Gap Analysis and Development of a Protocol for Goal-Directed Therapy for Septic Shock in a Pediatric Emergency Department in Puerto Rico after Hurricane Maria

Background: Septic shock is one of the leading causes of pediatric mortality worldwide. Goal directed therapy and early administration of antibiotics within the first hour have been shown to decrease mortality from sepsis. An inadequate triage system, number of medical providers, and lack of equipment and medications are known barriers to following best practice in resource constrained settings. In Puerto Rico, the exodus of physicians to the mainland after the hurricane’s widespread devastation, coupled with a lack of supplies, has intensified the existing gap in pediatric care for a vulnerable patient population. Our aim was to describe the gap analysis and initial development of a protocol to identify potential patients with sepsis and improve timeliness of interventions (time to fluids and to antibiotics) based on national treatment guidelines, in a mid-resource setting. Methods: From August 2016 to January 2017, through interviews, questionnaires and focus groups involving emergency department nurses, physicians, support staff and hospital leadership, gaps and barriers to recognition and management of sepsis were identified. Baseline metrics for care management of sepsis were extracted from a retrospective chart review for May to July 2016. A protocol was developed through multi-disciplinary collaboration between the emergency room, different subspecialties, and hospital leadership based on identified gaps, available resources, and nationally recognized guidelines. Results: The gap analysis revealed nurses did not feel comfortable identifying changes in vital signs that reflect sepsis (85%), did not believe fluid boluses could be given over 15 minutes (55%), and did not believe that a septic patient could receive multiple fluid boluses safely (72%). Only 13% of patients who met sepsis screening criteria were classified in the correct triage category. 17% of patients received antibiotics within the first hour of arrival and 27% received initial antibiotics more than 4 hours after arrival. Approximately 50% of patients did not receive a fluid bolus. Based on needs assessment and gap analysis, the following tools were developed: a triage classification system, sepsis scale score, sepsis Fast Pass to the ED, sepsis protocol algorithm, and Sepsis order set. These tools will be implemented using a comprehensive QI approach with PDSA cycles and education including in-situ simulation. Conclusions: Needs assessment and chart review revealed significant gaps in the standard of care of pediatric patients with sepsis in a mid-resource pediatric ED. We developed several intervention tools as part of a bundled QI protocol to be implemented in March 2018.