PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content Sepsis Septic

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

IMPACT OF SEPSIS ON PATIENT OUTCOMES Educational Content

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

Epidemiology-Pediatric • Sepsis is a leading cause of illness & death among U. S. children • > 42, 000 cases annually (4 th 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 -701 Kutko Pediatr Crit Care Med 2003; 4: 333 -337 Carcillo Crit Care Med 2002 30(6): 1365 -1378

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

Sepsis Disease Spectrum Presentation of sepsis reflects a spectrum

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

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 ≥ 3 sec (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 m. L/kg/hr • Hypotension Carcillo Crit Care Med 2002 30(6): 1365 -1378

2 Major Types of Septic Shock • Cold Shock • Warm Shock • Cold extremities • Warm extremities • Capillary refill ≥ 3 sec • Flash capillary refill • Myocardial Dysfunction • Vasomotor Paralysis • Low CI and high SVRI • High CI and low SVRI • Sick heart with significant • Hyperdynamic heart vasoconstriction to maintain perfusion to organs with vasodilation

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

Further Definitions • Fluid-refractory shock: • Shock despite 60 cc/kg in 1 st 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

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

THE EVIDENCE Educational Content

p <. 001 Each hour of delay associated with 50% increased odds of mortality p <. 001 Han et al. , Pediatrics 112: 2003

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 Rivers et al. , NEJM 2001

Early Rapid Fluid Resuscitation in Pediatric Septic Shock is Associated with Improved Outcomes Time-sensitive % Mortality Fluid-sensitive Oliveira et al, Ped Emergency Care 24: 2008

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

EVIDENCED BASED GUIDELINES Educational Content

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 1 st 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 fluiddopamine-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

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

ACCM Guidelines: 60 cc/kg in 15 minutes PALS Guidelines: 60 cc/kg in 60 minutes

The PSSC Clinical Pathway

TRIAGE TRIGGER TOOL High Risk Conditions Vital Signs of Perfusion

TRIAGE TRIGGER TOOL Identify as at risk for sepsis if: 1. Hypotension or 2. Meets 3/8 criteria or 3. Meets 2/8 criteria if high-risk

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

PEDIATRIC SEPTIC SHOCK COLLABORATIVE Educational Content (Quality Improvement Primer)

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

Plan-Do-Study-Act

EXAMPLE OF QI INITIATIVE Quality Improvement Primer

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

Background PALS (2006) Recognize altered mental status and poor perfusion 5 min Establish vascular access and begin resuscitation 5 min 1 st hour: Push repeated 20 m. L/kg IVF up to 3 60 min § Administer antibiotics STAT yes Fluid responsive (i. e. normalization of BP and/or perfusion)? Consider ICU monitoring 60 min no Begin vasoactive drug therapy and titrate to correct hypotension / poor perfusion Modified from Pediatric Advanced Life Support Manual. American Heart Association. 2006. 60 min

Needs Assessment

Needs Assessment Fluid adherence n= 29 (mean # days) Fluid non-adherence n= 98 (mean # days) % decrease P value Hospital LOS 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 Hospital LOS 6. 8 10. 9 57% 0. 009 ICU LOS 5. 5 6. 8 59% 0. 035

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

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

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

Team Members Middle Management Frontline workers Physicians Nursing Respiratory Nursing assistants Pharmacists Research Assistants Pharmacy Head Statistical Support Computer Support Upper Level Management Physician Leadership Nursing Leadership Hospital Leadership

Equipment MD’s are too busy with patient to put in orders Waiting for IV team Don’t know how to use pressure bag Holding for other procedures CA’s cannot be reached Need labels to sent labs CA’s usually get labels but are busy holding for IV Can’t find pressure bag Wrong fluid device used People CA phones numbers not uniformly posted, some don’t have phones Hesitance to use IO People don’t know pharmacy number No IV access Access tenuous Pharmacists difficult to get a hold of Don’t know to use pressure bag Too many patients Too busy to recognize septic patients No pocket cards for bedside reference Poor knowledge of protocol Not enough MDS No visible algorithms No trigger system Environment No educational sessions 60 ml/kg within 60 minutes MD’s don’t know who the nurses are No accountability/feedback Poor RN/MD communication Many trainees to educate, many adult trainees Many trainees Methods

Needs Assessment: Pareto

Change Hypotheses • Educational sessions MDs October 6 • Educational sessions RNs • Didactics • Net learning • Skills Day (pressure bags) • Computer Orderset September 21, October 2 Ongoing October 12 September 26 • Visible algorithm • Posters October 16 • Pocket cards October 27 • Clock October 19 • Bedside Survey October 10

ED Septic Shock Orderset

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 60 cc/kg in 60 minute goal for IVFs! You met the antibiotics in 60 minute goal! You met the pressor initiation at 60 minute goal!

MEASURE: Run Chart

MEASURE: SPC Chart Upper Control Limit Lower Control Limit

Example SPC chart

The Improvement Guide: 1996

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