Improvement Insights

A critical look at latest academic and publications research including The Joint Commission Journal on Quality and Patient Safety as well as Health Research Services initiatives with partner organizations.

Improving Sepsis Recognition and Management in the PICU

05/14/2020

Rhea Vidrine, MD; Matthew Zackoff, MD, MEd; Erika L. Stalets, MD, MS; and Maya Dewan, MD, MPH

Severe sepsis carries a significant morbidity, mortality and financial burden as the leading cause of pediatric mortality worldwide.1 With sepsis accounting for 18% of pediatric hospitalizations in the United States, and a mortality rate of approximately 20%, the financial cost due to sepsis is valued at greater than $7 billion.

To tackle this problem, the Surviving Sepsis Campaign and the American College of Critical Care Medicine recommend implementing sepsis bundles to improve the recognition and management of sepsis across the acute care continuum.3,4

Our improvement brief in the May 2020 issue of The Joint Commissions Journal on Quality and Patient Safety describes how implementing a sepsis clinical decision support tool and sepsis huddles as part of a comprehensive sepsis bundle in the pediatric intensive care unit (PICU) was associated with improvement in the timely antibiotic administration for patients with severe sepsis. Our efforts focused on addressing these two key failure modes for meeting our sepsis resuscitation goals:

1. Delayed Sepsis Recognition 
In many centers, improving the timeliness of sepsis recognition remains the most difficult barrier to meeting sepsis management goals. Recognizing sepsis in the pediatric population, especially in patients with complex medical conditions associated with heterogeneity in “normal” exam findings and multiple comorbid conditions to explain vital sign abnormalities, is a daunting task. The only currently feasible solution is a high index of suspicion and frequent assessments with changes in clinical status. 

While our sepsis clinical decision support tool and unit-wide education initiative has increased awareness of sepsis, how do we consistently recognize sepsis in patients who cannot mount fevers or who have abnormal temperature regulation at baseline? What is the most effective way to teach a new nurse or provider what pediatric sepsis looks like? 

To address this, we initiated a multifaceted educational approach, including:

  • high and low fidelity simulation
  • informational posters throughout the unit
  • creation of a virtual reality sepsis simulation 

Direct, one-on-one education through the simulation scenarios (both high and low fidelity), are the most productive strategies. Continuous re-education using different modalities on the variable presentation of pediatric sepsis is vital to improving sepsis recognition and management, as even the best clinical decision support tools still rely on human factors. 

2. Failure to Consistently Perform Sepsis Huddles 
Sepsis huddles help to:

  • improve interprofessional communication among the patient care team to enable collaboration and formation of a plan
  • facilitate a safety culture
  • promote the sharing of ideas and learning from each other in a safe, non-threatening environment

Sepsis huddles in our unit are performed when a patient is first admitted with known severe sepsis or when there is a new concern for sepsis for an already admitted patient. The huddle participants include the patient’s PICU providers (physicians and advanced practice providers), nurses (bedside and shift leadership) and respiratory therapists. During a huddle, the team performs a focused exam and reviews pertinent lab data to determine if is there a concern for sepsis and whether the sepsis algorithm should be initiated.

With initial implementation of our sepsis huddles, providers and staff viewed them as a nuisance–another valueless task to perform in an already busy PICU. However, with consistent encouragement to perform huddles supported by data on the positive impact on care delivery, our medical team has grown to see these huddles as an opportunity for collaboration, education and a path to improved outcomes for our patients. 

Sepsis huddles now serve as:

  • a safe space for discussion about a patient’s trajectory
  • a means for shared situation awareness of worrisome signs or symptoms
  • an opportunity for education about septic shock manifestations and management in the pediatric population

Sepsis recognition in the pediatric population remains a difficult task and is a key driver to ensure timely sepsis treatment – ultimately preventing patient morbidity and mortality. It is our responsibility to the patients we care for to not settle for the status quo and to continue to collaborate and innovate to improve the recognition and treatment of sepsis. 


Rhea Vidrine, MD, is clinical fellow in the Division of Critical Care Medicine at Cincinnati Children’s Hospital Medical Center (CCHMC) and the Department of Pediatrics at the University of Cincinnati College of Medicine (UCCM). 

Matthew Zackoff, MD, MEd, is attending physician in the Division of Critical Care Medicine at CCHMC, and instructor in the Department of Pediatrics at UCCM. 

Erica Stalets, MD, MC, is medical director in the Pediatric Intensive Care Unit at CCHMC, and assistant professor in the Department of Pediatrics at UCCM.

Maya Dewan, MD, MPH, is attending physician in the Division of Critical Care Medicine at CCHMC, and assistant professor in the Department of Pediatrics at UCCM. 

References 
1. Weiss, S. L. et al. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am. J. Respir. Crit. Care Med. 191, 1147–1157 (2015).
2. Carlton, E. F., Barbaro, R. P., Iwashyna, T. “Jack” & Prescott, H. C. Cost of Pediatric Severe Sepsis Hospitalizations. JAMA Pediatr. (2019) doi:10.1001/jamapediatrics.2019.2570.
3. Rhodes, A. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Crit. Care Med. 45, 486 (2017).
4. Davis, A. L. et al. American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit. Care Med. 45, 1061–1093 (2017).