New electronic sepsis alert system drastically reduces missed diagnoses
Monday, June 19, 2017
Using an electronic sepsis alert (ESA) can reduce missed sepsis diagnoses by 76 percent, according to a new study published in the Annals of Emergency Medicine.
Doctors in the United States treat more than 75,000 children for severe sepsis each year. Severe sepsis is associated with substantial morbidity and up to 20 percent mortality, and accounts for more than $4.8 billion in U.S. healthcare expenditures.
Many children initially present compensated shock without apparent hypotension, which makes early and accurate diagnosis of pediatric severe sepsis difficult.
"Sepsis is a killer and notoriously difficult to identify accurately in children, which is why this alert is so promising," said lead study author Fran Balamuth, M.D., Ph.D.,MSCE, of Children’s Hospital of Philadelphia, in a press release issued by the American College of Emergency Physicians.
"Identifying the rare child with severe sepsis or septic shock among the many non-septic children with fever and tachycardia in a pediatric ER is truly akin to finding the proverbial 'needle in a haystack.' This alert, especially with the inclusion of physician judgment, gets us much closer to catching most of those very sick children and treating them quickly."
Researchers built a two-stage electronic sepsis alert, then implemented the ESA into the hospital's electronic health record (EHR). Documentation of age-based tachycardia, bradycardia or hypotension at any time during the ED visit triggers the first stage of the two-stage alert, which prompts the triage nurse or other healthcare provider to answer more questions about the patient’s status. Depending on the answers to those questions, the attending physician may choose to initiate a sepsis protocol.
The researchers conducted the study in a freestanding academic children’s hospital emergency department with more than 90,000 annual visits. The study period was June 1, 2013, to May 31, 2015. The scientists included all patients presenting to the ED during the study period, including patients transferred to another ED after receiving an initial dose of intravenous antibiotics.
Of the patients enrolled in the study, 1.2 percent had positive ESAs. Of these, 23.8 percent had positive huddles that led to the decision to place the patient on sepsis protocol.
The two-stage ESA missed only 4 percent of patients who later developed severe sepsis. The researchers attribute the missed diagnosis to patient complexity, particularly among participants with developmental delays.
The ESA used in this study gathered information through a series of interactive screens. The first screen appears when the patient has tachycardia or hypotension, and asks questions about fever, hypothermia or concern for infection.
If the nurse answers yes to any of these three questions, the system requires the healthcare professional to answer a series of screening questions. Answering yes to any of these questions prompts the appearance of a third screen that requires the attending physician to perform a bedside evaluation and determines if the sepsis pathway is appropriate.
Tachycardia and hypotension are important signs of sepsis. If the child has a normal pulse during triage but develops tachycardia later in the visit, the ESA will fire an alert at the start of the tachycardia.
The ESA may trigger an alert at any time during the ED visit, but only once per visit at most. Documentation of hypotension can also trigger an alert at any time during the ED stay, but hypotension can trigger the alert more than once.
Positive first-stage and second-stage alerts triggers a "sepsis huddle," during which the emergency physician and treatment team hold a brief, focused patient evaluation and discussion.
Time-sensitive, goal-directed therapy is always the rule when it comes to sepsis. Using a triage protocol to recognize severe pediatric sepsis leads to better resuscitation management and shorter hospital stay.
The ESA may also trigger a series of questions regarding underlying high-risk conditions, mental status and perfusion. An affirmative answer to any of these questions triggers the second-stage alert.
The ESA will ask, "Is there fever, hypothermia, or concern for infection with this patient?" The nurse or care provider at the patient’s bedside will use clinical judgment to determine concern for infection in patients without fever. For example, the care provider may be concerned about respiratory distress in patients at risk for aspiration pneumonia or increased seizure frequency in children with an underlying seizure disorder.
The ESA screen then prompts the care provider to perform an additional assessment of peripheral capillary refill time and existing high-risk conditions. Patients with high-risk conditions, such as those receiving a bone marrow or solid organ transplant, who have an indwelling catheter, asplenia, malignancy or significant central nervous system abnormality, were deemed a priori and placed on sepsis alert as outlined by the American Academy of Pediatrics.
The triage nurse completes the mental status assessment, which appears as a drop-down menu on the ESA. An algorithm dichotomizes the information into normal and abnormal to trigger sepsis alerts as needed.
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