First name
Mary
Middle name
Kate
Last name
Abbadessa

Title

Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock.

Year of Publication

2022

Number of Pages

213-224

Date Published

05/2022

ISSN Number

1097-6760

Abstract

STUDY OBJECTIVE: To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock.

METHODS: This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure.

RESULTS: Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

DOI

10.1016/j.annemergmed.2022.04.008

Alternate Title

Ann Emerg Med

PMID

35641356
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Title

Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinician Identification.

Year of Publication

2017

Number of Pages

Date Published

2017 May 27

ISSN Number

1097-6760

Abstract

STUDY OBJECTIVE: Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department (ED).

METHODS: This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.

RESULTS: There were 182,509 ED visits during the study period, with 86,037 before electronic sepsis alert implementation and 96,472 afterward, and 1,112 (1.2%) positive electronic sepsis alerts. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the electronic sepsis alert alone to detect severe sepsis were sensitivity 86.2% (95% confidence interval [CI] 82.0% to 89.5%), specificity 99.1% (95% CI 99.0% to 99.2%), positive predictive value 25.4% (95% CI 22.8% to 28.0%), and negative predictive value 100% (95% CI 99.9% to 100%). Inclusion of the clinician screen identified 43 additional electronic sepsis alert-negative children, with severe sepsis sensitivity 99.4% (95% CI 97.8% to 99.8%) and specificity 99.1% (95% CI 99.1% to 99.2%). Electronic sepsis alert implementation increased ED sepsis detection from 83% to 96%.

CONCLUSION: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert-negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

DOI

10.1016/j.annemergmed.2017.03.019

Alternate Title

Ann Emerg Med

PMID

28583403
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Title

Longitudinal effect of high frequency training on CPR performance during simulated and actual pediatric cardiac arrest.

Year of Publication

2021

Number of Pages

100117

Date Published

2021 Jun

ISSN Number

2666-5204

Abstract

<p><strong>Study aim: </strong>To determine the impact of high-frequency CPR training on performance during simulated and real pediatric CPR events in a pediatric emergency department (ED).</p>

<p><strong>Methods: </strong>Prospective observational study. A high-frequency CPR training program (Resuscitation Quality Improvement (RQI)) was implemented among ED providers in a children's hospital. Data on CPR performance was collected longitundinally during quarterly retraining sessions; scores were analyzed between quarter 1 and quarter 4 by nonparametric methods. Data on CPR performance during actual patient events was collected by simultaneous combination of video review and compression monitor devices to allow measurement of CPR quality by individual providers; linear mixed effects models were used to analyze the association between RQI components and CPR quality.</p>

<p><strong>Results: </strong>159 providers completed four consecutive RQI sessions. Scores for all CPR tasks during retraining sessions significantly improved during the study period. 28 actual CPR events were captured during the study period; 49 observations of RQI trained providers performing CPR on children were analyzed. A significant association was found between the number of prior RQI sessions and the percent of compressions meeting guidelines for rate (β coefficient -0.08; standard error 0.04; p = 0.03).</p>

<p><strong>Conclusions: </strong>Over a 15 month period, RQI resulted in improved performance during training sessions for all skills. A significant association was found between number of sessions and adherence to compression rate guidelines during real patient events. Fewer than 30% of providers performed CPR on a patient during the study period. Multicenter studies over longer time periods should be undertaken to overcome the limitation of these rare events.</p>

DOI

10.1016/j.resplu.2021.100117

Alternate Title

Resusc Plus

PMID

34223376
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Title

Analysis of CPR quality by individual providers in the pediatric emergency department.

Year of Publication

2020

Number of Pages

37-44

Date Published

2020 08

ISSN Number

1873-1570

Abstract

<p><strong>OBJECTIVES: </strong>To describe chest compression (CC) quality by individual providers in two pediatric emergency departments (EDs) using video review and compression monitor output during pediatric cardiac arrests.</p>

<p><strong>METHODS: </strong>Prospective observational study. Patients &lt;18 yo receiving CC for &gt;1 min were eligible. Data was collected from video review and CC monitor device in a synchronized fashion and reported in 'segments' by individual providers. Univariate comparison by age (&lt;1 yo, 1-8 yo, &gt;8 yo) was performed by chi-square testing for dichotomous variables ('high-quality' CPR) and nonparametric testing for continuous variables (CC rate and depth). Univariate comparison of ventilation rate (V) was made between segments with an advanced airway versus without.</p>

<p><strong>RESULTS: </strong>524 segments had data available; 42/524 (8%) met criteria for 'high-quality CC'. Patients &gt;8 yo had more segments meeting criteria (18% vs. 2% and 0.5%; p &lt; 0.001). Segments compliant for rate were less frequent in &lt;1 yo (17% vs. 24% vs. 27%; p = 0.03). Segments compliant for depth were less frequent in &lt;1 year olds and 1-8 year olds (5% and 9% vs. 20%, p &lt; 0.001.) Mean V for segments with an advanced airway was higher than with a natural airway (24 ± 18 vs. 14 ± 10 bpm, p &lt; 0.001). Hyperventilation was more prevalent in CPR segments with an advanced airway (66% vs. 32%, p &lt; 0.001).</p>

<p><strong>CONCLUSIONS: </strong>CC depth is rarely guideline compliant in infants. Hyperventilation is more prevalent during CPR periods with an advanced airway in place. Measuring individual provider CPR quality is feasible, allowing future studies to evaluate the impact of CPR training.</p>

DOI

10.1016/j.resuscitation.2020.05.026

Alternate Title

Resuscitation

PMID

32505613
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Title

Simulation as a Dynamic Tool to Reorganize Pediatric Emergency Department Resuscitation During the Coronavirus Disease 2019 Pandemic and Beyond.

Year of Publication

2021

Number of Pages

286-289

Date Published

2021 May 01

ISSN Number

1535-1815

Abstract

<p><strong>BACKGROUND: </strong>The coronavirus disease 2019 pandemic has challenged hospitals and pediatric emergency department (PED) providers to rapidly adjust numerous facets of the care of critically ill or injured children to minimize health care worker (HCW) exposure to severe acute respiratory syndrome coronavirus 2.</p>

<p><strong>OBJECTIVE: </strong>We aimed to iteratively devise protocols and processes that minimized HCW exposure while safely and effectively caring for children who may require unanticipated aerosol-generating procedures.</p>

<p><strong>METHODS: </strong>As part of our PED's initiative to optimize clinical care and HCW safety during the coronavirus disease 2019 pandemic, regular multidisciplinary systems and process simulation sessions were conducted. These sessions allowed us to evaluate and reorganize patient flow, test and improve communication modalities, alter the process for consultation in resuscitations, and teach and reinforce the appropriate donning and use of personal protective equipment.</p>

<p><strong>RESULTS: </strong>Simulation was a highly effective method to disseminate new practices to PED staff. Numerous workflow modifications were implemented as a result of our in situ systems and process simulations. Total number of persons in the resuscitation room was minimized, use of a "command post" with remote providers was initiated, communication devices and strategies were trialed and adopted, and personal protective equipment standards that optimized HCW safety and communication were enacted.</p>

<p><strong>CONCLUSIONS: </strong>Simulation can be an effective and agile tool in restructuring patient workflow and care of the most critically ill or injured patients in a PED during a novel pandemic.</p>

DOI

10.1097/PEC.0000000000002384

Alternate Title

Pediatr Emerg Care

PMID

33903290
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Title

Repurposing Video Review Infrastructure for Clinical Resuscitation Care in the Age of COVID-19.

Year of Publication

2020

Number of Pages

Date Published

2020 Aug 25

ISSN Number

1097-6760

Abstract

<p>Within the context of the coronavirus disease 2019 (COVID-19) pandemic, minimizing health care worker exposure to the novel coronavirus has become a paramount part of the provision of health care in all settings across the world. Limited supply of personal protective equipment, personnel shortages as a result of exposure, and ensuring the safety and health of workers have all dictated the need to minimize the number of health care workers with direct patient contact. In resuscitation events, there is high likelihood of multiple aerosol-generating procedures and increased risk of viral transmission; therefore, limiting personnel is of particular importance. The development of creative solutions to allow vital team contributions to occur outside of the direct patient care space whenever possible is critical.</p>

DOI

10.1016/j.annemergmed.2020.08.030

Alternate Title

Ann Emerg Med

PMID

33160721
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Title

Analysis of Missed Sepsis Patients in a Pediatric Emergency Department With a Vital Sign-Based Electronic Sepsis Alert.

Year of Publication

2020

Number of Pages

Date Published

2020 Jul 15

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVE: </strong>To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED).</p>

<p><strong>METHODS: </strong>Retrospective cohort study in a tertiary care children's hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications.</p>

<p><strong>RESULTS: </strong>There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients.</p>

<p><strong>CONCLUSIONS: </strong>In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.</p>

DOI

10.1097/PEC.0000000000002207

Alternate Title

Pediatr Emerg Care

PMID

33003131
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Title

Sepsis in Complex Patients in the Emergency Department: Time to Recognition and Therapy in Pediatric Patients With High-Risk Conditions.

Year of Publication

2020

Number of Pages

Date Published

2020 Jan 09

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVES: </strong>To compare timeliness of sepsis recognition and initial treatment in patients with and without high-risk comorbid conditions.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study of patients presenting to a pediatric emergency department (ED) who triggered a vital sign-based electronic sepsis alert resulting in bedside "huddle" assessment per institutional practice. A positive sepsis alert was defined as age-specific tachycardia or hypotension, concern for infection, and at least 1 of the following: abnormal capillary refill, abnormal mental status, or a high-risk condition. High-risk conditions were derived from the American Academy of Pediatrics sepsis alert tool. Patients with a positive alert underwent bedside huddle resulting in a decision regarding initiation of sepsis protocol. Placement on the protocol and time to initiation of protocol and individual therapies were compared for patients with and without high-risk conditions.</p>

<p><strong>RESULTS: </strong>During the 1-year study period, there were 1107 sepsis huddle alerts out of 96,427 ED visits. Of these, 713 (65%) had identified high-risk conditions, and 394 (35%) did not. Among patients with sepsis huddles, there was no difference in sepsis protocol initiation for patients with high-risk conditions compared with those without (24.8% vs 22.0%, P = 0.305). Between patients with high-risk conditions and those without, there were no differences in median time from triage to sepsis protocol activation, triage to initial intravenous antibiotic, triage to initial intravenous fluid therapy, or ED length of stay.</p>

<p><strong>CONCLUSIONS: </strong>Timeliness of care initiation was no different in high-risk patients with sepsis when using an electronic sepsis alert and protocolized sepsis care.</p>

DOI

10.1097/PEC.0000000000002038

Alternate Title

Pediatr Emerg Care

PMID

31929394
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