A mentor of mine once challenged the room of learners in which I sat with a simple but thought-provoking question, “If a child has sepsis and no one is there to recognize it, does the child still have sepsis?” Immediately our minds drifted to the dilemma of trees falling in a forest and the unanswerable question of whether or not sounds are made in the absence of an active listener. The more important message, however, was that the timely recognition of and provision of life-saving interventions for sepsis require a focused, collaborative effort that starts with the moment a child presents for medical care. In this month’s Pediatrics (10.1542/peds.2020-007369), Holly Depinet and colleagues share a multi-institutional quality improvement initiative from the Pediatric Septic Shock Collaborative (PSSC) aimed at reducing mortality among children presenting to the emergency department with sepsis.
The PSSC, formed under the American Academy of Pediatrics Section on Emergency Medicine, is comprised of interprofessional front-line clinicians and institutional leadership at 19 different emergency departments. Together as detailed in this study, they aimed to reduce aggregate 3- and 30-day mortality by 20% among children presenting to the emergency department with sepsis over a nearly 3-year period. To accomplish this goal, the PSSC provided each site with resources to support the screening and identification of sepsis, implementing bedside care team huddles, developing care bundles for the administration of fluid boluses and antibiotics, sepsis education, and for using electronic health record tools.
A total of 7,192 patients were included in the initiative over a 31-month period. Overall, 30-day mortality decreased from 2.3% to 1.4% while 3-day mortality did not change significantly over time. However, as with most QI work, the details matter as much as the primary outcome. Participating sites saw process improvements in the proportion of patients with vital signs documented within 20 minutes (74% to 78%) and receipt of antibiotic therapy within 60 minutes (47% to 50%) but not with administration of the first fluid bolus within 20 minutes. While the magnitude of improvement may seem minor, small but demonstrable improvements have the potential to improve outcomes for the 75,000 children treated for severe sepsis each year in the United States.1
What should you take away from this important work? For starters, the PSSC realized success with an initiative that was not prescriptive in nature, but instead provided tools that each institution could incorporate into their unique workflows. Such an approach improves the generalizability of the work beyond the nuances of a single institution. Second, the results of this initiative continue to support previous observations that improvement in sepsis care is not necessarily the result of achieving a single metric.2 Rather, having an elevated awareness of recognizing sepsis and almost reflexively intervening with evidence-informed care can and does drive improvement in patient outcomes.
- Hartman ME, Linde-Zwirble WT, Angus DC, et al. Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med. 2013 Sep; 14(7):686-93.
- Evans IVR, Phillips GS, Alpern ER, et al. Association between the New York sepsis care mandate and in-hospital mortality for pediatric sepsis. JAMA. 2018 July 24;320(4):358-367.