Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support

Abstract

Background Sepsis is an uncontrolled inflammatory reaction caused by infection. Clinicians in the pediatric intensive care unit (PICU) developed a paper-based tool to identify patients at risk of sepsis. To improve the utilization of the tool, the PICU team integrated the paper-based tool as a real-time clinical decision support (CDS) intervention in the electronic health record (EHR). Objective This study aimed to improve identification of PICU patients with sepsis through an automated EHR-based CDS intervention. Methods A prospective cohort study of all patients admitted to the PICU from May 2017 to May 2019. A CDS intervention was implemented in May 2018. The CDS intervention screened patients for nonspecific sepsis criteria, temperature dysregulation and a blood culture within 6 hours. Following the screening, an interruptive alert prompted nursing staff to complete a perfusion screen to assess for clinical signs of sepsis. The primary alert performance outcomes included sensitivity, specificity, and positive and negative predictive value. The secondary clinical outcome was completion of sepsis management tasks. Results During the 1-year post implementation period, there were 45.0 sepsis events per 1,000 patient days over 10,805 patient days. The sepsis alert identified 392 of the 436 sepsis episodes accurately with sensitivity of 92.5%, specificity of 95.6%, positive predictive value of 46.0%, and negative predictive value of 99.7%. Examining only patients with severe sepsis confirmed by chart review, test characteristics fell to a sensitivity of 73.3%, a specificity of 92.5%. Prior to the initiation of the alert, 18.6% (13/70) of severe sepsis patients received recommended sepsis interventions. Following the implementation, 34% (27/80) received these interventions in the time recommended, p = 0.04. Conclusion An EHR CDS intervention demonstrated strong performance characteristics and improved completion of recommended sepsis interventions.

Evaluation of a Sepsis Alert in the Pediatric Acute Care Setting

“…Vidrine et al 8 implemented a sepsis alert in the pediatric intensive care unit (ICU) and found a sepsis alert in this context improved time between physiologic indicators of sepsis and clinical action. Dewan et al 9 also implemented a sepsis prediction tool and clinical decision support in the pediatric intensive care setting and found that the alert had adequate sensitivity and specificity to identify severe sepsis. Other estimates of embedded sepsis alerts have demonstrated adequate predictive values as a tool to identify cases of severe sepsis.…”

Computerized Clinical Decision Support Systems for the Early Detection of Sepsis Among Pediatric, Neonatal, and Maternal Inpatients: Scoping Review

“…The remaining 5 pediatric studies [ 73 , 74 , 80 , 82 , 83 ], all conference abstracts, did not specify the CCDS system criteria used for sepsis case identification and were not included in Table 3 . A total of 2 particular systems appear to be the subject of more than one study: the first in the studies by Dewan et al [ 61 ] and Vidrine et al [ 81 ] and the second in the studies by Stinson et al [ 77 ] and Viteri et al [ 82 ]. One journal article [ 64 ] is counted twice in Table 3 , as it contains 2 separate electronic CCDS systems with different criteria: one with automated continuous screening and the other with clinician-initiated screening.…”

Clinical evaluation of an interoperable clinical decision-support system for the detection of systemic inflammatory response syndrome in critically ill children

“…To our knowledge, we present the first interoperable CDSS for detection of pediatric SIRS that has been successfully evaluated in a clinical-driven study, using routine data, broad eligibility criteria for patients of all pediatric ages and underlying diseases, and an appropriate reference standard. Previous CDSS rather tried to optimize SIRS criteria or were using non-specific sepsis criteria, often with impressive results [ 15 , 19 , 20 ]; other approaches aimed at predicting severe sepsis [ 16 , 18 ] or improving time to goal-directed therapy [ 17 ]. All these studies focused on recognizing severe sepsis or septic shock directly instead of SIRS as the initial clinical feature; some used their own criteria differing from the IPSCC definition or set different age ranges, excluding newborns, infants or young adults, thereby limiting the routine (re)use of such system [ 14 ].…”

“…All these studies focused on recognizing severe sepsis or septic shock directly instead of SIRS as the initial clinical feature; some used their own criteria differing from the IPSCC definition or set different age ranges, excluding newborns, infants or young adults, thereby limiting the routine (re)use of such system [ 14 ]. Often, the reference standard used seems problematic such as in Dewan et al [ 15 ], who chose initiated treatment as reference. The documented time of treatment might not reflect the clinically relevant time as SIRS onset is often missed during clinical routine, as underlined by our findings.…”

“…However, current research for pediatric SIRS detection by CDSS is scarce [ 14 ]. Related approaches were described by Dewan et al [ 15 ], Scott et al [ 16 ], Vidrine et al [ 17 ], Le et al [ 18 ], Sepanski et al [ 19 ], Cruz et al [ 20 ] and Eisenberg et al [ 21 ], but focused on severe sepsis, septic shock, or therapy improvements rather than SIRS diagnosis. To our knowledge, a CDSS for detection of pediatric SIRS has not yet been successfully developed.…”