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Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

ABSTRACT: Severe sepsis requires timely, resource-intensive resuscitation, a challenge when a sepsis diagnosis is not confirmed. The overall goals were to create a pediatric sepsis program that provided high-quality critical care in severe sepsis (Sepsis Stat), and, in possible sepsis, flexible evaluation and treatment that promoted stewardship (Sepsis Yellow). The primary aims were to decrease time to antibiotics and the intensive care unit requirement. Methods:A 2-tiered clinical pathway was implemented at 6 pediatric emergency departments and urgent care centers, incorporating order sets, education, paging. The Sepsis Stat pathway included 2 nurses, hand delivery of antibiotics, resuscitation room use. The Sepsis Yellow pathway included prioritized orders, standardized procedures, close monitoring, and evaluation of whether antibiotics were warranted. Results:From April 2012 to December 2017, we treated 3,640 patients with suspected and confirmed sepsis. Among the 932 severe sepsis patients, the 30-day, in-hospital mortality was 0.9%. Arrival to recognition time improved from 50 to 4 minutes. Recognition to antibiotic time demonstrated an in-control process in our goal range with a median of 43 minutes for Sepsis Stat patients, 59 minutes for Sepsis Yellow patients. The proportion of severe sepsis patients requiring intensive care unit care declined from 45% to 34%. On the Sepsis Yellow pathway, 23% were de-escalated with discharge to home without antibiotics. Conclusions:This novel 2-tiered approach to pediatric sepsis quality improvement in varied emergency care settings improved process and outcome measures in severe sepsis while promoting stewardship and de-escalation where appropriate. Matching resources to the degree of illness was important in supporting quality care in potentially septic children.

SUBMITTER: Scott HF

PROVIDER: S-EPMC7056288 | biostudies-literature | 2020 Jan-Feb

REPOSITORIES: biostudies-literature

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Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

Scott Halden F HF Kempe Allison A Deakyne Davies Sara J SJ Krack Paige P Leonard Jan J Rolison Elise E Mackenzie Joan J Wathen Beth B Bajaj Lalit L

Pediatric quality & safety 20200111 1

Severe sepsis requires timely, resource-intensive resuscitation, a challenge when a sepsis diagnosis is not confirmed. The overall goals were to create a pediatric sepsis program that provided high-quality critical care in severe sepsis (Sepsis Stat), and, in possible sepsis, flexible evaluation and treatment that promoted stewardship (Sepsis Yellow). The primary aims were to decrease time to antibiotics and the intensive care unit requirement.<h4>Methods</h4>A 2-tiered clinical pathway was impl ...[more]

PMID: 32766482

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Project description:Diagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care.Sixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to.Ten studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains.There is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research.PROSPERO registration: CRD42015027555.

Project description:ObjectivesTo describe the Children's Hospital Association's Improving Pediatric Sepsis Outcomes sepsis definitions and the identified patients; evaluate the definition using a published framework for evaluating sepsis definitions.DesignObservational cohort.SettingMulticenter quality improvement collaborative of 46 hospitals from January 2017 to December 2018, excluding neonatal ICUs.PatientsImproving Pediatric Sepsis Outcomes Sepsis was defined by electronic health record evidence of suspected infection and sepsis treatment or organ dysfunction. A more severely ill subgroup, Improving Pediatric Sepsis Outcomes Critical Sepsis, was defined, approximating septic shock.InterventionsParticipating hospitals identified patients, extracted data, and transferred de-identified data to a central data warehouse. The definitions were evaluated across domains of reliability, content validity, construct validity, criterion validity, measurement burden, and timeliness.Measurements and main resultsForty hospitals met data quality criteria across four electronic health record platforms. There were 23,976 cases of Improving Pediatric Sepsis Outcomes Sepsis, including 8,565 with Improving Pediatric Sepsis Outcomes Critical Sepsis. The median age was 5.9 years. There were 10,316 (43.0%) immunosuppressed or immunocompromised patients, 4,135 (20.3%) with central lines, and 2,352 (11.6%) chronically ventilated. Among Improving Pediatric Sepsis Outcomes Sepsis patients, 60.8% were admitted to intensive care, 26.4% had new positive-pressure ventilation, and 19.7% received vasopressors. Median hospital length of stay was 6.0 days (3.0-13.0 d). All-cause 30-day in-hospital mortality was 958 (4.0%) in Improving Pediatric Sepsis Outcomes Sepsis; 541 (6.3%) in Improving Pediatric Sepsis Outcomes Critical Sepsis. The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated strengths in content validity, convergent construct validity, and criterion validity; weakness in reliability. Improving Pediatric Sepsis Outcomes Sepsis definitions had significant initial measurement burden (median time from case completion to submission: 15 mo [interquartile range, 13-18 mo]); timeliness improved once data capture was established (median, 26 d; interquartile range, 23-56 d).ConclusionsThe Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated feasibility for large-scale data abstraction. The patients identified provide important information about children treated for sepsis. When operationalized, these definitions enabled multicenter identification and data aggregation, indicating practical utility for quality improvement.

Dataset Information

Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

Publications

Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

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