Electronic Sepsis Research Articles

Barriers and facilitators to effective electronic health record-based sepsis screening in the pediatric intensive care unit.

The Pediatric Surviving Sepsis Campaign supports the implementation of automated tools for early sepsis recognition. In 2019 the C.S. Mott Children's Hospital Pediatric Intensive Care Unit deployed an electronic medical record (EMR)-based screening for early recognition and treatment of sepsis. We analyzed all automated primary sepsis alerts, secondary screens, and bedside huddles from November 2019 to January 2020 (Cohort 1) and from November 2020 to January 2021 (Cohort 2) to identify barriers and facilitators for the use of this tool. We distributed surveys to frontline providers to gather feedback on end-user experience. In Cohort 1, 895 primary alerts were triggered, yielding 503 completed secondary screens and 40 bedside huddles. In Cohort 2, 925 primary alerts were triggered, yielding 532 completed secondary screens and 12 bedside huddles. Surveys assessing end-user experience identified the following facilitators: (1) 73% of nurses endorsed the bedside huddle as value added; (2) 74% of medical providers agreed the bedside huddle increased the likelihood of interventions. The greatest barriers to successful implementation included the (1) overall large number of primary alerts from the automated tool and (2) rate of false alerts, many due to routine respiratory therapy interventions. Our data suggests that the successful implementation of EMR-based sepsis screening tools requires countermeasures focusing on 3 key drivers for change: education, technology, and patient safety. While both medical providers and bedside nurses found merit in our EMR-based sepsis early recognition system, continued refinement is necessary to avoid sepsis alert fatigue.

Blood Culture Ordering After Sepsis Alerts and Subsequent Patient Outcomes: An Electronic Health Record-Based Study.

Sepsis is a global health priority associated with high mortality. Clinical decision support systems have been developed to support clinicians with sepsis management. Ordering blood cultures (BCs) for suspected sepsis patients are strongly recommended by clinical guidelines. However, limited evidence exists investigating BC ordering following sepsis alerts and subsequent patient outcomes. This study aimed to investigate this issue using electronic health record data from an acute care hospital in Australia. Of 4,092 patients, only 16.6% had a BC ordered following a sepsis alert. The median time from the first sepsis alert to a BC order was 15.3 hours. Patients had 5.89 times higher odds of being diagnosed with sepsis if a BC was ordered following a sepsis alert than those without BC ordered (p<0.0001). Further investigation is needed to understand reasons behind the delay or failure to order a BC despite receiving electronic sepsis alerts and how decision support can be optimized to improve patient outcomes.

Sepsis Prediction Model for Determining Sepsis vs SIRS, qSOFA, and SOFA

The Sepsis Prediction Model (SPM) is a proprietary decision support tool created by Epic Systems; it generates a predicting sepsis score (PSS). The model has not undergone validation against existing sepsis prediction tools, such as Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), or quick Sepsis-Related Organ Failure Asessement (qSOFA). To assess the validity and timeliness of the SPM compared with SIRS, qSOFA, and SOFA. This retrospective cohort study included all adults admitted to 5 acute care hospitals in a single US health system between June 5, 2019, and December 31, 2020. Data analysis was conducted from March 2021 to February 2023. A sepsis event was defined as receipt of 4 or more days of antimicrobials, blood cultures collected within ±48 hours of initial antimicrobial, and at least 1 organ dysfunction as defined by the organ dysfunction criteria optimized for the electronic health record (eSOFA). Time zero was defined as 15 minutes prior to qualifying antimicrobial or blood culture order. Of 60 507 total admissions, 1663 (2.7%) met sepsis criteria, with 1324 electronic health record-confirmed sepsis (699 [52.8%] male patients; 298 [22.5%] Black patients; 46 [3.5%] Hispanic/Latinx patients; 945 [71.4%] White patients), 339 COVID-19 sepsis (183 [54.0%] male patients; 98 [28.9%] Black patients; 36 [10.6%] Hispanic/Latinx patients; and 189 [55.8%] White patients), and 58 844 (97.3%; 26 632 [45.2%] male patients; 12 698 [21.6%] Black patients; 3367 [5.7%] Hispanic/Latinx patients; 40 491 White patients) did not meet sepsis criteria. The median (IQR) age was 63 (51 to 73) years for electronic health record-confirmed sepsis, 69 (60 to 77) years for COVID-19 sepsis, and 60 (42 to 72) years for nonsepsis admissions. Within the vendor recommended threshold PSS range of 5 to 8, PSS of 8 or greater had the highest balanced accuracy for classifying a sepsis admission at 0.79 (95% CI, 0.78 to 0.80). Change in SOFA score of 2 or more had the highest sensitivity, at 0.97 (95% CI, 0.97 to 0.98). At a PSS of 8 or greater, median (IQR) time to score positivity from time zero was 68.00 (6.75 to 605.75) minutes. For SIRS, qSOFA, and SOFA, median (IQR) time to score positivity was 7.00 (-105.00 to 08.00) minutes, 74.00 (-22.25 to 599.25) minutes, and 28.00 (-108.50 to 134.00) minutes, respectively. In this cohort study of hospital admissions, balanced accuracy of the SPM outperformed other models at higher threshold PSS; however, application of the SPM in a clinical setting was limited by poor timeliness as a sepsis screening tool as compared to SIRS and SOFA.

Sepsis Prediction in Hospitalized Children: Clinical Decision Support Design and Deployment.

Following development and validation of a sepsis prediction model described in a companion article, we aimed to use quality improvement and safety methodology to guide the design and deployment of clinical decision support (CDS) tools and clinician workflows to improve pediatric sepsis recognition in the inpatient setting. CDS tools and sepsis huddle workflows were created to implement an electronic health record-based sepsis prediction model. These were proactively analyzed and refined using simulation and safety science principles before implementation and were introduced across inpatient units during 2020-2021. Huddle compliance, alerts per non-ICU patient days, and days between sepsis-attributable emergent transfers were monitored. Rapid Plan-Do-Study-Act (PDSA) cycles based on user feedback and weekly metric data informed improvement throughout implementation. There were 264 sepsis alerts on 173 patients with an 89% bedside huddle completion rate and 10 alerts per 1000 non-ICU patient days per month. There was no special cause variation in the metric days between sepsis-attributable emergent transfers. An automated electronic health record-based sepsis prediction model, CDS tools, and sepsis huddle workflows were implemented on inpatient units with a relatively low rate of interruptive alerts and high compliance with bedside huddles. Use of CDS best practices, simulation, safety tools, and quality improvement principles led to high utilization of the sepsis screening process.

A Rapid Response Team (RRT) System at a Cancer Center: Innovative Approaches to System Organization and Clinical RRT Pathways.

The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.

Clinical Impact of a Sepsis Alert System Plus Electronic Sepsis Navigator Using the Epic Sepsis Prediction Model in the Emergency Department

BackgroundThe Epic Sepsis Prediction Model (SPM) is a proprietary sepsis prediction algorithm that calculates a score correlating with the likelihood of an International Classification of Diseases, Ninth Revision code for sepsis. ObjectiveThis study aimed to assess the clinical impact of an electronic sepsis alert and navigator using the Epic SPM on time to initial antimicrobial delivery. MethodsWe performed a retrospective review of a nonrandomized intervention of an electronic sepsis alert system and navigator using the Epic SPM. Data from the SPM site (site A) was compared with contemporaneous data from hospitals within the same health care system (sites B–D) and historical data from site A. Nonintervention sites used a systemic inflammatory response syndrome (SIRS)–based alert without a sepsis navigator. ResultsA total of 5368 admissions met inclusion criteria. Time to initial antimicrobial delivery from emergency department arrival was 3.33 h (interquartile range [IQR] 2.10–5.37 h) at site A, 3.22 h (IQR 1.97–5.60; p = 0.437, reference site A) at sites B–D, and 6.20 h (IQR 3.49–11.61 h; p < 0.001, reference site A) at site A historical. After adjustment using matching weights, there was no difference in time from threshold SPM score to initial antimicrobial between contemporaneous sites. Adjusted time to initial antimicrobial improved by 2.87 h (p < 0.001) at site A compared with site A historical. ConclusionsImplementation of an electronic sepsis alert system plus navigator using the Epic SPM showed no difference in time to initial antimicrobial delivery between the contemporaneous SPM alert plus sepsis navigator site and the SIRS-based electronic alert sites within the same health care system.

Prevalence, risk factors, and outcomes associated with delayed second doses of antibiotics in sepsis at a large academic medical center.

To evaluate the prevalence, risk factors, and clinical impact of delays in second doses of antibiotics in patients with sepsis. Single-center, retrospective, observational study. Large teaching hospital. Adult patients who triggered an electronic sepsis alert in the emergency department (ED), received ≥2 doses of vancomycin or an antipseudomonal beta-lactam, and were discharged with an ICD-10 sepsis code. We assessed the prevalence of delays in second doses of antibiotics by ≥25% of the recommended dose interval and conducted multivariate regression analyses to assess for risk factors for delays and in-hospital mortality. The cohort included 449 patients, of whom 123 (27.4%) had delays in second doses. In-hospital death occurred in 31 patients (25.2%) in the delayed group and 71 (21.8%) in the non-delayed group (p = 0.44). On multivariate analysis, only location in a non-ED unit at the time second doses were due was associated with delays (OR 2.75, 95% CI 1.20-6.32). In the mortality model, significant risk factors included malignant tumor, respiratory infection, and elevated Sequential Organ Failure Assessment (SOFA) score but not delayed second antibiotic doses (OR 1.19, 95% CI 0.69-2.05). In a subgroup analysis, delayed second doses were associated with higher mortality in patients admitted to non-intensive care units (ICUs) (OR 4.10, 95% CI 1.32-12.79). Over a quarter of patients with sepsis experienced delays in second doses of antibiotics. Delays in second antibiotic doses were not associated with higher mortality overall, but an association was observed among patients admitted to non-ICUs.

1184: PREVALENCE, RISK FACTORS, AND OUTCOMES ASSOCIATED WITH DELAYED SECOND DOSES OF ANTIBIOTICS IN SEPSIS

Introduction: Best practice guidelines and quality measures emphasize timely administration of initial antibiotics in patients with sepsis but there are limited data on the prevalence, risk factors, and clinical impact of delays in subsequent doses. Methods: We retrospectively identified all adult patients admitted to a large academic hospital who triggered an electronic sepsis alert in the emergency department (ED), received ≥2 doses of vancomycin or an antipseudomonal beta-lactam, and were discharged with an ICD-10 sepsis code between January 2018-December 2019. We calculated the prevalence of delays in second doses of vancomycin or antipseudomonal beta-lactams, defined as ≥25% of the recommended dose interval (accounting for initial renal function), and conducted multivariable regression analyses to assess for risk factors for delays (including demographics, comorbidities, SOFA score, lactate, creatinine clearance, source of infection, time in the ED, ICU admission, ED vs non-ED location at time of 2nd dose, need for stress dose steroids) and the association between delays and short-term mortality (in-hospital death or discharge to hospice). Results: The cohort included 449 patients with sepsis, of whom 123 (27.4%) had delays in second doses of vancomycin or antipseudomonal beta-lactams. Short-term mortality occurred in 38 patients (30.9%) in the delayed group and 89 (27.3%) in the non-delayed group (p=0.45). On multivariable analysis, only location in a non-ED unit at the time second doses were due was significantly associated with delays (OR 2.75, 95% CI 1.20-6.32). In the mortality model, significant risk factors included malignancy (OR 2.11, 95% CI 1.26-3.53), respiratory infection (OR 1.91, 95% CI 1.15-3.17), and elevated SOFA score (OR 1.16, 95% CI 1.08-1.25), but not delayed second antibiotic doses (OR 1.19, 95% CI 0.69-2.05). Conclusions: Over a quarter of patients treated for sepsis in the ED experienced delays in second doses of antibiotics; these delays were more likely when the patient had transferred out of the ED before the second dose was due, suggesting that transitions of care may have contributed. Delayed second doses were not significantly associated with mortality, although our study may be underpowered to detect small differences in this outcome.

733: IMPACT OF ELECTRONIC SEPSIS ALERT ON PEDIATRIC SEPSIS OUTCOMES: AN INTERRUPTED TIME SERIES ANALYSIS

Introduction: Pediatric sepsis is a significant cause of morbidity and mortality in children; guidelines now recommend a systematic screening tool to enhance early recognition of children with sepsis. However, it is unknown whether a screening tool that uses electronic clinical data to alert clinicians about a concern for sepsis can impact outcomes. We hypothesized that an electronic sepsis alert would decrease mortality, ICU admission, vasoactive use, and organ dysfunction at day 3 and day 7. Methods: This was a single-center, retrospective study of emergency department sepsis episodes from January 20, 2011 to May 20, 2021. Sepsis episodes were identified by a validated computational algorithm which reflects presence of infection with organ dysfunction (cardiac, respiratory, hematologic or renal) using data in the electronic health record. The sepsis alert was positive with elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. We performed an interrupted time series analysis to compare outcomes before and after implementation of the electronic sepsis alert in March 2014. Interrupted time series analysis is a quasi-experimental design which can assess a level change (difference between predicted vs observed outcomes immediately post-intervention) as well as changes in trends (slope) before and after intervention. Outcomes included mortality, ICU admission, vasoactive use, and organ dysfunction at day 3 and day 7. Results: Of 3,269 total sepsis episodes, 770 occurred prior to and 2,429 occurred after sepsis alert implementation (70 missing alert status). After adjusting for season, there was no change in mortality (p=0.30), ICU admission (p=0.39) or vasoactive use (p=0.10). Sepsis alert implementation was associated with a significant change in organ dysfunction at day 3 (p=0.03) and day 7 (p< 0.0001). Specifically, there was an increasing slope of organ dysfunction prior to sepsis alert, which was stabilized after alert implementation. Conclusions: Using electronic clinical health data, implementation of a sepsis alert may impact rate of day 3 and day 7 organ dysfunction, though did not impact mortality, ICU admission or vasoactive use in our single center.

Evaluation of the effectiveness of an automated sepsis predictive tool on patient outcomes.

To evaluate the effectiveness of a multidisciplinary, hospital-wide program as part of an electronic sepsis alert tool. We used data from 15 hospitals about adult patients with severe sepsis or septic shock. Nine intervention hospitals implemented an Epic sepsis prediction tool, education, and standardized order sets (six control hospitals did not). A difference-in-difference approach evaluated their effectiveness: 1) pre-implementation period (January 1, 2016-November 15, 2018) and 2) implementation period (November 16, 2018-June 30, 2019). Outcomes included mortality, receipt of the SEP-1 bundle of care, broad spectrum antibiotic use, ICU stay, and length of stay of 6926 patients. The difference of 6.7 percentage points between the intervention and control groups in SEP-1 bundle completion was not statistically significant (p = 0.105). The increase over time for antibiotic administration ≤1 h of time zero was not larger for hospitals in the intervention group (11.7%) compared to the control-group (7.6%, p = 0.084). Differences among hospitals in both groups were not statistically different for mortality (p = 0.174), ICU stays (p = 0.174), and length of stay (p = 0.652) from pre- to implementation period. The intervention to facilitate timely sepsis care did not improve patient outcomes among those with severe sepsis or septic shock.

Piloting an Electronic Sepsis Alerting System to Reduce Inpatient Sepsis-related Serious Safety Events.

Background: Electronic surveillance systems that enable continuous patient screening for emerging signs of sepsis may improve sepsis recognition and patient outcomes. Objectives: An electronic sepsis alerting system was piloted on Pediatric Medicine units at a tertiary care hospital. The pilot served to refine the system and accompanying workflow before hospital-wide implementation, aiming to reduce inpatient serious safety events related to delayed sepsis recognition. Methods: The multitiered intervention included (1) an electronic sepsis screening and alerting system; (2) an interdisciplinary huddle workflow; (3) risk stratification nomenclature (continue routine care, sepsis watch, code sepsis) to reconcile alerts; and (4) streamlined documentation and ordering tools. Iterative changes were made to the tools and workflow using plan, do, study, act cycle methodology. Measures of clinician adherence to the workflow were tracked monthly during the pilot (% alerts reconciled, % alerts with documented huddle note). Alert to huddle time and huddle to reconciliation time (target: 10 minutes) served as outcome measures for the pilot. The frequency of consults to the hospital’s critical care response team for the indication of query sepsis was monitored as a balancing measure. Alert frequency, rate of corresponding clinical concern for sepsis, and missed sepsis cases were tracked as measures of screening tool utility. Results: During the 3-month pilot, 86% of alerts were reconciled and 67% had a documented huddle note. The median alert to huddle time decreased from 9 to 3 minutes over the course of the pilot. The median huddle to reconciliation time decreased from 14 to 8 minutes. The frequency of CCRT consults during the pilot was 1 per month, which was increased slightly from the baseline frequency of 0.67 consults per month over the previous year. An alert was triggered for 4.1% of opportunities (average 2.2 alerts per day). Of the alerts reconciled, 29% indicated a concern for sepsis. There were four instances of clinical concern for sepsis where no alert was triggered. The sepsis huddle workflow was followed in three of these instances. Conclusions/implications: Pilot results suggest clinician adherence to a new streamlined approach to care for inpatients at risk for sepsis. Involving clinicians in system design and embedding electronic tools within existing care processes supported workflow uptake. Future efforts will focus on optimizing the alerting system’s clinical accuracy and examining its impact on clinical outcomes.

Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis.

Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial

BackgroundTo evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality.MethodsThe SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of “possible sepsis alert” to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days.DiscussionThe trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021.Trial registrationClinicalTrials.gov NCT04078594. Registered on September 6, 2019

Evaluation of a Sepsis Alert in the Pediatric Acute Care Setting.

Severe sepsis can cause significant morbidity and mortality in pediatric patients. Early recognition and treatment are vital to improving patient outcomes. The study aimed to evaluate the impact of a best practice alert in improving recognition of sepsis and timely treatment to improve mortality in the pediatric acute care setting. A multidisciplinary team adapted a sepsis alert from the emergency room setting to facilitate identification of sepsis in acute care pediatric inpatient areas. The sepsis alert included clinical decision support to aid in timely treatment, prompting the use of intravenous fluid boluses, and antibiotic administration. We compared sepsis-attributable mortality, time to fluid and antibiotic administration, proportion of patients who required transfer to a higher level of care, and antibiotic days for the year prior to the sepsis alert (2017) to the postimplementation phase (2019). We had 79 cases of severe sepsis in 2017 and 154 cases in 2019. Of these, we found an absolute reduction in both 3-day sepsis-attributable mortality (2.53 vs. 0%) and 30-day mortality (3.8 vs. 1.3%) when comparing the pre- and postintervention groups. Though our analysis was underpowered due to small sample size, we also identified reductions in median time to fluid and antibiotic administration, proportion of patients who were transferred to the intensive care unit, and no observable increase in antibiotic days. Electronic sepsis alerts may assist in improving recognition of sepsis and support timely antibiotic and fluid administration in pediatric acute care settings.

Evaluation of a novel approach to recognising community-acquired paediatric sepsis at ED triage by combining an electronic screening algorithm with clinician assessment

ObjectiveWe report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric ED.MethodsAn electronic sepsis screening tool was implemented...

Plan-Do-Study-Act Methodology: Refining an Inpatient Pediatric Sepsis Screening Process.

Introduction:Pediatric sepsis remains a leading cause of death of children in the United States. Timely recognition and treatment are critical to prevent the onset of severe sepsis and septic shock. Electronic screening tools aid providers in identifying patients at risk for sepsis. Our overall project goal was to decrease the number of sepsis-related emergent transfers to the pediatric intensive care unit by optimizing sepsis screening tools, interruptive alerts, and a new paper tool and huddle process using Plan-Do-Study-Act (PDSA) methodology.Methods:Our team utilized historical data to develop inpatient electronic sepsis screening tools to identify pediatric patients at risk for sepsis. Using PDSA iterative cycles over 3 months, we tested the design of an interruptive alert, paper tool, and a new sepsis huddle process.Results:During the PDSA, the clinical teams conducted huddles on all patients who received an interruptive alert (n = 35). Eighty percent of huddles had a 5.7 minute average response time and an average duration of 5.3 minutes. Completion of the huddle outcome notes occurred 83% of the time, and 70% had feedback related to the alert, paper form, and huddle process. The number of days between sepsis-related emergent transfers to the pediatric intensive care unit increased from a median of 17.5 to 57.5 days, with a single point as high as 195 days between events.Conclusions:The inpatient sepsis team learned valuable lessons using PDSA methodology. The results of the iterative cycles allowed the team to optimize and refine the tests of change. System-wide implementation benefited from the application of this quality improvement tool.

Analysis of Missed Sepsis Patients in a Pediatric Emergency Department With a Vital Sign-Based Electronic Sepsis Alert.

To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED). Retrospective cohort study in a tertiary care children's hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications. There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients. In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.

Sepsis in Complex Patients in the Emergency Department: Time to Recognition and Therapy in Pediatric Patients With High-Risk Conditions.

To compare timeliness of sepsis recognition and initial treatment in patients with and without high-risk comorbid conditions. This was a retrospective cohort study of patients presenting to a pediatric emergency department (ED) who triggered a vital sign-based electronic sepsis alert resulting in bedside "huddle" assessment per institutional practice. A positive sepsis alert was defined as age-specific tachycardia or hypotension, concern for infection, and at least 1 of the following: abnormal capillary refill, abnormal mental status, or a high-risk condition. High-risk conditions were derived from the American Academy of Pediatrics sepsis alert tool. Patients with a positive alert underwent bedside huddle resulting in a decision regarding initiation of sepsis protocol. Placement on the protocol and time to initiation of protocol and individual therapies were compared for patients with and without high-risk conditions. During the 1-year study period, there were 1107 sepsis huddle alerts out of 96,427 ED visits. Of these, 713 (65%) had identified high-risk conditions, and 394 (35%) did not. Among patients with sepsis huddles, there was no difference in sepsis protocol initiation for patients with high-risk conditions compared with those without (24.8% vs 22.0%, P = 0.305). Between patients with high-risk conditions and those without, there were no differences in median time from triage to sepsis protocol activation, triage to initial intravenous antibiotic, triage to initial intravenous fluid therapy, or ED length of stay. Timeliness of care initiation was no different in high-risk patients with sepsis when using an electronic sepsis alert and protocolized sepsis care.

Impact of a Multidisciplinary Sepsis Initiative on Knowledge and Behavior in a Pediatric Center.

Our institution performed an educational initiative targeting previously identified barriers to pediatric sepsis recognition and treatment. We hypothesized that provider knowledge, attitude, and behavior would be improved 1 year after implementation. This was a prospective, observational study of a multi-faceted quality initiative introduced to providers in the Emergency Department, inpatient wards, and Pediatric Intensive Care Unit of a tertiary care children's hospital. Educational platforms consisted of quarterly electronic sepsis "newsletters," brightly colored posters highlighting protocol and screening strategies displayed throughout the hospital, and low-fidelity simulation sessions (drills) led by trained staff and incorporated into daily workflows. The content was driven by feedback from a baseline needs assessment of sepsis education. One year after implementation, the needs assessment was repeated. Over 3 months, facilitators conducted 197 drills and captured a majority of nurses (89%), pediatrics residents (96%), and respiratory therapists (62%). By 6 months, 241 sessions had been completed. Approximately 55.4% of the 442 eligible staff participated in our post-intervention survey. Overall, knowledge of diagnostic criteria for pediatric sepsis and septic shock increased from pre-intervention levels (P = 0.015). Among post-implementation respondents, drill participants outperformed their colleagues (P = 0.001). A greater percentage of post-intervention respondents indicated comfort with sepsis recognition (P < 0.001), and fewer reported hesitating to bring sepsis concerns to their care team (P < 0.01). Our findings suggest that a multidisciplinary curriculum balancing active education-through brief, targeted simulation-and general awareness-through electronic resources and a poster campaign-can improve sepsis-related knowledge, attitude, and behavior among pediatric practitioners.

Performance of an Automated Screening Algorithm for Early Detection of Pediatric Severe Sepsis.

To create and evaluate a continuous automated alert system embedded in the electronic health record for the detection of severe sepsis among pediatric inpatient and emergency department patients. Retrospective cohort study. The main outcome was the algorithm's appropriate detection of severe sepsis. Episodes of severe sepsis were identified by chart review of encounters with clinical interventions consistent with sepsis treatment, use of a diagnosis code for sepsis, or deaths. The algorithm was initially tested based upon criteria of the International Pediatric Sepsis Consensus Conference; we present iterative changes which were made to increase the positive predictive value and generate an improved algorithm for clinical use. A quaternary care, freestanding children's hospital with 404 inpatient beds, 70 ICU beds, and approximately 60,000 emergency department visits per year PATIENTS:: All patients less than 18 years presenting to the emergency department or admitted to an inpatient floor or ICU (excluding neonatal intensive care) between August 1, 2016, and December 28, 2016. Creation of a pediatric sepsis screening algorithm. There were 288 (1.0%) episodes of severe sepsis among 29,010 encounters. The final version of the algorithm alerted in 9.0% (CI, 8.7-9.3%) of the encounters with sensitivity 72% (CI, 67-77%) for an episode of severe sepsis; specificity 91.8% (CI, 91.5-92.1%); positive predictive value 8.1% (CI, 7.0-9.2%); negative predictive value 99.7% (CI, 99.6-99.8%). Positive predictive value was highest in the ICUs (10.4%) and emergency department (9.6%). A continuous, automated electronic health record-based sepsis screening algorithm identified severe sepsis among children in the inpatient and emergency department settings and can be deployed to support early detection, although performance varied significantly by hospital location.