Cathy Masuda, RN, MN Quality & Safety Leader BCCH

Inpatient Sepsis :Identification &

Mitigation

Background

Patient Condition Worsens

Recognition of deterioration by

“someone”

Assistance sought

Medical Intervention

Management by most appropriate

resources

Relocation to appropriate care area if required

DELAY

INCONSISTENT

INCONSISTENT

DELAY

DELAY

INCONSISTENT

DELAY

12 Severe Sepsis cases reviewed (2009) showed 0% compliance with 100% of all recommended treatment aspects within recommended timeframes.

Background

• 2010-11 development of Pediatric Sepsis Guidelines (Provincially adopted through CHBC)

http://childhealthbc.ca/?drawer=Sepsis%20Guidelines

Current State

Current State:Challenges

Current State:Challenges

Background: Developmentally delayed, medically complex school-age child . High-utilizer of system. Long-term inpatient due to complicated post-operative recovery.

Overview:

Discussion:Even with a robust system in place we still encounter those one-off situations. Some contributing factors in this situation:

• RN bias about patient due to “knowing” the patient. Therefore, did not escalate IV start urgency… resulted in delay in antibiotics and IV bolus

• RN not aware of sepsis screening protocol (even though prompt onflowsheet). Also charting done on a notepad and then transcribed so ability to pick up PEWS deterioration (as in EARLY WARNING) doesn’t happen with late entry charting

• Once medical team responded, the junior resident also made assumptions about a surface contamination and response being typical of this patient

• Covering attending would not cover for another surgeon’s patients due to current workload and MRP was not in town. On-site medical team covered after urgent call

• RN did not escalate surgical team lack of response concerns (Escalation Protocol exists) in a timely manner

Patient Condition Worsens

Recognition of deterioration by

“someone”Assistance sought

Medical Intervention

Management by most appropriate

resources

Relocation to appropriate care area if required

Delay

Delay

Delay

Current State

Future State

Provincial • Standardized PEWS Process

throughout the province• Process includes:

– standard work for identification, notification and mitigation/escalation of care for the deteriorating child.

– situational awareness– sepsis screening– daily management

National• In partnership with Canadian

Association of Pediatric Health Centers looking at pediatric sepsis

• Goal is to establish national standards for prevention, recognition and treatment of sepsis (Next slide)

• Currently conducting a PDSA testing a national screening tool throughout select sites in the province

NOTE: Any work being done through BCPSQC regarding Pediatrics should be done in partnership with CHBC & BCCH

Infection

SepticShock

SevereSepsis

Sepsis

INFECTION SEPSIS SEVERE SEPSIS

SEPTIC SHOCK

Prevention Hand hygiene practices, Vaccinations, NI improvement bundles (VAP, CRBSI, CAUTI, SSI), IC Guidelines, Antibiotic stewardship, Auditing (IC & NSQIP)

PAIRS response process, Antibiotic stewardship, HH, NI bundles, IC bundles

PAIRS response process (ICU consult), Antibiotic stewardship, HH, NI bundles, IC bundles

HH, NI bundles, IC bundles

Recognition/Dx Sepsis Guideline, Sepsis Screening, PEWS & Situational Awareness (PAIRS)

Advanced lab dx, Research at CFRI; Screening, PAIRS

PAIRS, Advanced lab dx,

PAIRS, Advanced lab dx,

Tx/Follow-up Sepsis Guideline, Antibiotic stewardship

Order set, Antibiotic stewardship

Order set, Antibiotic stewardship,

Order set, Antibiotic stewardship, Code Blue, ECLS

Trajectory of septic shock & known interventions