Improving adherence to PALS septic shock guidelines.
OBJECTIVE
Few studies have demonstrated improvement in adherence to Pediatric Advanced Life Support guidelines for severe sepsis and septic shock. We sought to improve adherence to national guidelines for children with septic shock in a pediatric emergency department with poor guideline adherence.


METHODS
Prospective cohort study of children presenting to a tertiary care pediatric emergency department with septic shock. Quality improvement (QI) interventions, including repeated plan-do-study-act cycles, were used to improve adherence to a 5-component sepsis bundle, including timely (1) recognition of septic shock, (2) vascular access, (3) administration of intravenous (IV) fluid, (4) antibiotics, and (5) vasoactive agents. The intervention focused on IV fluid delivery as a key driver impacting bundle adherence, and adherence was measured using statistical process control methodology.


RESULTS
Two-hundred forty-two patients were included: 126 subjects before the intervention (November 2009 to March 2011), and 116 patients during the QI intervention (October 2011 to May 2013). We achieved 100% adherence for all metrics, including (1) administration of 60 mL/kg IV fluid within 60 minutes (increased from baseline adherence rate of 37%), (2) administration of vasoactive agents within 60 minutes (baseline rate of 35%), and (3) 5-component bundle adherence (baseline rate of 19%). Improvement was sustained over 9 months. The number of septic shock cases between each death from this condition increased after implementation of the QI intervention.


CONCLUSIONS
Using QI methodology, we have demonstrated improved adherence to national guidelines for severe sepsis and septic shock.
Department of Emergency Medicine, Pediatric Section, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina; and raina.paul@childrens.harvard.edu.
Raina
R
Paul
Division of Emergency Medicine, and Medicine Critical Care Program, Boston Children's Hospital, Boston, Massachusetts.
Elliot
E
Melendez
Division of Emergency Medicine, and.
Anne
A
Stack
Division of Emergency Medicine, and.
Andrew
A
Capraro
Division of Emergency Medicine, and.
Michael
M
Monuteaux
Division of Emergency Medicine, and.
Mark I
MI
Neuman
D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001900:Boston; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D042241:Early Diagnosis; D061345:Early Medical Intervention; D004636:Emergency Service, Hospital; D005260:Female; D005440:Fluid Therapy; D019983:Guideline Adherence; D017052:Hospital Mortality; D006776:Hospitals, Pediatric; D006801:Humans; D007260:Infusion Pumps; D007262:Infusions, Intravenous; D007318:Inservice Training; D007902:Length of Stay / Q000706:statistics & numerical data; D008020:Life Support Care / Q000379:methods*; D008297:Male; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration*; D018805:Sepsis / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D012772:Shock, Septic / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D016019:Survival Analysis; D014662:Vasoconstrictor Agents / Q000008:administration & dosage
D000900:Anti-Bacterial Agents; D014662:Vasoconstrictor Agents
PALS; adherence; guidelines; quality improvement; sepsis; septic shock; severe sepsis