Sepsis is highly elusive in its early stages. To combat it, hospitals must adopt tools, team-based approaches and change culture.
By Megan McDonnell Busenbark
Rory Staunton was 12 years old when he went diving for a basketball in his school gym and scraped his arm—business as usual for a boy his age. But the next day, Rory was vomiting and feverish. He had pain in his leg. A visit to the pediatrician led to a trip to a New York City hospital emergency room. Doctors there believed Rory had an upset stomach and dehydration, so they gave him fluids and sent him home.
What doctors failed to see was that a deadly toxin had entered Rory's blood through the seemingly innocent cut on his arm. Warning signs of severe illness went unnoticed. Three nights after he left that emergency room, 12-year-old Rory was dead. The cause: severe septic shock brought on by infection.
That was in April 2012. The following January, Gov. Andrew M. Cuomo announced "Rory's Regulations," making New York the first state to require all hospitals to adopt best practices for the early identification and treatment of sepsis—a leading cause of death in hospitalized children.
Sepsis, often called blood poisoning, is the body's overwhelming and potentially deadly response to an infection. It affects more than 1 million people in the United States each year, according to the Centers for Disease Control and Prevention. This includes more than 40,000 children, 4,500 of whom die each year from the disease and related complications—a higher mortality than pediatric cancer.
"Children don't need to die of sepsis," says Joseph A. Carcillo, M.D., professor of critical care medicine and pediatrics at the University of Pittsburgh. "But it's a very complex process because organizationally, there are so many people involved in the care of these children. And culturally, we've come to accept death from sepsis."
Sepsis treatment requires a culture of teamwork and empowerment
Pediatric sepsis experts estimate about 55 percent of patients develop sepsis before they get to the hospital—what starts as a scratch playing basketball in the gym can evolve into something more serious as the immune system overreacts to an infection. This is where pre-hospital surveillance in ambulatory care and emergency response units becomes critical. In other cases, hospitalized patients' underlying conditions, such as cancer, pneumonia or irritable bowel disease triggers sepsis. For some, it may result from a hospital acquired infection.
Some cases can be averted by preventing the infection. The key is to detect and treat sepsis when it's present. Severe sepsis and septic shock are the later, most critical stages of sepsis where organs fail, blood pressure drops and patients can die. But pediatric sepsis experts agree these stages do not pose the biggest challenge for children's hospitals because there are guidelines for treatment at these levels.
"If you are given the diagnosis of severe sepsis, most children's hospitals will be able to manage it very well," says Charles Macias, M.D., MPH, chief clinical systems integration officer, Texas Children's Hospital in Houston, and national co-chair of CHA's Improving Pediatric Sepsis Outcomes collaborative and the National Expert Advisory Committee. "The big challenge is doing that at a time when the child first presents or first manifests the symptoms—and catching it early."
And therein lies the problem because sepsis is often highly elusive in its earliest stage. With typical symptoms that include fever, elevated heart rate and respiratory rate, early sepsis can mimic many other conditions. Some children may not even exhibit these symptoms when sepsis is on the horizon. And, this is one illness where time is always of the essence.
"Once you have sepsis, every 30 minutes that goes by that you don't treat the infection, the bacteria double," Carcillo says. "Say it takes eight hours to figure out that the child has sepsis, and then it's doubled 16 times. So, eight hours later, when you've figured it out, the child is very ill."
The research shows every hour delay in treatment increases mortality by nearly 8 percent. And, so far in pediatrics, there has been no silver bullet for early detection and diagnosis. "There's not a magic test you can run that says this particular child with a fever and high heart rate has sepsis as opposed to RSV bronchiolitis, for example," says Toni Wakefield, M.D., pediatric hospitalist at Dell Children's Medical Center and assistant professor of pediatrics at Dell Medical School in Austin, Texas.
"The lack of laboratory tests with 100 percent specificity to tell you this is sepsis hinders our ability to pick out those who have sepsis and those who don't." As a result, early pediatric sepsis often travels in a clinical care team's blind spot—and it travels fast in a child's small body.
To combat it and to drive early detection, diagnosis and treatment, experts say children's hospitals should start by creating a culture of teamwork and empowerment. "Enabling the institution, regardless of provider or venue, to take actionable and effective steps is going to be important to make these outcome changes," Macias says.
"And everyone has to be part of that team, including administrators and clinicians. It doesn't matter what subspecialty you're in or whether you're a nurse or a physician, you've got to function as a team within the infrastructure across the entire institution if you're going to make a difference."
"Huddle up" for sepsis
Boston Children's Hospital set out to make a difference when it launched a clinical care project to improve antibiotic timing in children with concern for sepsis. Elliot Melendez, M.D., associate director of safety and quality, Division of Medicine Critical Care, Division of Emergency Medicine at Boston Children's Hospital, says when he and his team looked at antibiotic timing in children in intensive care units who showed early signs or concern for sepsis, they were taking three hours on average to give an antibiotic.
Based on adult literature, the current acceptable measure is to administer antibiotic within an hour of signs or concern for sepsis. So, the team went to work on its process with the goal of reducing the time it takes to recognize signs or concern for sepsis and the time it takes to act. "One of the initial interventions was the implementation of a ‘sepsis huddle,'" Melendez says. "Just like a football team, we get together and we huddle, and we say we are worried about this patient or we're not worried about this patient, and if not, we can shut off the process."
The huddle takes place in front of the patient's bed space with the bedside nurse, charge nurse, attending, fellow, resident and nurse practitioner. If the team agrees there is a concern for sepsis, they assign roles and priorities, including obtaining timely blood cultures and antibiotics from the pharmacy, and they create a detailed follow-through plan. The team then combined this huddle with a sepsis trigger tool.
"This tool enchances recognition of children at risk for sepsis—if a child has a new fever and a new tachycardia, and he or she has certain risk factors like a central line, immunodeficiency, or chronic illness—this is someone we should worry about a lot quicker," Melendez says. "When we see these signs, it should trigger the huddle."
The implementation of the sepsis recognition tool and the path for improved communication through the sepsis huddle in the PICU has reduced the time to administer antibiotics to children with concern for sepsis from 180 minutes to 71 minutes—more than a 50 percent reduction. The processes are also driving down ICU length of stay (LOS), Melendez says. Before these initiatives, the average ICU LOS at Boston Children's Hospital was 25 days. Now, it's just eight days. To learn more about their sepsis work, read Boston Children's 2015 Pediatric Quality Award entry.
Empowering the front lines to diagnose sepsis
Five years ago, Macias says there was reluctance to make the diagnosis of sepsis due to a lack of empowerment on the front lines and hesitance to escalate care to colleagues. Since then, Texas Children's Hospital has instituted electronic medical record trigger tools for decision support. So, if a member of the care team suspects sepsis and the EMR data back that up, that person is more comfortable and confident about raising a red flag for possible sepsis.
"It empowers nurses, physicians and respiratory care practitioners to say, ‘I need to act on this, because it's not just me,'" Macias says. "Here's a medical calculation showing this person is at risk. And, that has changed our culture."
That culture change has also led to a change in outcomes at Texas Children's. These changes include a 50 percent decrease in the amount of time it takes to get from the first diagnosis to the administration of antibiotics, and a 9 percent decrease in PICU-related sepsis mortality in the last five years. "In the end, we can look at process measures, but what is most compelling is the number of lives we save," Macias says.
The adult dilemma of sepsis treatment
When it comes to sepsis, the definitions, data and guidelines for care all hail from the adult world, which only further complicates sepsis care in pediatrics. "Children are different, so the adult work is not going to be applicable as is," Wakefield says. "It needs modification for a child's physiology." UNC Hospital in Chapel Hill, N.C. is not only taking that into account, but it's operating in an inverted universe—where pediatric sepsis care at UNC Children's Hospital helps inform care on the adult side of the system.
As one example, pediatrics is used to giving fluid resuscitations to children with sepsis in a weight-based bundle, taking the child's physiology into account. However, emergency room or inpatient nurses for adults are accustomed to giving a set number of liters per patient, according to Tina Schade Willis, M.D., associate chief medical officer for quality at UNC Hospitals, which includes UNC Children's Hospital. "Our pediatric nurses have been able to help the adult side with how to think about measuring fluid in a weight-based way," Schade Willis says. "We try to collaborate as much as we can to help each other."
UNC Children's Hospital also served as the June 2015 launching ground for the system's new Code Sepsis program before taking it live with adults. Just like with a Code Blue, any staff member or nurse can pick up the phone and use the same number they would to call a code. "They can say, ‘I have a Code Sepsis in Room X,'" Schade Willis says.
"That will activate our pediatric or adult rapid response team, depending on whether it's an adult or pediatric patient." When the rapid response team arrives, they understand this is likely a sepsis patient and are ready to use the sepsis bundle, she says. There's also a Code Sepsis pharmacist for adults and for pediatrics who is notified to speed time to administer antibiotics.
In the PICU, an "informal" Code Sepsis approach—a direct outreach to the most senior ICU physician versus calling the operator—requires that physician to assess the patient at the bedside immediately. If the patient is deemed septic, they go through the formal Code Sepsis pathway. "The lesson learned was, if you use that phrase, even if you're not calling through a formal system, it puts everyone in the mindset you actually have to get this done quickly, and it requires a team coming together," Schade Willis says. "Just like a trauma or any other code scenario."
This team-based approach has reduced the time it takes to get blood cultures and administer antibiotics and the first fluid resuscitation from several hours down to, in some cases, 10 minutes. The key to the team's success, Schade Willis says, is incorporating sepsis in routine emergency measures training and holding ongoing large-scale sepsis simulations. "Simple low-fidelity, hands-on practice has been the most important thing beyond an electronic health record trigger, screening tool or educational process," says Schade Willis. "The hands-on training has changed everything."
More sepsis care complications
While shortening the time to administer antibiotics is critical when treating a child with sepsis, experts say there is a balance to strike when deciding to administer them. "The other side is the antibiotic stewardship movement, which is to say that you shouldn't overuse antibiotics," Carcillo says. "That is coming from a fear of multiple drug-resistant organisms."
While Wakefield warns that teams should not reflexively withhold antibiotics in the name of good stewardship. She adds: "You can't go blasting for every patient. It's important to balance early treatment of patients to filter out those patients who don't need that early, broadened antibiotic because antibiotic stewardship is also really important."
A new mindset for pediatric sepsis
Pediatric sepsis experts also agree that this leading killer of hospitalized children needs to move from its long-held position as an afterthought to a top-of-mind concern for all children's hospitals. "We need to have a system that at least makes people ask the question, ‘Could it be sepsis?" Wakefield says. "You may not want to run every test and give every child who has a fever an antibiotic, but you want to be able to ask the question and look at the child more carefully."
With this new mindset must come the old adage, never assume. "Assuming that you're doing a good job is actually not a good assumption," says Melendez, whose institution delivers yearly reviews with blinded feedback on physician performance around sepsis. "My advice is measure, measure, measure—unless you begin to measure your personal processes and outcomes, you can't presume you're good at this. Because unfortunately, that's where you learn you're not."
In the case of 12-year-old Rory Staunton, that advice could have made all the difference in the world.
Megan McDonnell Busenbark is a writer and founder of Encore Communications, LLC, in New Fairfield, Connecticut. Send questions or comments to firstname.lastname@example.org.