Best practices in pediatric sepsis: building and sustaining an evidence-based pediatric sepsis quality improvement program

Abstract

Pediatric sepsis is a common problem worldwide and is associated with significant morbidity and mortality. Best practice recommendations have been published by both the American College of Critical Care Medicine and the Surviving Sepsis Campaign to guide the recognition and treatment of pediatric sepsis. However, implementation of these recommendations can be challenging due to the complexity of the care required and intensity of resources needed to successfully implement programs. This paper outlines the experience with implementation of a pediatric sepsis quality improvement program at Primary Children's Hospital, a free-standing, quaternary care children's hospital in Salt Lake City. The hospital has implemented sepsis projects across multiple care settings. Challenges, lessons learned, and suggestions for implementation are described.PLAIN LANGUAGE SUMMARYSepsis is a life-threatening condition that results from an inappropriate response to an infection by the body's immune system. All children are potentially susceptible to sepsis, with nearly 8,000 children dying from the disease in the US each year. Sepsis is a complicated disease, and several international groups have published guidelines to help hospital teams treat children with sepsis appropriately. However, because recognizing and treating sepsis in children is challenging and takes a coordinated effort from many different types of healthcare team members, following the international sepsis guidelines effectively can be difficult and resource intensive. This paper describes how one children's hospital (Primary Children's Hospital in Salt Lake City, Utah) approached the challenge of implementing pediatric sepsis guidelines, some lessons learned from their experience, and suggestions for others interested in implementing sepsis guidelines for children.

Keywords: Pediatrics; guideline adherence; pediatric emergency medicine; quality improvement; sepsis; septic shock.

Figure 1.

Timeline of pediatric sepsis quality improvement program implementation at Primary Children’s Hospital. Pediatric sepsis initiatives began in the Emergency Department in 2007, followed by the Pediatric Intensive Care Unit and Cardiac Intensive Care Unit in 2017, and the Medical/Surgical Units in 2019. Ongoing and future areas for implementation include the Cancer Unit and other hospitals within the Intermountain Healthcare System.

Figure 2.

Annotated statistical process control (SPC) p-chart of 2-Element Bundle Compliance in the Primary Children’s Hospital Emergency Department from January, 2007 through May, 2021. The 2-Element Bundle consists of delivery of intravenous fluids to restore perfusion and/or hypotension and administration of broad-spectrum intravenous antibiotics. Compliance is defined as receipt of both bundle elements within 60 minutes of sepsis recognition. Order set implementation had the greatest impact on compliance and Code Sepsis PDSA had the most influence on decreasing variability.

Figure 3.

Pareto analysis of time to intravenous (IV) fluid administration delays. Panel A. Baseline analysis of 2012 through quarter 1 of 2015 demonstrated that IV access was the largest single contributor to IV fluid administration delays. Panel B. From quarter 2, 2015 through 2018, following the Code Sepsis Plan-Do-Study-Act (PDSA) cycle, IV access was no longer a significant contributor to IV fluid administration delays.