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

Balamuth, Fran; Alpern, Elizabeth R.; Abbadessa, Mary Kate; Hayes, Katie; Schast, Aileen; Lavelle, Jane; Fitzgerald, Julie C.; Weiss, Scott L.; Zorc, Joseph J.

doi:10.1016/j.annemergmed.2017.03.019

Cited by 99 publications

(92 citation statements)

References 23 publications

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“…The positive predictive value noted here for prediction of sepsis positive is higher than that published previously for pediatric sepsis alerts, [27][28][29] and this is likely due to the inclusion of patients with known sepsis. The NNS to identify a patient episode with new or current sepsis of two and with new severe sepsis of 19 is feasible within the PICU setting given that screening only requires a quick bedside perfusion assessment by the nurse.…”

Section: Discussioncontrasting

confidence: 81%

“…The use of two-stage alerts for sepsis screening has been previously studied in both the adult intermediate care area and pediatric emergency department settings. 28,30 In adult patients, use of a two-step nurse-driven paper tool demonstrated high sensitivity and specificity, although it did not significantly change the care of patients with sepsis. 30 Our intervention is similar to a successful two-stage alert followed by a huddle as described in a pediatric emergency department.…”

Section: Discussionmentioning

confidence: 99%

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Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support

et al. 2020

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Background Sepsis is an uncontrolled inflammatory reaction caused by infection. Clinicians in the pediatric intensive care unit (PICU) developed a paper-based tool to identify patients at risk of sepsis. To improve the utilization of the tool, the PICU team integrated the paper-based tool as a real-time clinical decision support (CDS) intervention in the electronic health record (EHR). Objective This study aimed to improve identification of PICU patients with sepsis through an automated EHR-based CDS intervention. Methods A prospective cohort study of all patients admitted to the PICU from May 2017 to May 2019. A CDS intervention was implemented in May 2018. The CDS intervention screened patients for nonspecific sepsis criteria, temperature dysregulation and a blood culture within 6 hours. Following the screening, an interruptive alert prompted nursing staff to complete a perfusion screen to assess for clinical signs of sepsis. The primary alert performance outcomes included sensitivity, specificity, and positive and negative predictive value. The secondary clinical outcome was completion of sepsis management tasks. Results During the 1-year post implementation period, there were 45.0 sepsis events per 1,000 patient days over 10,805 patient days. The sepsis alert identified 392 of the 436 sepsis episodes accurately with sensitivity of 92.5%, specificity of 95.6%, positive predictive value of 46.0%, and negative predictive value of 99.7%. Examining only patients with severe sepsis confirmed by chart review, test characteristics fell to a sensitivity of 73.3%, a specificity of 92.5%. Prior to the initiation of the alert, 18.6% (13/70) of severe sepsis patients received recommended sepsis interventions. Following the implementation, 34% (27/80) received these interventions in the time recommended, p = 0.04. Conclusion An EHR CDS intervention demonstrated strong performance characteristics and improved completion of recommended sepsis interventions.

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Section: Discussioncontrasting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support

et al. 2020

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“…Although conducted at a single center, we included more than 50 pediatric emergency medicine attending and fellow physicians and screened 184 patients. We utilized an existing systematic sepsis recognition program to assist screening, but accurate enrollment ultimately relied on clinician judgment of key e9lements that defined septic shock, i.e., suspicion of bacterial infection and abnormal perfusion. With this approach, only 15% of eligible patient were missed and only 4% of enrolled patients did not have septic shock.…”

Section: Discussionmentioning

confidence: 99%

“…Enrollment was open at all times during the 6‐month study period. We leveraged activation of our institution's sepsis clinical pathway to identify eligible patients, although patients with suspected septic shock not identified by this pathway were also eligible. Reliance on clinician judgment of suitability for enrollment best approximates “usual care” and is commonly employed in pragmatic trials .…”

Section: Methodsmentioning

confidence: 99%

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study

Balamuth

Kittick

McBride

et al. 2019

Academic Emergency Medicine

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Background: Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment. However, the optimal type of crystalloid fluid is unknown. We aimed to determine the feasibility of conducting a pragmatic randomized trial to compare balanced (lactated Ringer's [LR]) with 0.9% normal saline (NS) fluid resuscitation in children with suspected septic shock.Methods: Open-label pragmatic randomized controlled trial at a single academic children's hospital from January to August 2018. Eligible patients were >6 months to <18 years old who were treated in the emergency department for suspected septic shock, operationalized as blood culture, parenteral antibiotics, and fluid resuscitation for abnormal perfusion. Screening, enrollment, and randomization were carried out by the clinical team as part of routine care. Patients were randomized to receive either LR or NS for up to 48 hours following randomization. Other than fluid type, all treatment decisions were at the clinical team's discretion. Feasibility outcomes included proportion of eligible patients enrolled, acceptability of enrollment via the U.S. federal exception from informed consent (EFIC) regulations, and adherence to randomized study fluid administration.Results: Of 59 eligible patients, 50 (85%) were enrolled and randomized. Twenty-four were randomized to LR and 26 to NS. Only one (2%) of 44 patients enrolled using EFIC withdrew before study completion. Total median (interquartile range [IQR]) crystalloid fluid volume received during the intervention window was 107 (60 to 155) mL/ kg and 98 (63 to 128) mL/kg in the LR and NS arms, respectively (p = 0.50). Patients randomized to LR received a median (IQR) of only 20% (13 to 32) of all study fluid as NS compared to 99% (64% to 100%) of study fluid as NS in the NS arm (absolute difference = 79%, 95% CI = 48% to 85%).C onclusions: A pragmatic study design proved feasible to study comparative effectiveness of LR versus NS fluid resuscitation for pediatric septic shock.From the

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“…The introduction of a vital sign-based electronic sepsis screening tool with bedside clinician documentation did improve the recognition of sepsis in their pediatric population. 13 Despite the improvement reported in their study, the EHR-based tool relied on a two-stage alerting system that required additional clinician documentation beyond that necessary for routine patient care.…”

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confidence: 97%

Automating a Manual Sepsis Screening Tool in a Pediatric Emergency Department

et al. 2018

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Severe sepsis and septic shock continue to cause significant morbidity and mortality in children worldwide. 1 To that end, the World Health Organization, along with its decision-mak-ing body the World Health Assembly, adopted a resolution on May 24, 2017, to improve the prevention, diagnosis, and management of sepsis-a crucial step in reducing the global burden of sepsis. 2 The prevalence of pediatric severe sepsis and septic shock has been increasing; however, advances are being Keywords ► EHR workflow design ► emergency medicine ► screening tool ► pediatric sepsis AbstractObjective This article describes the method of integrating a manual pediatric emergency department sepsis screening process into the electronic health record that leverages existing clinical documentation and keeps providers in their current, routine clinical workflows. Methods Criteria in the manual pediatric emergency department sepsis screening tool were mapped to standard documentation routinely entered in the electronic health record. Data elements were extracted and scored from the medical history, medication record, vital signs, and physical assessments. Scores that met a predefined sepsis risk threshold triggered interruptive system alerts which notified emergency department staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the new electronic tool to the manual process was completed by a two-tail paired t-test. Results The performance of the pediatric electronic sepsis screening tool was evaluated by comparing flowsheet row documentation of the manual, sepsis alert process against the interruptive system alert instance of the electronic sepsis screening tool. In an 8-week testing period, the automated pediatric electronic sepsis screening tool identified 100% of patients flagged by the manual process (n ¼ 29), on average, 68 minutes earlier.Conclusion Integrating a manual sepsis screening tool into the electronic health record automated identification of pediatric sepsis screening in a busy emergency department. The electronic sepsis screening tool is as accurate as a manual process and would alert bedside clinicians significantly earlier in the emergency department course. Deployment of this electronic tool has the capability to improve timely sepsis detection and management of patients at risk for sepsis without requiring additional documentation by providers.

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

Cited by 99 publications

References 23 publications

Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support

Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study

Automating a Manual Sepsis Screening Tool in a Pediatric Emergency Department

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