Problem Addressed

• A common, fatal condition: Severe sepsis occurs in more than 42,000 pediatric inpatients in the United States each year, with roughly 10 to 20 percent of these young patients dying. Sepsis is more common in chronically ill children.²
• Failure to diagnose and treat in timely manner: Prompt recognition and treatment is critical to improving sepsis outcomes. Expert guidelines disseminated by the Surviving Sepsis Campaign (a collaborative of the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine) specify that timely fluid resuscitation and antibiotic administration are key to improving sepsis outcomes.³ Yet suboptimal treatment of pediatric sepsis remains common,⁴ including the following:
  • Delayed administration of antibiotics.
  • Use of narrow-spectrum antibiotics (which treat a limited number of organism types) rather than broad-spectrum medications.
  • Inconsistent monitoring of physiologic parameters, such as blood pressure, central venous pressure, and mixed venous oxygen saturation.
  • Lack of treatment protocols and processes to support early, goal-directed therapy, a critical care medicine technique that involves aggressive management and monitoring of hemodynamics in patients at high risk of septic shock.⁵

Description of the Innovative Activity

• Triage tool to flag potential for sepsis: The Emergency Department (ED) triage nurse takes the patient’s vital signs (e.g., heart rate, temperature, blood pressure) when the patient arrives. A computerized triage system flags patients with vital sign values that suggest the possibility of sepsis or shock.
• Activation of protocol: Having noted the system alert, the ED triage nurse considers whether the shock protocol should be implemented. If the patient is at high risk of infection (due to existence of malignancy, bone marrow or solid-organ transplant, asplenia, central venous catheter, or immunodeficiency) and/or appears ill, the triage nurse initiates the protocol by calling a designated pager number, which notifies the charge nurse, pharmacist, transport team, and intensive care unit (ICU) charge nurse that a shock protocol patient is in the ED. (The shock protocol can also be activated by any ED nurse or physician at any point in the patient’s ED stay.) Each month, approximately 30 to 60 children with suspected sepsis are enrolled in the protocol.
• Protocol-based treatment: The guideline-based protocol covers all aspects of the treatment, as outlined below:
  • Placement in resuscitation room: The triage nurse places the patient in a room designated for sepsis treatment (called the “resuscitation room”).
  • Priority treatment: An ED bedside nurse and attending physician evaluate the patient and initiate treatment using a standardized order set that includes preprinted forms for requesting laboratory studies and antibiotics. Treatment includes the following:
    • Vascular access: The nurse ensures vascular access within 5 to 10 minutes of protocol initiation; the nurse notifies the physician if vascular access has not been achieved after 5 minutes.
    • Rapid fluid resuscitation: Nurses administer fluid (20 mL/kg per bolus, up to three boluses) within 15 minutes of protocol initiation (bone marrow transplant and cardiac patients receive 10 mL/kg per bolus). Under the protocol, fluids are administered rapidly, using a rapid infuser system or manual syringe delivery through the patient’s intravenous line. Previously, fluids were administered using a pump over the course of 1 hour.
    • Quick laboratory tests and antibiotic therapy: The protocol assists physicians in determining appropriate laboratory tests and treatment, recommending several antibiotic options along with the order in which medications should be administered. Hospital pharmacists prioritize orders for antibiotic therapy for sepsis patients, and then hand-deliver the medications to the patient’s bedside. (In the past, the ED nurse had to go to the pharmacy to pick up the order, leaving the patient unattended). As a result, antibiotics are administered within 30 minutes of protocol initiation. Laboratory technicians also prioritize all ordered tests for children on the protocol, thus allowing them to report results to the ED attending physician within 15 minutes of receiving the order.
    • Frequent vital sign monitoring and triage tool to flag abnormalities: ED nurses measure vital signs every 15 minutes, providing supplemental oxygen, pulse oximetry, and cardiopulmonary monitoring as necessary. The nurses plot vital sign measures and treatment steps on a graphical flow sheet (originally paper-based but now electronic) to facilitate clinician interpretation of trends and patient responses to therapy, communication during patient handoffs to the ICU, and identification of vital sign abnormalities specified in the protocol. Once the shock protocol has been completed, nurses continue to monitor vital signs every 15 minutes for 1 hour, every 30 minutes for the second hour, and then hourly for the next 2 hours.
  • Admission to hospital units based on severity: Children who require less than 60 mL/kg of fluid resuscitation (three boluses) receive care in a regular hospital unit. Children who require 60 mL/kg or more also can be admitted to a regular hospital unit if they seem to have improved during their time in the ED (although nurses take vital signs each hour for 4 hours to make sure they do not decline). Those who have received more than 60 mL/kg and have not improved are admitted to the ICU.
• As-needed support from transport team: Given the urgency of sepsis care and the time constraints faced by busy ED clinicians, the hospital’s patient transport team (which includes a nurse, respiratory therapist, and emergency medical technician) assist the ED bedside nurse in providing sepsis care as needed. For example, these team members can obtain vascular access, administer medications and fluids, document care, and transport the patient to the ICU.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• Faster initiation of fluid resuscitation: The time from triage (when the triage nurse first assesses the patient) to initiation of fluid resuscitation fell more than 60 percent after implementation of the protocol, from 56 minutes to 22 minutes.
• Earlier administration of antibiotics: The time from triage to first administration of antibiotics fell more than 70 percent, from 138 to 38 minutes.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Root cause analysis: A multidisciplinary team (comprising ED and ICU physicians and nurses, nurse leaders and educators, a pharmacist, the patient transport team, patient care assistants, and information technology or IT staff) conducted a root cause analysis to identify obstacles to timely pediatric sepsis care, including varying staff experience in evaluating patients for sepsis, inadequate nurse staffing ratios, infrequent vital sign measurement, lack of standardization of diagnostic testing and antibiotic use, and other barriers.
• Development of protocol and associated tools and processes: The program team conducted a literature search, but could not find other institutions that had developed a shock protocol specifically for pediatric patients. As a result, the team identified shock protocols for adult patients and drew upon relevant material from the Surviving Sepsis Campaign guidelines to develop the protocol, standardized order set, and automated triage tool. Clinical experts from provided specific input on topics, such as acceptable fluid volumes, appropriate antibiotic use, and required laboratory testing. The team also addressed other barriers to timely sepsis care, including changing the fluid administration method and expanding the types of staff (beyond the ED bedside nurse) who could provide sepsis care and monitoring.
• Staff education: One month before rolling out the protocol, the program team held 2-hour educational sessions for ED nurses and the transport team to explain the protocol, automated triage tool, order set, and new processes. The team repeated these sessions 4 months after initiation of the protocol. The team also sent e-mails describing the new protocol and procedure to all ED and ICU staff.
• Chart review and performance feedback: During the first few months after implementation, the program team reviewed patient charts to determine if clinicians properly adhered to the protocol, and then provided individual feedback as necessary.
• Updating protocol based on clinician input: Every 2 months, a subset of team members (selected physicians and nurses, the pharmacist, and the transport team) solicited feedback from clinicians that resulted in protocol changes (e.g., adding new laboratory measures and medication options, changes in disposition status). The team e-mailed updates to providers on an ongoing basis, posted them on the ED bulletin board, and discussed them during mandatory quarterly nursing meetings.
• Transition to electronic form: During the initial development of the program, the hospital was in the midst of transitioning to an electronic IT system. As a result, the team created the protocol, order set, and triage tool on paper, with input from IT staff designed to facilitate a later transition to an electronic format. Once the system became operational, IT staff executed that transition.

Resources Used and Skills Needed

• Staffing: The program required no new staff, as existing staff incorporate it into their daily routines. Reallocation of labor allowed the transport team to provide sepsis care in the ED.
• Costs: Program development required staff time and a minimal financial outlay to generate the paper-based order sets and flow sheets.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Ensure leadership buy-in: Hospital leaders must be convinced that the project is worthwhile, and then be vocal about supporting it. Leadership support helps staff buy in to the implementation process. At Texas Children’s Hospital, nursing leaders mandated that the shock protocol be used.
• Involve multidisciplinary team: Developing a shock protocol requires the involvement of representatives from multiple disciplines, including ED and ICU physicians and nurses, respiratory therapists, pharmacists, and laboratory technicians. Each team member can provide valuable feedback on different aspects of work processes.
• Partner with ICU: Evaluate the working relationship between the ICU and ED to determine the best location for initiation of sepsis patient care.
• Ensure sufficient time for planning: Even though clinical guidelines already exist, planning a protocol-driven process for sepsis care can take up to 1 year, especially in a large hospital. (It took 9 months at Texas Children's.) Key steps include gathering all relevant staff, performing a thorough root cause analysis, obtaining feedback, and planning an implementation strategy.
• Design data management plan: Because monitoring the program impact helps to ensure its success, develop a plan for what measures should be tracked, who will collect and analyze the data, and how often performance reports will be run.
• Communicate throughout development process: During the development phase, keep ICU and ED staff updated about the need for the program and development of the protocol.
• Encourage requests for help during implementation: Team leaders should encourage staff to contact them if they face implementation barriers (such as resistance from a physician or general questions and concerns). To the extent possible, these leaders should provide rapid assistance and feedback so that problems can be resolved in a timely manner.

Sustaining This Innovation

• Look for creative ways to expand labor capacity: ED bedside nurses are busy professionals who must provide care not only to patients at risk of sepsis, but also to other ED patients. Hence, they may need some support from others who can provide timely sepsis care in the ED, such as a “shock team,” other hospital nurses, and/or respiratory therapists.
• Provide individual feedback on adherence: For some defined period following implementation, review patient charts to determine if the protocol has been followed appropriately and provide feedback to clinicians regarding both areas in which they excel and those in need of improvement.
• Share data on program impact: Sharing data that demonstrates the program's benefits will keep staff engaged and encourage them to continuing adhering to the protocol. It can also convince hospital leaders to continue supporting the program.
• Make changes based on feedback: Inviting feedback and modifying the protocol based on constructive suggestions will ensure that the protocol remains relevant in the current work environment.