Clinician-to-Clinician Update Clinician-to-Clinician Update

Standardizing Care and Improving Outcomes in Pediatric Septic Shock

March 2018

Pediatric sepsis is a major cause of morbidity and mortality throughout the world. Developing nations with high numbers of children experience most of this burden, but even the United States’ statistics are grim. Pediatric sepsis is responsible for the deaths of more than 4,000 American children per year, a mortality rate higher than that for pediatric cancer.1

In the United States, septic shock cases are rare but deadly. Representing 0.34% of 28.2 million pediatric emergency department (ED) cases annually2, severe sepsis results in a reported 10% hospital mortality rate.3 For best outcomes, sepsis must be recognized early and treated quickly, ideally within 60 minutes of initial evaluation. Diagnosing sepsis, however, can be challenging. No single blood test exists for sepsis. Rather, it is identified through the presence of a grouping of clinical signs and symptoms that occur in association with an infection or other insult to the body, such as trauma, pancreatitis or burns. Immunocompromised and postsurgery patients and those with neuromuscular disease, respiratory conditions, and cardiac disease are predisposed to sepsis as well. The signs and symptoms identifying the condition, however, have themselves been the subject of debate. In 2005, an international panel of experts proposed consensus guidelines on identifying signs and symptoms of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.1

Guidelines for the management of pediatric septic shock are also currently in place, but adherence is inconsistent. To improve adherence, a number of quality improvement initiatives have been launched.4 A 2005–2008 campaign resulted in a reduction in mortality rates.5 Still, varying strategies exist for identifying, managing, and monitoring children who present with sepsis in the ED.6

March-2018-Pediatric-Consult-ED-Feature-Article-Main-Image
— A nurse attends to a patient in the pediatric intensive care unit at University of Minnesota Masonic Children’s Hospital.

In 2013, a campaign launched within 25 U.S. pediatric EDs attempted to standardize care and reduce the relative rate of mortality due to septic shock by 20%. The Pediatric Septic Shock Collaborative (PSSC), sponsored by the American Academy of Pediatrics’ Section on Emergency Medicine, trialed several clinician resources in this effort. University of Minnesota Masonic Children’s Hospital was the only Minnesota hospital to participate.

University of Minnesota Health Emergency Medicine physician Jeff Louie, MD, led the hospital’s campaign. The PSSC provided a septic shock identification tool and a set of guidelines based on evidence-based practices and designed to aid clinicians in recognizing and managing sepsis. Also included were a web-based learning module and handouts for staff.

In instructing on the use of the PSSC tools, Louie focused on educating the ED nurses, staff, and residents on how to check vital signs to recognize sepsis. During the 2013–2016 PSSC initiative, no deaths from septic shock occurred in children who were initially diagnosed and managed in the hospital ED, nor were there any in 2017. In the 4 years prior to the PSSC (2008 to 2012), 2 occurred.

The team has also pursued additional screening of high-risk children, such as transplant and oncology patients, and Louie estimates that approximately 20% of ED patients managed for septic shock were not initially thought to be at risk for the condition.

The PSSC achieved a more than two-thirds reduction in sepsis mortality overall across participating sites.7 Children’s hospitals are now implementing the PSSC tools and benefitting from lessons learned during the initiative. In 2016, the Improving Pediatric Sepsis Outcomes collaborative gained momentum, and now more than 40 children’s hospitals of all sizes have begun work on a multiyear improvement initiative.

Complete results on PSSC will be presented at the 2018 Pediatric Academic Societies conference.

References

  1. Wheeler, DS. Introduction to pediatric sepsis. Open Inflamm J. 2011 Oct. 7; 4 (Suppl 1-M):1-3.
  2. Singhal S, Allen MW, McAnnally J, Smith KS, Donnelly JP, Wang HE. National estimates of emergency department visits for pediatric severe sepsis in the United States. Peer J. 2013;1:e79.
  3. Watson RS, Carcillo JA, Linde-Zwirble WT. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med. 2003 Mar 1; 167(5):695-701.
  4. Paul R, Melendez E, Stack A, Capraro A, Monuteaux M, Neuman M. Improving adherence to PALS septic shock guidelines. Pediatrics. 2014;Vol.133(5):e1–e9.
  5. Levy MM, Dellinger RP, Townsend SR, et al. The surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38(2): 367-374.
  6. Thompson GC, Macias CG. Recognition and management of sepsis in children: practice patterns in the emergency department. J Emerg Med. 2015 Oct; 49(4),391-399.
  7. Macias CG. Results from the Pediatric Septic Shock (PSSC) Collaborative. 2017 Quality and Safety in Children’s Health Conference. Children’s Hospital Association. March 22, 2017. Orlando, FL. https://tinyurl.com/ycm67b6n. Accessed January 31, 2018.

When to refer

Emergency services personnel at University of Minnesota Masonic Children’s Hospital care for a diverse range of pediatric patients, including a high-acuity population of cancer patients, transplant patients, and other children with complex care needs. The hospital’s Pediatric Emergency Department (ED) is one of the most highly rated Univeristy of Minnesota Health clinical services in patient and family satisfaction, and by this measure, one of the highest-rated ED’s in the country. It is also one of the most efficient in the country in time from patient presentation to admission or discharge. Pediatric ED leadership is working to meet a goal of less than 60 minutes from admission decision to transfer to a unit.

Our pediatric ED team has extensive experience in identifying and treating pediatric sepsis and septic shock. Our staff’s participation in a national research collaborative seeking to reduce mortality from septic shock has improved our patient outcomes. Tools tested and developed within the collaborative have helped support the identification of these conditions and standardize their management nationwide. Our pediatric ED team continues to gather data and evaluate its use of the protocol and to educate the team and improve adherence. The team has also developed additional sepsis-treatment resources for staff and residents.

The hospital and the University of Minnesota Medical School continues to innovate in the training of pediatric providers. The medical school is 1 of 4 in the United States participating in the federally funded Education in Pediatrics across the Continuum (EPAC), a pilot program testing the feasibility of medical education based on the demonstration of defined outcomes rather than time in training.

For a copy of the Mothers’ And Children’s Specialty Directory, visit mhealth.org/childrens-directory.

To find current clinical trials available through M Health providers, visit studyfinder.umn.edu.

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