High Reliability Pediatric Septic Shock Quality Improvement Initiative and Decreasing Mortality

Abstract

Background and objective: Septic shock impacts mortality, morbidity, and health care costs. A quality improvement (QI) initiative was launched to improve early recognition and timely treatment of patients with septic shock in a pediatric emergency department (PED). Our primary aim was to describe the longitudinal effectiveness of the program, iterative changes in clinical practice, and associated outcomes.

Methods: We implemented multiple interventions during our QI initiative (February 2007 to December 2014). Analysis of compliance and outcomes focused on a bundle consisting of: (1) timely antibiotics, (2) intravenous fluids (IVF) for rapid reversal of perfusion abnormalities and/or hypotension. Logistic regression was used to obtain adjusted odds ratios (ORs) for death and pediatric ICU (PICU) admission.

Results: A total of 1380 patients were treated for septic shock; 93% met screening criteria at triage. Implementation of the various processes improved timely interventions. One example included implementation of a sepsis order set, after which the mean proportion of patients receiving timely antibiotics increased to its highest rate. The odds of death were 5 times as high for children who did not receive bundle-compliant care (OR, 5.0 [95% Confidence Interval 1.9, 14.3]) compared with those who did (OR, 0.20 [95% Confidence Interval 0.07, 0.53]). Among PICU admitted patients, the odds of mortality were greater for children who presented with abnormal mental status and a higher pediatric index of mortality 2 score.

Conclusions: QI methodology improved septic shock program goal adherence and decreased mortality without increasing PICU admissions or PED length of stay over the 8-year period, supporting continued emphasis on early recognition, timely IVF resuscitation, and antibiotic administration.