Abstract
Electronic alert systems to identify potential sepsis in children presenting to the emergency department (ED) often either alert too frequently or fail to detect earlier stages of decompensation where timely treatment might prevent serious outcomes. We created a predictive tool that continuously monitors our hospital's electronic health record during ED visits. The tool incorporates new standards for normal/abnormal vital signs based on data from ∼1.2 million children at 169 hospitals. Eighty-two gold standard (GS) sepsis cases arising within 48h were identified through retrospective chart review of cases sampled from 35,586 ED visits during 2012 and 2014-2015. An additional 1,027 cases with high severity of illness (SOI) based on 3M's All Patient Refined - Diagnosis-Related Groups (APR-DRG) were identified from these and 26,026 additional visits during 2017. An iterative process assigned weights to main factors and interactions significantly associated with GS cases, creating an overall "score" that maximized the sensitivity for GS cases and positive predictive value for high SOI outcomes. Tool implementation began August 2017; subsequent improvements resulted in 77% sensitivity for identifying GS sepsis within 48h, 22.5% positive predictive value for major/extreme SOI outcomes, and 2% overall firing rate of ED patients. The incidence of high-severity outcomes increased rapidly with tool score. Admitted alert positive patients were hospitalized nearly twice as long as alert negative patients. Our ED-based electronic tool combines high sensitivity in predicting GS sepsis, high predictive value for physiologic decompensation, and a low firing rate. The tool can help optimize critical treatments for these high-risk children.
Highlights
Disseminated infections in children, including sepsis, may lead to organ dysfunction, decompensation, and death [1]
Testing all possible combinations of four weights was carried out separately for weight ranges “0” to “3” and “1” to “4”, and for Children at High Risk Alert Tool (CAHR-AT) firing cut-offs from “3” to “7”. An exception to this method of assigning and testing possible weights was made for significant two-factor interactions that had a negative association with the gold standard (GS) cases
10% of all emergency department (ED) arrivals were assigned a discharge primary service line of “Infectious Disease” (ID) by the All Patient Refined – Diagnosis-Related Groups (APR-DRG)® V32 grouper, just 0.2% of arrivals were identified by chart review as GS sepsis or severe sepsis cases
Summary
Disseminated infections in children, including sepsis, may lead to organ dysfunction, decompensation, and death [1]. A number of alert tools utilize the electronic health record (EHR) to aid in identifying severe sepsis or septic shock at a child’s initial ED presentation [6,7,8,9] These electronic alerts often incorporate vital sign thresholds that are not evidence-based, leading to low specificity and positive predictive value [10, 11]. Some alerts use indicators that tend to occur later during the illness, such as hypotension, altered mental status, need for supplemental oxygen, and lactic acidosis Given their typical occurrence later in the progression towards physiologic decompensation, these indicators may be less useful for inclusion in an ED-based early recognition alert tool [12]
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