Poor Compliance with Sepsis Guidelines in a Tertiary Care Children’s Hospital Emergency Room

Abstract

ObjectivesThis study aimed to assess factors related to adherence to the Pediatric Advanced Life Support guidelines for severe sepsis and septic shock in an emergency room (ER) of a tertiary care children’s hospital.MethodsThis was a retrospective, observational study of children (0–18 years old) in The Children’s Hospital of San Antonio ER over 1 year with the International Consensus Definition Codes, version-9 (ICD-9) diagnostic codes for “severe sepsis” and “shocks.” Patients in the adherent group were those who met all three elements of adherence: (1) rapid vascular access with at most one IV attempt before seeking alternate access (unless already in place), (2) fluids administered within 15 min from sepsis recognition, and (3) antibiotic administration started within 1 h of sepsis recognition. Comparisons between groups with and without sepsis guideline adherence were performed using Student’s t-test (the measurements expressed as median values). The proportions were compared using chi-square test. p-Value ≤0.05 was considered significant.ResultsA total of 43 patients who visited the ER from July 2014 to July 2015 had clinically proven severe sepsis or SS ICD-9 codes. The median age was 5 years. The median triage time, times from triage to vascular access, fluid administration and antibiotic administration were 26, 48.5, 76, and 135 min, respectively. Adherence to vascular access, fluid, and antibiotic administration guidelines was 21, 26, and 34%, respectively. Appropriate fluid bolus (20 ml/kg over 15–20 min) was only seen in 6% of patients in the non-adherent group versus 38% in the adherent group (p = 0.01). All of the patients in the non-adherent group used an infusion pump for fluid resuscitation. Hypotension and ≥3 organ dysfunction were more commonly observed in patients in adherent group as compared to patients in non-adherent group (38 vs. 14% p = 0.24; 63 vs. 23% p = 0.03).ConclusionOverall adherence to sepsis guidelines was low. The factors associated with non-adherence to sepsis guidelines were >1 attempt at vascular access, delay in antibiotic ordering, fluid administration using infusion pump, absence of hypotension, and absence of three or more organs in dysfunction at ER presentation.

Association of Antibiotics Administration Timing With Mortality in Children With Sepsis in a Tertiary Care Hospital of a Developing Country

“…Previous studies evaluating adherence to practice guidelines have shown similar data. Our median time to administer antibiotics was 105 min (IQR: 65-185.5 min), while the reported median times from Boston Children's Hospital, Stollery Children's Hospital, Children's Hospital of San Antonio, and Children's Hospital of Philadelphia were 96, 115, 135, and 140 min, respectively (11,13,14,25).…”

The Use of a Rapid Fluid Infusion System in Children

“…Even after recognition of shock states, lack of knowledge of fluid resuscitation guidelines and technical limitation of fluid delivery often delay adequate resuscitation 1,2,11,15 . The LifeFlow device serves as technique that appears to offer speed, efficiency and control of volume infused and as a resource to overcome the barrier of fluid delivery in shock states.…”

“…Studies based on these guidelines show that earlier fluid delivery directed at reversal of shock reversal leads to decreased morbidity 7-9 , mortality 2,7,[9][10][11][12] , and hospital length of stay (LOS) 9, [11][12][13] . Unfortunately, timely fluid delivery is often not achieved due to the technical challenges of obtaining adequate vascular access and delivering fluid boluses quickly in patients with shock or hypotension 11,[14][15][16] . Current methods of fluid bolus delivery in the pediatric emergency care setting include infusion pumps, gravity drip, pressure bags, rapid infusers, and the push-pull syringe technique 17,18 .…”

<p>Improving fluid resuscitation in pediatric shock with LifeFlow^®: a retrospective case series and review of the literature</p>

“…Children with decompensated shock (prolonged capillary refill plus hypotension) are at the highest risk, with over 30% mortality 1. Earlier fluid delivery targeted at shock reversal results in decreased morbidity,1–3 mortality,1,3–8 and hospital length of stay (LOS) 3,7,9–12. For example, in a prospective cohort study evaluating adherence with guideline recommendations for fluid resuscitation in pediatric septic shock, patients for whom all aspects of the protocol were met had a 57% shorter hospital LOS 9.…”

“…This method also carries the risk of air embolism 17. Infusion pumps deliver a maximum rate of 1,000 mL/hr and can achieve 60 mL/kg over 15 mins only in patients weighing <4 kg, but are still commonly used as a method of fluid bolus delivery 9,12. With PPT and DRT, providers may be able to achieve the guideline-recommended rates of infusion,17,18 but these methods are complex and labor-intensive, and both techniques may introduce bacterial contamination into the sterile stopcock 19–22.…”