Introduction: Pediatric sepsis remains a leading cause of death of children in the United States. Timely recognition and treatment are critical to prevent the onset of severe sepsis and septic shock. Electronic screening tools aid providers in identifying patients at risk for sepsis. Our overall project goal was to decrease the number of sepsis-related emergent transfers to the pediatric intensive care unit by optimizing sepsis screening tools, interruptive alerts, and a new paper tool and huddle process using Plan-Do-Study-Act (PDSA) methodology. Methods: Our team utilized historical data to develop inpatient electronic sepsis screening tools to identify pediatric patients at risk for sepsis. Using PDSA iterative cycles over 3 months, we tested the design of an interruptive alert, paper tool, and a new sepsis huddle process. Results: During the PDSA, the clinical teams conducted huddles on all patients who received an interruptive alert (n = 35). Eighty percent of huddles had a 5.7 minute average response time and an average duration of 5.3 minutes. Completion of the huddle outcome notes occurred 83% of the time, and 70% had feedback related to the alert, paper form, and huddle process. The number of days between sepsis-related emergent transfers to the pediatric intensive care unit increased from a median of 17.5 to 57.5 days, with a single point as high as 195 days between events. Conclusions: The inpatient sepsis team learned valuable lessons using PDSA methodology. The results of the iterative cycles allowed the team to optimize and refine the tests of change. System-wide implementation benefited from the application of this quality improvement tool.
Changes in protein synthesis, protein phosphorylation and lipid phosphorylation in the amphibian oocyte plasma membrane have been correlated with electrical changes following steroid induction of the completion of the first meiotic division. The oocyte first depolarizes from about -60 mV (inside negative) to about -25 mV 1 to 2 hr before breakdown of the large nucleus followed by a further depolarization beginning 3 to 6 hr after nuclear breakdown. The initial depolarization is associated with appearance of previously described cycloheximide-sensitive cytoplasmic factor(s) which induce both nuclear breakdown and plasma membrane depolarization. We found a similar ED50 (0.4 microM) for cycloheximide inhibition of nuclear breakdown, membrane depolarization, and [3H]-leucine incorporation. Emetine (1 nM to 1 mM) was inactive. The period of cycloheximide sensitivity (first 5 hr) is essentially the same for plasma membrane depolarization and nuclear breakdown. The onset of the second depolarization phase following nuclear breakdown is associated with a marked increase in the rate of [3H]-leucine and [32PO4] incorporation into membrane protein and lipid. Polyacrylamide gel electrophoresis of membrane protein and lipoprotein indicated that a major newly synthesized membrane component is proteolipid. An increase in [32PO4] incorporation into membrane phosphatidylserine and phosphatidylethanolamine (with a decrease in phosphatidylcholine [32PO4] begins during the second depolarization phase and coincides with the appearance of excitability in the oocyte plasma membrane. In toto, the bulk of the biochemical changes (proteins, phosphoproteins, proteolipids, phospholipids) appear to be associated with plasma membrane components and coincide with stepwise changes in membrane permeability to specific ions (e.g. Cl-).
OBJECTIVE: The pediatric sepsis literature lacks studies examining the inpatient setting, yet sepsis remains a leading cause of death in children’s hospitals. More information is needed about sepsis arising in patients already hospitalized to improve morbidity and mortality outcomes. This study describes the clinical characteristics, process measures, and outcomes of inpatient sepsis cases compared with emergency department (ED) sepsis cases within the Improving Pediatric Sepsis Outcomes data registry from 46 hospitals that care for children. METHODS: This retrospective cohort study included Improving Pediatric Sepsis Outcomes sepsis cases from January 2017 to December 2019 with onset in inpatient or ED. We used descriptive statistics to compare inpatient and ED sepsis metrics and describe inpatient sepsis outcomes. RESULTS: The cohort included 26 855 cases; 8.4% were inpatient and 91.6% were ED. Inpatient cases had higher sepsis-attributable mortality (2.0% vs 1.4%, P = .025), longer length of stay after sepsis recognition (9 vs 5 days, P <.001), more intensive care admissions (57.6% vs 54.1%, P = .002), and greater average vasopressor use (18.0% vs 13.6%, P <.001) compared with ED. In the inpatient cohort, >40% of cases had a time from arrival to recognition within 12 hours. In 21% of cases, this time was >96 hours. Improved adherence to sepsis treatment bundles over time was associated with improved 30-day sepsis-attributable mortality for inpatients with sepsis. CONCLUSIONS: Inpatient sepsis cases had longer lengths of stay, more need for intensive care, and higher vasopressor use. Sepsis-attributable mortality was significantly higher in inpatient cases compared with ED cases and improved with improved sepsis bundle adherence.
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