Sepsis-Alert System in the ED May Cut Racial Disparity in Pediatric Sepsis Recognition

By Will Boggs MD

September 17, 2019

NEW YORK (Reuters Health) - A pediatric emergency department (ED) electronic sepsis alert system may reduce racial disparities in sepsis recognition, new findings hint.

In adult populations, black patients have been reported to have worse sepsis outcomes than white patients, but racial differences in pediatric sepsis have not been studied.

Children's Hospital of Philadelphia (CHOP) implemented a two-stage electronic health record (EHR)-based sepsis alert in 2014. Stage 1 screens children for tachycardia and/or hypotension, and stage 2 bases a team decision to initiate the sepsis pathway on nursing assessment of sepsis risk factors.

Dr. Fran Balamuth of CHOP and colleagues assessed racial differences in sepsis recognition in their retrospective study of more than 97,000 ED visits (58.4% by non-Hispanic black patients and 23.6% by non-Hispanic white patients).

Overall, 13.0% of visits had positive first alert results, 1.3% had positive second alert results, and 0.25% (242 patients) had a sepsis pathway activation using the alert system. An additional 84 patients (0.086%) had sepsis-pathway activation outside of the alert system based on clinical judgment.

After adjustment for age, sex and payer, the odds of having a positive first alert result were similar among black and white patients, the researchers report in Pediatrics, online September 13.

In contrast, white patients had 2.4-fold higher odds of a positive second alert result and 40% higher odds of sepsis-pathway activation, compared with black patients, both significant results.

Sepsis-pathway activation did not differ between white and black patients treated through the alert and/or huddle process. But white patients had 3.4-fold higher odds of sepsis-pathway activation than black patients when treated outside of the alert process by using clinical judgment alone.

The median time from ED triage to initial antibiotic treatment did not differ significantly between white and black patients treated on the sepsis pathway, although these times were nominally longer for black patients than for white patients.

"These findings may suggest that using the sepsis alert reduces racial differences in sepsis detection and treatment when compared with using clinician judgment alone, a hypothesis that will be examined in future prospective studies," the researchers conclude.

Dr. Raina M. Paul from Advocate Children's Hospital, in Park Ridge, Illinois, who recently reviewed the recognition, diagnostics, and management of pediatric severe sepsis and septic shock in the ED, told Reuters Health by email, "Implicit bias is a real entity that we all need to tackle. Although I was not surprised that the clinician-driven sepsis activation revealed this implicit bias, I found it quite interesting that the use of a relatively objective EHR alert was successful in mitigating this racial disparity."

"Having been part of implementing this same EHR at another institution with relative ease, this is promising for other institutions and thus our patients," she said.

"There are several studies, including those done by this senior author (Balamuth), demonstrating that using an electronic sepsis alert in the pediatric-ED setting is associated with improved outcomes, including reducing organ dysfunction," she said. "The data has been promising, prompting the Improving Pediatric Sepsis Collaborative (IPSO), the largest QI (quality improvement) collaborative to date (of which I am the data co-chair), to unanimously recommend the use of a sepsis alert in the ED as well as the inpatient environment for its 50+ participating hospitals (representing 7000+ patients to date)."

"I agree wholeheartedly with the authors, and as a QI expert, that equitable care is the forgotten tenant in pediatric sepsis QI research," Dr. Paul said. "Research thus far, including my own, has focused on other Institute for Healthcare Improvement (IHI) recommended domains, such as timeliness and effective care. This manuscript opens the door to further investigation in this domain and is a welcome addition to the QI literature."

Dr. Balamuth did not respond to a request for comments.


Pediatrics 2019.