Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative

Abstract

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.

Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis

“… 34 Similarly, a recently published IPSO interim analysis found that bundle compliant care was associated with significant reduction in mortality. 40 These results suggest that all bundled-care elements are likely important rather than one singular intervention, which is also emphasized in the 2020 Pediatric Surviving Sepsis Campaign guidelines. 20 …”

“…An investigation of a 1-hour sepsis bundle implementation following the New York State mandate found that completion of the entire bundle (obtaining blood cultures, administering broad-spectrum antibiotics, and a 20 mL/kg IV fluid bolus) within 1 hour was associated with lower risk-adjusted odds of in-hospital mortality (OR, 0.59; 95% CI, 0.38-0.93), whereas administration of antibiotics in isolation within 1 hour was not (OR, 0.78; 95% CI, 0.55-1.12) . Similarly, a recently published IPSO interim analysis found that bundle compliant care was associated with significant reduction in mortality . These results suggest that all bundled-care elements are likely important rather than one singular intervention, which is also emphasized in the 2020 Pediatric Surviving Sepsis Campaign guidelines …”