Quality Improvement Methods Improve Sepsis Care in Children

Veronica Hackethal, MD

April 18, 2014

A quality improvement (QI) intervention can improve adherence to pediatric septic shock guidelines, and possibly improve mortality, according to a study by researchers in Winston-Salem, North Carolina, and Boston, Massachusetts, published online April 7 in Pediatrics.

According to background information in the article, the American Heart Association's 2010 Pediatric Advanced Life Support (PALS) septic shock guidelines include 5 main recommendations: identifying septic shock and gaining vascular access within 5 minutes, and administering antibiotics, vasoactive agents, and intravenous (IV) fluid within 60 minutes.

Adherence to the 5-component PALS septic shock guidelines was studied in the Boston Children's Hospital emergency department (ED) before (November 2009 - March 2011) and during (October 2011 - May 2013) a QI intervention. Because adherence to timely administration of IV fluid had previously been low in this ED, the intervention focused on this variable and consisted of repeated "plan-do-study-act" cycles.

The first cycle centered on training and reminders using meetings, emails, and feedback. The second cycle focused on decreasing system errors and making adherence easier, including posting and distributing the algorithm and introducing a standardized order set in the electronic medical record, with an automatic alert to highlight patients requiring prompt, additional care. The third cycle focused on management. A "shock clock" served as a visual reminder about timely completion of the algorithm.

A total of 242 patients were included in the analysis. The median time to develop severe sepsis or septic shock was 52 minutes. Timely IV fluid administration improved from 37% preintervention to 100% during the intervention (median time decreased from 83 to 33 minutes). Timely administration of vasoactive agents improved from 35% at baseline to 100% (median time decreased from 90 to 35 minutes). By September 2012, adherence to all 5 guideline components improved from 19% to 100%; adherence remained near 100% for the remainder of the study.

Using an IV fluid pump was the biggest impediment to guideline adherence; using an appropriate fluid delivery device was linked to improvement. Septic shock cases increased between each sepsis death, suggesting decreased mortality.

Septic shock definitions were based on the International Sepsis Consensus Conference guidelines, which can be difficult to apply at the bedside and capture in the patient record and could have limited the study. Lack of randomization may have precluded determination of causality: whether improvements were a result of the intervention or something else. Finally, the study lasted 9 months and was unable to evaluate permanent change.

The authors note that education alone was not effective in improving guideline adherence, requiring other strategies for improvement. They also point out that more than half of patients failed to meet criteria for septic shock on arrival in the ED. Rather, their condition evolved while in the ED, underlining the importance of continually monitoring and assessing at-risk children.

"Through implementation of a QI initiative, we were able to improve the care of patients with septic shock in a pediatric ED," the authors conclude. "This process was possible without additional resources and has proved sustainable over time."

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online April 7, 2014. Abstract

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