High Reliability Pediatric Septic Shock Quality Improvement Initiative and Decreasing Mortality.

Abstract

Septic shock impacts mortality, morbidity, and health care costs. A quality improvement (QI) initiative was launched to improve early recognition and timely treatment of patients with septic shock in a pediatric emergency department (PED). Our primary aim was to describe the longitudinal effectiveness of the program, iterative changes in clinical practice, and associated outcomes. We implemented multiple interventions during our QI initiative (February 2007 to December 2014). Analysis of compliance and outcomes focused on a bundle consisting of: (1) timely antibiotics, (2) intravenous fluids (IVF) for rapid reversal of perfusion abnormalities and/or hypotension. Logistic regression was used to obtain adjusted odds ratios (ORs) for death and pediatric ICU (PICU) admission. A total of 1380 patients were treated for septic shock; 93% met screening criteria at triage. Implementation of the various processes improved timely interventions. One example included implementation of a sepsis order set, after which the mean proportion of patients receiving timely antibiotics increased to its highest rate. The odds of death were 5 times as high for children who did not receive bundle-compliant care (OR, 5.0 [95% Confidence Interval 1.9, 14.3]) compared with those who did (OR, 0.20 [95% Confidence Interval 0.07, 0.53]). Among PICU admitted patients, the odds of mortality were greater for children who presented with abnormal mental status and a higher pediatric index of mortality 2 score. QI methodology improved septic shock program goal adherence and decreased mortality without increasing PICU admissions or PED length of stay over the 8-year period, supporting continued emphasis on early recognition, timely IVF resuscitation, and antibiotic administration.