Objective Recognition of pediatric sepsis is a key clinical challenge. We evaluated the performance of a sepsis recognition process including an electronic sepsis alert (ESA) and bedside assessment in a pediatric emergency department (ED). Methods Cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive ESA, defined as 1) elevated heart rate or hypotension, 2) concern for infection, and 3) at least one: abnormal capillary refill, abnormal mental status, or high-risk condition. Positive ESA prompted team assessment/huddle to determine need for sepsis protocol. Clinicians could initiate team assessment/huddle based on clinical concern without positive ESA. Severe sepsis outcome defined as: 1) activation of the sepsis protocol in the ED or 2) development of severe sepsis requiring intensive care unit admission within 24 hours. Results There were 182,509 ED visits during the study period, with 86,037 pre-ESA implementation and 96,472 post-implementation, and 1112 (1.2%) positive ESAs. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the ESA alone to detect severe sepsis were sensitivity 86.2% (95%CI 82.0, 89.5), specificity 99.1% (95% CI 99.0, 99.2), positive predictive value 25.4% (95% CI 22.8, 28.0), and negative predictive value 100% (95% CI 99.9, 100). Inclusion of the clinician screen identified 43 additional ESA negative children with severe sepsis sensitivity 99.4% (97.8, 99.8%); specificity 99.1% (95% CI 99.0, 99.2). ESA implementation increased ED sepsis detection from 83% to 96%. Conclusions ESA for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of ESA negative patients further improved sensitivity. Implementation of the ESA was associated with improved recognition of severe sepsis.

Ultrasound-guided intravenous access is a feasible alternative to traditional peripheral intravenous access in the pediatric emergency setting. We observed a high first-stick success rate even in patients who had failed traditional peripheral intravenous access attempts, few complications, and a long intravenous survival time.

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Objectives: To evaluate if nurses can reliably perform ultrasound-guided peripheral intravenous catheter placement in children with a high success rate after an initial training period. A secondary aim was to analyze complication rates of ultrasound-guided peripheral intravenous catheters. Methods: A database recorded all ultrasound-guided peripheral intravenous catheter encounters in the emergency department from November 2013 to April 2019 including the emergency department nurse attempting placement, number of attempts, and whether it was successful. Patient electronic medical records were reviewed for the time of and reason for intravenous removal. The probabilities of first-attempt successful intravenous placement and complication at successive encounters after an initial training period were calculated. These probabilities were plotted versus encounter number to graph best-fit logarithmic regressions. Results: A total of 83 nurses completed a standardized training program in ultrasound-guided peripheral intravenous catheter placement including 10 supervised ultrasound-guided peripheral intravenous catheter placements. In total, 87% (3513/4053) of the ultrasound-guided peripheral intravenous catheter placed after the training program were successful on the first attempt. The probability of successfully placing an ultrasound-guided peripheral intravenous catheter increased as nurses had more experience placing ultrasound-guided peripheral intravenous catheters (R2 = 0.18) and was 83% at 10 encounters. Twenty-five percent (904/3646) of ultrasound-guided peripheral intravenous catheters had complications, and there was no statistically significant relationship between the number of encounters per nurse and complication rates (R2 < 0.001). Conclusion: Nurses can reliably place ultrasound-guided peripheral intravenous catheters at a high success rate after an initial training period. First-attempt success rates were high and increased from 67% to 83% for the first 10 unsupervised encounters after training and remained high. The complication rate was low and did not change as nurses gained more experience.

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