Adherence to Sepsis Guidelines and Hospital Stay

Elspeth Ferguson

SCH Journal Club

6th November 2012

Aims

• To determine if adherence to resuscitation guidelines in paediatrics improves the clinical outcome for septic children and infants

Objectives

• Select an appropriate paper from the literature• Discuss the paper’s methodology and findings• Look at what this paper adds to our knowledge• Should we change our practice?

Case

• 3yr girl presents to A&E• Febrile, tachycardic, spreading non-blanching rash• She requires 60ml/kg fluid resuscitation along with

broad spectrum antibiotics before transfer to PICU 2hr after presentation

• Would more timely resuscitation improve her outcome?

The Clinical Question

• Population Septic Children• Intervention 60ml/kg Fluid resuscitation

within 60min• Comparison Slower fluid resuscitation• Outcome Survival/Morbidity/Hospital

Stay• Design Cohort study

Literature Search

• Fluid resuscitation• Outcome (treatment)• Sepsis• Limited to all children (0-18yr), English language

• Searched Medline

Search Results and Article Selection

• 4 articles found• 2 appropriate

• Article selected as:– Most recent– From presentation– Considered reasons where following guidelines became a

problem

Adherence to PALS Sepsis Guidelines and Hospital Length of Stay

Paul, R., Neuman, MI., Monuteaux, M.C. and Melendez, E.

Pediatrics 2012 130:2 e273-e280

Current Practice

• APLS guidelines

• APLS vs PALS

Methodology

• Cohort Study• Retrospective identification via critical care area

admissions• November 2009 – March 2011• Diagnosis of severe sepsis/septic shock

Methodology Continued

• Review of medical records• Exclusions:

– Congenital heart disease– Renal failure– DKA– Sickle cell– Severe anaemia– DNAR

PALS Sepsis Guideline

Outcomes

• Overall adherence to algorithm– 4/5 steps dependent on need for inotropes

• Adherence to each part of algorithm– Time to recognition– Time to IV access– Time to 60ml/kg fluids– Time to antibiotics– Time to inotropes

Outcomes continued

• Length of PICU admission• Length of hospital stay

Basic Demographics

126 patients 14% severe sepsis, 86% septic shock

54 met criteria at presentation, 72 progressed to SS in ED

Median age 9yr, 15% <1yr60% had co-morbidities5% died

Are the results of the study valid?

1. Did the study address a clearly focused issue?

Yes

Cleary defined population

Outcomes clear

2. Did the authors use an appropriate method to answer their question?

Yes

Cohort study was an appropriate study

Detailed Questions

3. Was the cohort recruited in an acceptable way?

Yes

But: critical care areas ?likelihood of admission elsewhere

Actual definition vs clinical definition

Use of lab parameters for definitions

4. Was the exposure accurately measured to minimise bias?

Unclear

How accurate is documentation in this situation?

Do we document fluid finish time

Was only IV access considered?

Detailed questions continued

5. Was the outcome accurately measured to minimise bias?

Probably

But need to consider timings

What else affects discharge? Bed pressures/co-morbidities/Social factors

6. A. Have the authors identified all important confounding factors?

7. B. Have they taken account of the confounding factors in the design and/or analysis?

Yes

Comorbidity and illness severity considered, age/gender/time of presentation not found to influence outcome

Detailed questions continued

7. A. Was the follow up of subjects complete enough?

8. B. Was the follow up of subjects long enough? Yes

To answer their outcomes follow-up adequate

Longer term morbidity not considered

8. What are the Results?

Percentage adhering to the recognition, vascular access, and IVF administration goal times, as dependent on the preceding algorithm step.

Paul R et al. Pediatrics 2012;130:e273-e280

©2012 by American Academy of Pediatrics

What are the results continued

LOS Fluid adherence

Fluid non-adherence

Decrease P Value

Hospital 8 days 11.2 days 57% 0.039

PICU 5.5 days 7.2 days 42% 0.024

LOS Bundle adherence

Bundle non-adherence

Decrease P Value

Hospital 6.8 days 10.9 days 57% 0.009

PICU 5.5 days 6.8 days 59% 0.035

Results questions

9. How precise are the results?Generally precise, but large IQ ranges for fluid adherence

and inotropes

10. Do you believe the results?

Yes

Will the results help us at SCH?

11. Can the results be applied to the local population?

Yes – tertiary centre, minor differences in resus protocols

Things to consider – team sizes, access choice

12. Do the results of this study fit with other available evidence?

Yes

Summary and Conclusions

• Adherence to resuscitation guidelines particularly speed of IV fluid resuscitation is poor

• Timely management of septic children improves outcome

• Would it be worth looking at our resuscitation of septic children?