Transcript Department Presentation Title - Sheffield Children's Hospital

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
• Intervention
• Comparison
• Outcome
• Design
Septic Children
60ml/kg Fluid resuscitation
within 60min
Slower fluid resuscitation
Survival/Morbidity/Hospital
Stay
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% <1yr
 60% had co-morbidities
 5% 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/comorbidities/ Social factors
6.
5.
A. Have the authors identified all important confounding
factors?
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?
6. 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 nonadherence
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 nonadherence
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
and inotropes
10. Do you believe the results?
Yes
adherence
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?