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PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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Page 1: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

PEDIATRIC SEPTIC SHOCK COLLABORATIVE

Educational Content (Sepsis, Septic Shock, & QI Primer)

Page 2: 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

• Outline quality improvement strategies for change

Page 3: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

IMPACT OF SEPSIS ON PATIENT OUTCOMESEducational Content

Page 4: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 5: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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 Respir Crit Care Med 2003 167:695-701Kutko Pediatr Crit Care Med 2003; 4:333-337Carcillo Crit Care Med 2002 30(6):1365-1378

Page 6: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Conditions Associated with High Hospital Resource Use

Condition Mean Cost Mean LOS

Severe Sepsis ~$40,600 31 days

IRDS ~$35,000 25 days

Spinal cord injury ~$25,000 16 days

Prematurity ~$24,000 22 days

Heart valve disease ~$23,000 9 days

Watson RS et al, Am J Respir CCM 2003

Page 7: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Sepsis Disease Spectrum

Presentation of sepsis reflects a spectrum

SIRS Sepsis Severe Sepsis

Septic Shock

Page 8: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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 Pediatr Crit Care Med 2005 6(1):2-8

Page 9: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Carcillo Crit Care Med 2002

30(6):1365-1378

Page 10: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

•Warm Shock• Warm extremities

• Flash capillary refill

• Vasomotor Paralysis

• High CI and low SVRI

• Hyperdynamic heart with vasodilation

Page 11: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 12: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Carcillo Crit Care Med 2002

30(6):1365-1378

Page 13: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 14: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

THE EVIDENCEEducational Content

Page 16: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Rivers et al., NEJM 2001

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

Page 17: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Early Rapid Fluid Resuscitation in Pediatric Septic Shock is Associated with Improved

Outcomes

Oliveira et al, Ped Emergency Care 24:2008

Time-sensitive Fluid-sensitive

% M

ort

alit

y

Page 18: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Every hour delay in receiving effective antibiotics is associated with a 7.6% decrease in survival in

adults with septic shock

Kumar et al, Crit Care Med 34: 2006

Page 19: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

EVIDENCED BASED GUIDELINESEducational Content

Page 20: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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 Carcillo Crit Care Med 2002 30(6):1365-1378

Page 21: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 22: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

ACCM Guidelines: 60 cc/kg in 15 minutes

PALS Guidelines: 60 cc/kg in 60 minutes

Page 23: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

The PSSCClinical

Pathway

Page 24: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

0-20 min

Page 25: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

TRIAGE TRIGGER TOOLHigh Risk Conditions

Vital Signs

Signs of Perfusion

Page 26: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

TRIAGE TRIGGER TOOL

Identify as at risk for sepsis if:1. Hypotension or2. Meets 3/8 criteria or3. Meets 2/8 criteria if high-

risk

Page 27: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

0-20 min

Page 28: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

20-60 min

Page 29: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

>60 min

Page 30: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 31: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

PEDIATRIC SEPTIC SHOCK COLLABORATIVE

Educational Content (Quality Improvement Primer)

Page 32: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

QI BASICS

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

Page 33: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Plan-Do-Study-Act

Page 34: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

EXAMPLE OF QI INITIATIVEQuality Improvement Primer

Page 35: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 36: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Modified from Pediatric Advanced Life Support Manual. American Heart Association. 2006.

Recognize altered mental status and poor perfusion

Establish vascular access and begin resuscitation

Recognize altered mental status and poor perfusion

Establish vascular access and begin resuscitation

1st hour: Push repeated 20 mL/kg IVF up to 3

Administer antibiotics STAT

1st hour: Push repeated 20 mL/kg IVF up to 3

Administer antibiotics STAT

Fluid responsive (i.e. normalization of BP and/or perfusion)?

Fluid responsive (i.e. normalization of BP and/or perfusion)?

Begin vasoactive drug therapy and titrate to correct hypotension / poor perfusionBegin vasoactive drug therapy and titrate to correct hypotension / poor perfusion

Consider ICU monitoring

Consider ICU monitoring

Background

1st hour

noyes

5 min

5 min

60 min

60 min

60 min

PALS (2006)

Page 37: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Needs Assessment

0

10

20

30

40

50

60

70

80

90

100

PALS Intervention

% Adherence

Page 38: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Fluid adherence

n= 29(mean # days)

Fluid non-adherence

n= 98(mean # days)

% decrease P value

HospitalLOS

8.0 11.2 57% 0.039

ICU LOS 5.5 7.2 42% 0.024

Total algorithm adherence

n= 15(mean # days)

Total algorithm non-adherence

n= 112(mean # days)

% decrease P value

HospitalLOS

6.8 10.9 57% 0.009

ICU LOS 5.5 6.8 59% 0.035

Needs Assessment

Page 39: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 40: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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 of antibiotics: >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

Page 41: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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

Page 42: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Team Members

Frontline workers Physicians

NursingRespiratory

Nursing assistantsPharmacists

Middle Management

Statistical Support

Computer Support

Upper Level Management

Physician Leadership

Nursing Leadership

Hospital Leadership

Research Assistants

Pharmacy Head

Page 43: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

60ml/kg within 60 minutes

EnvironmentMethods

PeopleEquipment

No IV access

Access tenuous

Hesitance to use IO

Waiting for IV team

Wrong fluid device used

Can’t find pressure bag

Don’t know to use pressure bag

Don’t know how to use pressure bag

Pharmacists difficult to get a hold of

People don’t know pharmacy number

CA’s cannot be reached

Holding for other procedures

CA phones numbers not uniformly posted, some don’t have phones

Need labels to sent labs

CA’s usually get labels but are busy holding for IV

MD’s are too busy with patient to put in orders

Poor knowledge of protocol

No educational sessions

No visible algorithms

No pocket cards for bedside reference

Many trainees to educate, many adult trainees

Too busy to recognize septic patients

Too many patients

Not enough MDS

No trigger system

No accountability/feedback Poor RN/MD

communication

Many trainees

MD’s don’t know who the nurses are

Page 44: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Inotropes in 60 min

60ml/kg in 60 min

Vascular Access in 5 min

Antibiotics in 60 min

Recognition in 5 min

0

5

10

15

20

25

30

35

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Frequency Percent

Cumulative Percentage

Needs Assessment: Pareto

Page 45: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Change Hypotheses• Educational sessions MDs• Educational sessions RNs

• Didactics• Net learning• Skills Day (pressure bags)

• Computer Orderset

• Visible algorithm • Posters• Pocket cards

• Clock

• Bedside Survey

Ongoing

October 12

September 26

September 21, October 2

October 16

October 27

October 19

October 10

October 6

Page 46: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Modified from Pediatric Advanced Life Support Manual. American Heart Association.

RECOGNIZEaltered mental status / poor perfusion

VASCULAR ACCESS

RECOGNIZEaltered mental status / poor perfusion

VASCULAR ACCESS

IV FLUIDS60 mL/kg

pressure bag if >10kg

ANTIBIOTICS

IV FLUIDS60 mL/kg

pressure bag if >10kg

ANTIBIOTICS

Fluid Responsive (normalization of BP and/or perfusion)?

Fluid Responsive (normalization of BP and/or perfusion)?

VASOACTIVE DRUGtitrate quickly to correct

hypotension / poor perfusion

VASOACTIVE DRUGtitrate quickly to correct

hypotension / poor perfusion

Admission for

monitoring

Admission for

monitoring

no yes

SEVERE SEPSIS AND SEPTIC SHOCK PROTOCOL

WITHIN

0:05 min

WITHIN

1:00 hr

AT

1:00 hr

Page 47: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)
Page 49: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

ED Septic Shock Orderset

Page 50: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

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!

Page 51: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

MEASURE: Run Chart

Page 52: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Lower Control Limit

Upper Control Limit

MEASURE: SPC Chart

Page 53: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Example SPC chart

Nov 0

9

Dec 0

9

Jan

10

Feb 1

0

Mar

10

Apr 1

0

May

10

Jun

10

Jul 1

0

Aug 1

0

Sep 1

0

Oct 1

0

Nov 1

0

Dec 1

0

Jan

11

Feb 1

1

Mar

11

11-O

ct

11-N

ov

11-D

ec

12-J

an

12-F

eb0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total Bundle Adherence Pre and Post Intervention

Mean Adherence

Institutional Adherence

Lower Control Limit

Upper Control Limit

Month

Percent Adherence

INTERVENTION

Page 54: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

The Improvement Guide: 1996

Page 55: PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Sepsis, Septic Shock, & QI Primer)

Sepsis and Septic Shock• Early, timely goal directed therapy improves patient outcomes and mortality

• A systematic approach is necessary for a successful quality improvement project