Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinician Identification

Abstract

Study objective: Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department (ED).

Methods: This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.

Results: There were 182,509 ED visits during the study period, with 86,037 before electronic sepsis alert implementation and 96,472 afterward, and 1,112 (1.2%) positive electronic sepsis alerts. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the electronic sepsis alert alone to detect severe sepsis were sensitivity 86.2% (95% confidence interval [CI] 82.0% to 89.5%), specificity 99.1% (95% CI 99.0% to 99.2%), positive predictive value 25.4% (95% CI 22.8% to 28.0%), and negative predictive value 100% (95% CI 99.9% to 100%). Inclusion of the clinician screen identified 43 additional electronic sepsis alert-negative children, with severe sepsis sensitivity 99.4% (95% CI 97.8% to 99.8%) and specificity 99.1% (95% CI 99.1% to 99.2%). Electronic sepsis alert implementation increased ED sepsis detection from 83% to 96%.

Conclusion: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert-negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

Figure 1

Screen shots of the electronic sepsis alert (ESA) built into electronic health record. Panel A (1^st Stage Alert) automatically deploys in the electronic health record if the patient has tachycardia or hypotension. If assessment of yes to fever, hypothermia, or concern for infection (in Panel A), the screening questions in Panel B (2^nd Stage Alert) automatically deploy. If abnormal finding in capillary refill, high risk condition, or altered mental status (incorporated automatically from earlier in the triage process – not visible here), this is defined as ESA+ and Panel C appears prompting a sepsis huddle. This requires attending or fellow physician bedside evaluation to determine if the sepsis pathway is indicated (documented in Panel D). Panel E is a table describing these stages verbally.

Figure 2. STARD diagram for the performance of the ESA diagnostic test

Flow diagram illustrating alert performance in the ED population during the study period. ESA+ indicates patients that had positive both first and second stage alerts which resulted in a sepsis huddle. Of the ED census, there were 15,292 patients with a positive first stage alert, and of these 1112 had positive answers to one of the screening questions (high risk condition, abnormal capillary refill, or abnormal mental status) which resulted in a positive ESA and huddle. Of these, 265 were treated on the sepsis protocol. There were 43 additional patients with clinician identified sepsis (CIS) who were treated with the sepsis protocol despite a negative ESA.

Figure 3

Statistical process control chart demonstrating proportion of missed sepsis cases during the study. Black line is the proportion of missed cases during the study period. The total number of patients each month is indicated below the name of the month in parentheses. A missed case is a patient with severe sepsis in the PICU within 24 hours of their ED visit who was not treated with the ED sepsis protocol. The implementation of the ESA is marked with an arrow. Dashed lines are the upper and lower confidence limits defined as 2 standard deviations above and below the mean. Upper and lower control limits were recalculated each month, and a new mean was calculated when criteria were met for special cause variation. Aggregate proportions of missed cases for pre and post implementation period is indicated in the text box.