Effect of a Sepsis Educational Intervention on Hospital Stay

Objectives: To evaluate adherence to the sepsis bundle before and after an educational strategy and its impact on hospital stay. Design: A prospective, analytic, before-and-after study of children with severe sepsis and septic shock who presented to the emergency department. Setting: Carried out from January to December 2014 in the emergency department of a quaternary care hospital. Patients: Of a total of 19,836 children who presented to the emergency department, 4,383 had an infectious pathology, with 203 of these showing severe sepsis and septic shock (124 pre intervention, and 79 post intervention). Interventions: The healthcare providers caring for the patients in pediatric emergency received an educational intervention and an update on the bundle concepts proposed in 2010 by the Pediatric Advanced Life Support program of the American Heart Association and adapted by this study's investigators. Measurements and Main Results: The main cause of sepsis in both groups was respiratory (59 vs 33; p = 0.72), without differences in the Pediatric Index of Mortality 2 score (7.23 vs 8.1; p = 0.23). The postintervention group showed a reduced hospital stay (11.6 vs 7.9 d; p = 0.01), a shorter time before ordering fluid boluses (247 vs 5 min; p = 0.001), the application of the first dose of antibiotic (343 vs 271 min; p = 0.03), and a decreased need for mechanical ventilation (20.1% vs 7.5%; p = 0.01). Postintervention adherence to the complete bundle was 19.2%, compared with the preintervention group, which was 27.7% (p = 0.17). Conclusions: Adherence to a bundle strategy is low following an educational intervention. However, when patients are managed after instruction in guideline recommendations, hospital stay may be significantly reduced. © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

A national approach to pediatric sepsis surveillance

Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of agedependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment

Use of therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure in the turkish thrombocytopenia- associated multiple organ failure network

PubMedID: 25068251Objective: Thrombocytopenia-associated multiple organ failure can lead to high mortality in critically ill children, possibly related to consequences of thrombotic microangiopathy. Plasma exchange therapy may improve thrombotic microangiopathy. The purpose of this observational cohort study is to describe whether there is an association between use of plasma exchange therapy and outcome in the Turkish thrombocytopenia-associated multiple organ failure network.Setting-Interventions: We performed a retrospective cohort analysis in patients with thrombocytopenia-associated multiple organ failure at three different PICUs comparing those who received plasma exchange (+) plus standard therapies with those who did not receive plasma exchange (-) and only received standard therapies.Results: Among 42 of the enrolled patients with thrombocytopenia- associated multiple organ failure, all had a primary or secondary sepsis diagnosis. Fifteen received plasma exchange therapy (PE [+] group) and 27 received standard medical treatment without plasma exchange (PE [-] group). The mean age was 17.69 months (8.24-54.22) in the PE (+) group and 13.46 months (6.47-20.55) in the PE (-) group. Age (p = 0.232), gender (p = 0.206), thrombocyte count (p = 0.09), Organ Failure Index score (p = 0.111), and pediatric logistic organ dysfunction score (p = 0.177) at admission were not statistically different between groups. The overall 28-day mortality was higher in the PE (-) group (70.37%) compared with the PE (+) group (26.67%) (univariate p = 0.006; multivariate controlling for pediatric logistic organ dysfunction, Organ Failure Index, Pediatric Risk of Mortality scores, and neurological failure p = 0.048). Length of stay was increased in the PE (+) group (p = 0.004).Conclusions: The positive association found between use of plasma exchange therapy and improved survival supports the potential of this therapy in Turkish children with thrombocytopeniaassociated multiple organ failure. The positive, although less so, associated treatment effect observed after controlling for illness severity provides further rationale for performing a randomized controlled trial in the pediatric Turkish thrombocytopenia-associated multiple organ failure network. Sample size calculations call for a 100-patient trial with a pre hoc interim analysis after enrollment of 50 patients with thrombocytopenia-associated multiple organ failure. (Pediatr Crit Care Med 2014; 15:e354-e359). Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Effect of a Sepsis Educational Intervention on Hospital Stay

Objectives: To evaluate adherence to the sepsis bundle before and after an educational strategy and its impact on hospital stay. Design: A prospective, analytic, before-and-after study of children with severe sepsis and septic shock who presented to the emergency department. Setting: Carried out from January to December 2014 in the emergency department of a quaternary care hospital. Patients: Of a total of 19,836 children who presented to the emergency department, 4,383 had an infectious pathology, with 203 of these showing severe sepsis and septic shock (124 pre intervention, and 79 post intervention). Interventions: The healthcare providers caring for the patients in pediatric emergency received an educational intervention and an update on the bundle concepts proposed in 2010 by the Pediatric Advanced Life Support program of the American Heart Association and adapted by this study's investigators. Measurements and Main Results: The main cause of sepsis in both groups was respiratory (59 vs 33; p = 0.72), without differences in the Pediatric Index of Mortality 2 score (7.23 vs 8.1; p = 0.23). The postintervention group showed a reduced hospital stay (11.6 vs 7.9 d; p = 0.01), a shorter time before ordering fluid boluses (247 vs 5 min; p = 0.001), the application of the first dose of antibiotic (343 vs 271 min; p = 0.03), and a decreased need for mechanical ventilation (20.1% vs 7.5%; p = 0.01). Postintervention adherence to the complete bundle was 19.2%, compared with the preintervention group, which was 27.7% (p = 0.17). Conclusions: Adherence to a bundle strategy is low following an educational intervention. However, when patients are managed after instruction in guideline recommendations, hospital stay may be significantly reduced. © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies