Improving Adherence to PALS Septic Shock Guidelines

Abstract

BACKGROUND AND OBJECTIVES:Few studies have demonstrated improvement in adherence to Pediatric Advanced Life Support guidelines for severe sepsis and septic shock. We sought to improve adherence to national guidelines for children with septic shock in a pediatric emergency department with poor guideline adherence. METHODS:Prospective cohort study of children presenting to a tertiary care pediatric emergency department with septic shock. Quality improvement (QI) interventions, including repeated plan-do-study-act cycles, were used to improve adherence to a 5-component sepsis bundle, including timely (1) recognition of septic shock, (2) vascular access, (3) administration of intravenous (IV) fluid, (4) antibiotics, and (5) vasoactive agents. The intervention focused on IV fluid delivery as a key driver impacting bundle adherence, and adherence was measured using statistical process control methodology.RESULTS: Two-hundred forty-two patients were included: 126 subjects before the intervention (November 2009 to March 2011), and 116 patients during the QI intervention (October 2011 to May 2013). We achieved 100% adherence for all metrics, including (1) administration of 60 mL/kg IV fluid within 60 minutes (increased from baseline adherence rate of 37%), (2) administration of vasoactive agents within 60 minutes (baseline rate of 35%), and (3) 5-component bundle adherence (baseline rate of 19%). Improvement was sustained over 9 months. The number of septic shock cases between each death from this condition increased after implementation of the QI intervention.CONCLUSIONS: Using QI methodology, we have demonstrated improved adherence to national guidelines for severe sepsis and septic shock.

Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock

“…We demonstrated an improvement in mortality with early initiation of peripheral IV or intraosseous infusion of epinephrine. Whenever a guideline is published, it must be adapted to ensure adherence (14), and a delay in administration of a vasoactive drug until central venous (15) or peripheral access (16) is obtained has been noted as a barrier to adherence. This gap is important; for example, a delay in vasoactive drug start has been associated with increased mortality in pediatric meningococcal sepsis in the United Kingdom (17).…”

A prospective quality improvement study in the emergency department targeting paediatric sepsis

“…Use of a pressure bag, rapid infuser or manual push has been associated with improved sepsis guideline adherence 3. Standardised order sets have been shown to reduce variability in practice and hasten the delivery of time-sensitive sepsis interventions 5 7. Paediatric sepsis protocols have been associated with improved process measures such as time to intravenous antibiotic administration and time to intravenous fluid administration,5–7 22 23 and have been associated with improved outcome measures such as an increase in the number of cases of septic shock between each death 7.…”

Implementation of an Inpatient Pediatric Sepsis Identification Pathway

“…Previous studies of sepsis screens in the pediatric emergency room setting have focused on the identification of severe sepsis and septic shock. [6][7][8] The literature is not clear regarding the best approach to patients with early sepsis. It is likely that early implementation of fluids and antibiotics will prevent progression to severe sepsis and septic shock in at least some of these cases.…”

“…4,5 In pediatric emergency rooms, triage tools and septic shock protocols have been shown to reduce time to the recognition of septic shock and the initiation of antibiotics and fluids. [6][7][8] These also have been shown to positively affect outcomes including decreased length of stay and a trend toward decreased mortality. 7 These tools may have a role on pediatric inpatient units; however, their use in these settings has not been widely studied.…”