort, compliance with the original bundle was not associated with a decrease in 30-day sepsis-attributable mortality, whereas compliance with the modified bundle decreased mortality from 4.75% to 2.4% (P < .01).
Conclusions:
Timely treatment of pediatric sepsis is associated with reduced mortality. A time-liberalized care bundle was associated with greater mortality reductions.
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