title: Implementation of goal-directed therapy for children with suspected sepsis in the emergency department.
abstract: BACKGROUND
  Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation.
  
  
  OBJECTIVE
  To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines.
  
  
  METHODS
  Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions.
  
  
  RESULTS
  To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001).
  
  
  CONCLUSIONS
  The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.
authors.affiliation: Department of Pediatrics, Sections of Emergency Medicine and Infectious Diseases, Baylor College of Medicine, 6621 Fannin St, Suite A210, MC 1-1481, Houston, TX 77030, USA. acruz@bcm.edu
authors.forename: Andrea T
authors.initials: AT
authors.lastname: Cruz
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Perry
authors.forename: Eric A
authors.initials: EA
authors.lastname: Williams
authors.forename: Jeanine M
authors.initials: JM
authors.lastname: Graf
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Wuestner
authors.forename: Binita
authors.initials: B
authors.lastname: Patel
mesh_terms: D002648:Child; D003422:Critical Care / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D015278:Intensive Care Units, Pediatric; D058996:Quality Improvement; D018805:Sepsis / Q000175:diagnosis / Q000628:therapy*; D013997:Time Factors