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Pediatric Septic Shock Collaborative

Pediatric Septic Shock Collaborative. Educational Content (Sepsis, Septic Shock, & QI Primer). Goals. Review the impact of sepsis on patient outcomes Define the sepsis disease spectrum Review the evidenced based guidelines for the management of severe sepsis/septic shock

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Pediatric Septic Shock Collaborative

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  1. Pediatric Septic Shock Collaborative Educational Content (Sepsis, Septic Shock, & QI Primer)

  2. Goals • Review the impact of sepsis on patient outcomes • Define the sepsis disease spectrum • Review the evidenced based guidelines for the management of severe sepsis/septic shock • Outline quality improvement strategies for change

  3. Impact of Sepsis on Patient Outcomes Educational Content

  4. Epidemiology • Over 18 million cases worldwide each year • The annual incidence in the US of severe sepsis is approximately 3.0 cases per 1,000 • Sepsis kills approximately 1,400 people worldwide EVERYDAY

  5. Epidemiology-Pediatric • Sepsis is a leading cause of illness & death among U.S. children • > 42,000 cases annually (4th leading cause behind asthma, appendicitis, and poisonings) • 5-10% overall mortality (0-5% healthy children; 10% if underlying medical conditions) • 7-9 % of all childhood deaths are due to sepsis (more common than cancer) Watson Am J RespirCrit Care Med 2003 167:695-701 KutkoPediatrCrit Care Med 2003; 4:333-337 CarcilloCrit Care Med 2002 30(6):1365-1378

  6. Conditions Associated with High Hospital Resource Use Watson RS et al, Am J Respir CCM 2003

  7. Sepsis Disease Spectrum Presentation of sepsis reflects a spectrum

  8. Definitions • Systemic Inflammatory Response Syndrome (SIRS): 2 of 4 criteria • Temp <36 or >38.5 • HR >2 SD above normal for age (or bradycardia if <1 year old*) • RR > 2 SD above normal for age • Abnormal WBC or > 10% immature neutrophils • Sepsis: SIRS with suspected or confirmed infection • Severe sepsis: Sepsis + organ dysfunction or failure Goldstein PediatrCrit Care Med 2005 6(1):2-8

  9. Definitions • Septic shock= Hypothermia or hyperthermia and signs of cardiovascular organ dysfunction including • Altered or decreased mental status (inconsolable irritability, lack of interaction with parents and inability to be aroused) • Capillary refill ≥3sec (cold shock) or flash capillary refill (warm shock) • Diminished (cold shock) or bounding peripheral pulses (warm shock) • Mottled cool extremities (cold shock) • Decreased urine output <1 mL/kg/hr • Hypotension CarcilloCrit Care Med 2002 30(6):1365-1378

  10. Warm Shock Warm extremities Flash capillary refill Vasomotor Paralysis High CI and low SVRI Hyperdynamic heart with vasodilation 2 Major Types of Septic Shock • Cold Shock • Cold extremities • Capillary refill ≥ 3 sec • Myocardial Dysfunction • Low CI and high SVRI • Sick heart with significant vasoconstriction to maintain perfusion to organs

  11. Definitions • Compensated shock: • Systolic blood pressure within normal range with signs and symptoms of inadequate perfusion • Children more often present in compensated shock • Decompensated shock: • Signs of shock associated with systolic hypotension

  12. Further Definitions • Fluid-refractory shock: • Shock despite 60 cc/kg in 1st hour • Dopamine-resistant shock: • Shock despite adequate fluid resuscitation and 10 mcg/kg/min • Catecholamine-resistant shock: • Shock despite epinephrine or norepinephrine • Refractory shock: • Shock despite goal-directed use of inotropic agents, vasopressors, vasodilators, and maintenance of metabolic and hormonal homeostasis CarcilloCrit Care Med 2002 30(6):1365-1378

  13. Sepsis: A Disease Continuum • Patients with life-threatening infection often present with fever and excessive, persistent tachycardia • Tachycardia, tachypnea, and signs of worsening perfusion precede hypotension • Hypotension is a late, ominous sign in pediatrics • Often followed by cardiopulmonary collapse • Stopping progression to hypotension (decompensated shock) via early aggressive interventions improves outcomes

  14. The Evidence Educational Content

  15. p < .001 p < .001 Each hour of delay associated with 50% increased odds of mortality Han et al., Pediatrics 112: 2003

  16. Adult Mortality Reduced by 15% with Early Goal Directed Therapy For every 6 adults with septic shock who are treated effectively, 1 death is prevented Rivers et al., NEJM 2001

  17. Early Rapid Fluid Resuscitation in Pediatric Septic Shock is Associated with Improved Outcomes Time-sensitive Fluid-sensitive % Mortality Oliveira et al, Ped Emergency Care 24:2008

  18. Every hour delay in receiving effective antibiotics is associated with a 7.6% decrease in survival inadults with septic shock Kumar et al, Crit Care Med 34: 2006

  19. Evidenced Based Guidelines Educational Content

  20. Pediatric Septic Shock Guidelines • Early aggressive fluid resuscitation (up to 60 cc/kg in the first 15 minutes) • Proportionally larger quantities of fluid in children • Initial volume resuscitation commonly requires 40-60 cc/kg but can be as much as 200 cc/kg in the 1st hour • Reassess between boluses for signs of volume overload—hepatomegaly, rales, gallops • Vasoactive agents for fluid refractory shock • Can be given through peripheral IV until central access is obtained • Initiate dopamine for fluid-refractory shock • Initiate norepinephrine (warm shock) or epinephrine (cold shock) for fluid-dopamine-refractory shock • Remember short half life therefore rapid titrations are needed • Hydrocortisone for adrenal insufficiency • Identify need for invasive cardiovascular monitoring for fluid-refractory shock CarcilloCrit Care Med 2002 30(6):1365-1378

  21. Pediatric Septic Shock Guideline • Therapeutic goals include: • Capillary refill time ≤ 2 seconds • Normal pulses with no differential between peripheral and central pulses • Warm extremities • Urine output > 1 cc/kg/hr • Normal mental status • Normal blood pressure for age

  22. ACCM Guidelines: 60 cc/kg in 15 minutes PALS Guidelines: 60 cc/kg in 60 minutes

  23. The PSSCClinical Pathway

  24. 0-20 min

  25. TRIAGE TRIGGER TOOL High Risk Conditions Vital Signs Signs of Perfusion

  26. TRIAGE TRIGGER TOOL Identify as at risk for sepsis if: Hypotension or Meets 3/8 criteria or Meets 2/8 criteria if high-risk

  27. 0-20 min

  28. 20-60 min

  29. >60 min

  30. Intubation and Septic Shock • Low threshold for ET intubation even without primary respiratory failure • Up to 40% of cardiac output may be devoted to work of breathing; this can be unloaded • Atropine, ketamine preferred agents for sedation • Caution with etomidate

  31. Pediatric Septic Shock Collaborative Educational Content (Quality Improvement Primer)

  32. QI BASICS • Create a mission statement • Identify specific aims • Identify measures • Gather key stakeholders • Needs assessment • Rapid cycle change

  33. Plan-Do-Study-Act

  34. Example of qi initiative Quality Improvement Primer

  35. Mission Statement • To improve the care of children with severe sepsis and septic shock in a pediatric emergency medicine department

  36. Background PALS (2006) Recognizealtered mental status and poor perfusion Establish vascular access and begin resuscitation 5 min 5 min 1st hour • 1st hour: Push repeated 20 mL/kg IVF up to 3 • Administer antibiotics STAT 60 min 60 min Fluid responsive (i.e. normalization of BP and/or perfusion)? no yes Consider ICU monitoring Begin vasoactive drug therapy and titrate to correct hypotension / poor perfusion 60 min Modified from Pediatric Advanced Life Support Manual. American Heart Association. 2006.

  37. Needs Assessment

  38. Needs Assessment

  39. Aim Statement • Increase adherence to the Pediatric Advanced Life Support Guidelines • for severe sepsis and septic shock in the Children’s Hospital Boston Emergency department • from 19% overall adherence to the 5 component bundle to > 90% adherence • within one year

  40. Secondary Aims • COMPONENTS OF THE BUNDLE: • Improve recognition: > 90 % of patients are recognized within 5 minutes of meeting definition of SS • Improve attainment of vascular access:(peripheral, intraosseous or central): >90% of patients have access within 5 minutes of meeting definition of SS • Improve delivery of fluid:> 90% of patients have 60 ml/kg of isotonic fluid delivered within 60 minutes of meeting definition of SS • Improve delivery ofantibiotics: >90% of patients have antibiotics delivered within 60 minutes of meeting definition of SS • Improve delivery of vasoactive agents: > 90% of patients have a vasoactive agent begun at 60 minutes of meeting definition of SS

  41. Measures • Outcome Measures • Mortality • Length of stay in ICU, hospital • Days on vasoactive agents • Multiorgan dysfunction syndrome • Process Measures • Adherence to recognition, vascular access, IV fluid, antibiotic and vasoactive agents • Balancing Measures • ED length of stay • Increased respiratory support due to pulmonary edema

  42. Team Members Middle Management Frontline workers Physicians Nursing Respiratory Nursing assistants Pharmacists Research Assistants Upper Level Management Physician Leadership Nursing Leadership Hospital Leadership Pharmacy Head • Statistical Support • Computer Support

  43. Equipment People Holding for other procedures MD’s are too busy with patient to put in orders CA’s cannot be reached Need labels to sent labs CA’s usually get labels but are busy holding for IV CA phones numbers not uniformly posted, some don’t have phones Can’t find pressure bag Hesitance to use IO Waiting for IV team Don’t know how to use pressure bag People don’t know pharmacy number No IV access Wrong fluid device used Access tenuous Pharmacists difficult to get a hold of Don’t know to use pressure bag 60ml/kg within 60 minutes No pocket cards for bedside reference Too many patients Not enough MDS Poor knowledge of protocol MD’s don’t know who the nurses are Too busy to recognize septic patients No educational sessions No visible algorithms No accountability/feedback Poor RN/MD communication No trigger system Many trainees to educate, many adult trainees Many trainees Methods Environment

  44. Needs Assessment: Pareto

  45. Change Hypotheses October 6 • Educational sessions MDs • Educational sessions RNs • Didactics • Net learning • Skills Day (pressure bags) • Computer Orderset • Visible algorithm • Posters • Pocket cards • Clock • Bedside Survey September 21, October 2 Ongoing October 12 September 26 October 16 October 27 October 19 October 10

  46. ED Septic Shock Orderset

  47. Personal Feedback Hi, This email is to let you know that your patient  AT (24 year old Asperger's, panhypopit, vomiting and diarrhea)  met the criteria for septic shock. He had fever, tachycardia (SIRS) and hypotension. You met the recognition in 5 minute goal! You met the IV access in 5 minute goal! You met the 60cc/kg in 60 minute goal for IVFs! You met the antibiotics in 60 minute goal! You met the pressor initiation at 60 minute goal!

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