Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support.

BACKGROUND: Sepsis is an uncontrolled inflammatory reaction caused by infection. Clinicians in the pediatric intensive care unit (PICU) developed a paper-based tool to identify patients at risk of sepsis. To improve the utilization of the tool, the PICU team integrated the paper-based tool as a real-time clinical decision support (CDS) intervention in the electronic health record (EHR). OBJECTIVE: This study aimed to improve identification of PICU patients with sepsis through an automated EHR-based CDS intervention. METHODS: A prospective cohort study of all patients admitted to the PICU from May 2017 to May 2019. A CDS intervention was implemented in May 2018. The CDS intervention screened patients for nonspecific sepsis criteria, temperature dysregulation and a blood culture within 6 hours. Following the screening, an interruptive alert prompted nursing staff to complete a perfusion screen to assess for clinical signs of sepsis. The primary alert performance outcomes included sensitivity, specificity, and positive and negative predictive value. The secondary clinical outcome was completion of sepsis management tasks. RESULTS: During the 1-year post implementation period, there were 45.0 sepsis events per 1,000 patient days over 10,805 patient days. The sepsis alert identified 392 of the 436 sepsis episodes accurately with sensitivity of 92.5%, specificity of 95.6%, positive predictive value of 46.0%, and negative predictive value of 99.7%. Examining only patients with severe sepsis confirmed by chart review, test characteristics fell to a sensitivity of 73.3%, a specificity of 92.5%. Prior to the initiation of the alert, 18.6% (13/70) of severe sepsis patients received recommended sepsis interventions. Following the implementation, 34% (27/80) received these interventions in the time recommended, p = 0.04. CONCLUSION: An EHR CDS intervention demonstrated strong performance characteristics and improved completion of recommended sepsis interventions.

Improving Timely Recognition and Treatment of Sepsis in the Pediatric ICU.

BACKGROUND: Sepsis is a leading cause of pediatric mortality worldwide. The implementation of sepsis bundles and clinical decision support (CDS) tools have been useful in improving sepsis recognition and treatment. METHODS: Interventions targeted the pediatric ICU (PICU) sepsis identification process and focused on implementation of multidisciplinary sepsis huddles prompted by an automated CDS tool. The primary outcome measure was days between delayed sepsis recognition, with secondary outcome measures of the percentages of patients receiving goal-directed evidence-based sepsis therapies, including antibiotics within 1 hour, rapid fluid bolus within 20 minutes, and lactate measurement within 1 hour. The researchers also tracked median time to antibiotics. RESULTS: Average days between delayed sepsis recognition improved from one episode every 9 days to one episode every 28 days. The percentage of patients who received antibiotics within 1 hour improved from 33.9% to 45.5%, received a fluid bolus within 20 minutes increased from 54.7% to 61.8%, and had a lactate measured within 1 hour increased from 59.4% to 71.1% post-CDS alert; none were statistically significant. Median time to antibiotics prior to CDS alert implementation was 1.53 hours, with improvement to 1.05 hours postimplementation (p = 0.03). CONCLUSION: Implementation of multidisciplinary sepsis huddles and an automated CDS alert in the PICU led to an improvement in days between delayed sepsis recognition and a significant improvement in time to antibiotics.

Continuum of care in pediatric sepsis: a prototypical acute care delivery model.

Sepsis is a burdensome public health problem and a leading cause of infant and child morbidity and mortality across the world. Few proven therapies exist to treat septic shock and the mainstay of management remains judicious fluid resuscitation and timely antibiotics. In its most recent iteration, the American College of Critical Care Medicine (ACCM) guidelines on hemodynamic support in pediatric septic shock recommends an institutional approach to the management of septic shock rather than one aimed at the individual practitioner. The acute care delivery model has been proposed as a way to guide quality improvement in emergency care and to improve care delivery. In this review, we summarize current recommendations in the management of pediatric patients with septic shock, and highlight opportunities to provide seamless care by application of the acute care model.

Reappraisal of lymphatic mapping for midgut neuroendocrine patients undergoing cytoreductive surgery.

BACKGROUND: We previously reported that midgut neuroendocrine tumors (NETs) often develop alternative lymphatic drainage owing to lymphatic obstructions from extensive mesenteric lymphadenopathy, making intraoperative lymphatic mapping mandatory. We hypothesize that this innovative approach needs a longer term validation. METHODS: We updated our results by reviewing 303 patients who underwent cytoreduction from November 2006 to October 2011. Of these patients, 112 had lymphatic mappings and 98 were for midgut NET primaries. Among them, 77 mappings were for the initial cytoreduction and 35 were for reexploration and further cytoreduction. The operative findings, pathology reports, and long-term surgical outcomes were reviewed. RESULTS: Lymphatic mapping changed traditional resection margins in 92% of patients. Of the 35 patients who underwent reexploration without initial mapping, 19 (54%) showed a recurrence at or near the anastomotic sites. In contrast, none of the 112 mapped patients had shown signs of recurrence in a 1- to 5-year follow-up. Additionally, 20 of 45 ileocecal valves (44.4%) were spared in patients whose tumors were at the terminal ileum that, traditionally, would call for a right hemicolectomy. CONCLUSION: With a longer follow-up, lymphatic mapping has proven to be a safe and effective way to prevent local recurrences and preserve the ileocecal valve for selected patients.