Objectives Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock. Design Retrospective observational study. Setting PICU at an academic medical center. Patients One hundred thirty patients treated for severe sepsis or septic shock. Interventions None. Measurements and Main Results We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure–free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74–277 min) and to first appropriate antimicrobial was 177 minutes (90–550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27–12.06) and 3.59 (95% CI, 1.09–11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45–16.2) and 4.92 (95% CI, 1.30–18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure–free days (16 [interquartile range, 1–23] vs 20 [interquartile range, 6–26]; p = 0.04). Conclusions Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.

Pediatric residents infrequently lead or participate in real or mock resuscitations. Although confident in performing many of the necessary resuscitation skills, few residents performed critical components of these skills correctly. Current pediatric residency training may not provide sufficient experience to develop adequate skills, fund of knowledge, or confidence needed for resuscitation.

Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.

Objective Recognition of pediatric sepsis is a key clinical challenge. We evaluated the performance of a sepsis recognition process including an electronic sepsis alert (ESA) and bedside assessment in a pediatric emergency department (ED). Methods Cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive ESA, defined as 1) elevated heart rate or hypotension, 2) concern for infection, and 3) at least one: abnormal capillary refill, abnormal mental status, or high-risk condition. Positive ESA prompted team assessment/huddle to determine need for sepsis protocol. Clinicians could initiate team assessment/huddle based on clinical concern without positive ESA. Severe sepsis outcome defined as: 1) activation of the sepsis protocol in the ED or 2) development of severe sepsis requiring intensive care unit admission within 24 hours. Results There were 182,509 ED visits during the study period, with 86,037 pre-ESA implementation and 96,472 post-implementation, and 1112 (1.2%) positive ESAs. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the ESA alone to detect severe sepsis were sensitivity 86.2% (95%CI 82.0, 89.5), specificity 99.1% (95% CI 99.0, 99.2), positive predictive value 25.4% (95% CI 22.8, 28.0), and negative predictive value 100% (95% CI 99.9, 100). Inclusion of the clinician screen identified 43 additional ESA negative children with severe sepsis sensitivity 99.4% (97.8, 99.8%); specificity 99.1% (95% CI 99.0, 99.2). ESA implementation increased ED sepsis detection from 83% to 96%. Conclusions ESA for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of ESA negative patients further improved sensitivity. Implementation of the ESA was associated with improved recognition of severe sepsis.

The general guidelines for forensic evidence collection in cases of acute sexual assault are not well-suited for prepubertal victims. The decision to collect evidence is best made by the timing of the examination. Swabbing the child's body for evidence is unnecessary after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis.

To evaluate the effectiveness of an educational intervention on pediatric residents' resuscitation fund of knowledge, technical skills, confidence, and overall performance.

Objective To determine whether treatment with a protocolized sepsis guideline in the emergency department (ED) was associated with a lower burden of organ dysfunction (OD) by hospital day 2 compared to non-protocolized usual care in pediatric patients with severe sepsis. Design Retrospective cohort study Setting Tertiary care children’s hospital from January 1, 2012–March 31, 2014. Measurements and Main Results Subjects with international consensus defined severe sepsis and pediatric intensive care unit (PICU) admission within 24 hours of ED arrival were included. The exposure was the use of a protocolized ED sepsis guideline. The primary outcome was complete resolution of OD by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized ED guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, ED triage level, or OD on arrival to the ED. Patients treated with protocolized ED care were more likely to be free of OD on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, PIM-2 score, and timing of antibiotics and intravenous fluids (adjusted OR 4.2, 95% CI 1.7, 10.4). Conclusions Use of a protocolized ED sepsis guideline was independently associated with resolution of OD by hospital day 2 compared to non-protocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care.

Summary Objectives We aimed to determine whether implementation of a structured multi-disciplinary EEG monitoring pathway improved the timeliness of anti-seizure medication administration in response to electrographic seizures in encephalopathic critically ill children. Methods A multidisciplinary team developed a pathway to standardize EEG monitoring and seizure management in encephalopathic critically ill children, aiming to decrease the time from electrographic seizure onset to anti-seizure medication administration. Data was collected to inform the team of improvement opportunities which were then provided by an institutional pathway, staff education, and streamlined communication. Measurements were obtained prior to and after pathway implementation to assess for improvement. Results We collected data on 41 patients before and 21 after pathway implementation. There were no differences between the baseline and pathway groups in demographic characteristics, acute encephalopathy etiologies, or anti-seizure medications utilized. The median duration from seizure onset to anti-seizure medication administration was shorter for patients treated with the pathway (64 minutes [50, 101]) compared to patients treated prior to pathway implementation (139 minutes [71, 189]) (p=0.0006). The interval from seizure onset to anti-seizure medication order was shorter for the pathway group (31 minutes [20, 49]) than the baseline group (71 minutes [33, 131]) (p=0.003). The interval from anti-seizure medication order to administration was shorter for the pathway group (30 minutes [19, 40]) than the baseline group (40 minutes [17, 68]) (p=0.047). Seizure termination was more likely to occur following initial anti-seizure medication administration in the pathway than baseline group (67% vs. 27%, p=0.002). Significance Implementation of the pathway resulted in a significant reduction in the duration between electrographic seizure onset and anti-seizure medication administration, and a significant increase in the rate of electrographic seizure termination following an initial anti-seizure medication. Further study is needed to determine whether these changes are associated with improved outcomes.