How to use the paediatric sepsis pathway

Transcript

Welcome to the education resource video. Could this be sepsis? Including instructions on how to use the paediatric sepsis pathway In Queensland.

The World Health Organization has recognised sepsis as a global priority. Sepsis is infection with organ dysfunction. Recognition and treatment for sepsis is time critical.

The Queensland Paediatric Sepsis clinical pathway has been developed to align with international best practice guidelines and evidence. It has included statewide stakeholder and expert clinician consultation and input. The pathway is designed as a clinical support tool for all clinicians working in the emergency department, rural and regional settings and inpatient wards, but it does not replace clinical judgment.

In 2018, the Paediatric Patient Safety Review project reviewed sentinel incidents from critically unwell children from the years 2016 to 17.Of the 14 incidents, 10 were attributed to sepsis, and nine had a delayed or misdiagnosis of sepsis. In summary, 10 out of the 14 had sepsis. Seven of the nine deaths were related to sepsis and nine of the 10 had a delayed or misdiagnosis of sepsis. It is time for a paediatric sepsis pathway in Queensland.

Internationally, the surviving sepsis campaign guidelines recommends all institutions have a systematic screening tool and pathway or guideline to assist in the recognition and management of paediatric sepsis. In Australia and Queensland locally, we now have a clinical care standard that too recommends the use of a sepsis pathway to assist in the early recognition, treatment and ongoing management of sepsis.

Infection for children represents one of the most common reasons that they present to emergency departments. Sepsis and life-threatening infections remain one of the leading causes of childhood mortality. Sepsis accounts for a large proportion of the estimated over 3 million annual childhood deaths due to infection. This was published in 2013. In 2020, over 50% of the incidents of sepsis affected children and adolescents with a reported 48.9 million cases of sepsis worldwide, including adults and children. There were 20.3 million cases in children, less than five and 4.9 million in those were over five. In Australia, there were reported 55,000 cases with 8,700 deaths for both the adult and childhood population groups. We also need to note that these numbers are likely an underrepresentation of the actual true burden of sepsis and therefore reasons such as diagnostic coding.

Even in countries with a low childhood mortality, sepsis and invasive infections contribute up to 20% of childhood deaths and one out of four deaths in the paediatric intensive care unit. Unfortunately, the incidence has been rising in Australia over recent years. For those children that do survive paediatric sepsis up to one third will suffer from long-term sequelae due to amputations and brain injury acquired during sepsis amongst other things. This results in a lifelong challenge to patients, families, and the community.

Studies have shown improved outcomes with the sepsis change package implemented. Consisting of early recognition, diagnosis and treatment of sepsis will substantially reduce the duration of organ dysfunction leading to shorter hospital length of stay in I C U and in hospital. The delayed sepsis treatment is associated with high mortality rates, significant morbidity and higher cost to the healthcare system. Local data here in Queensland showed after implementing a statewide paediatric sepsis pathway in 12 emergency departments throughout Queensland, the time to delivery of the sepsis bundle, which consisted of collecting blood cultures and a lactate and the delivery of antibiotics and fluid improved over the 2018 to 19 period where the pathway was implemented by comparison to a paediatric intensive care unit population from 2015 to 18.

The paediatric sepsis pathway includes:

• a screening and recognition tool,
• a monitoring and reassessment guide,
• a comprehensive management plan to align with the clinical care standard,
• an antimicrobial prescription and administration guideline,
• a tear off information sheet for par for parents and cares of a child diagnosed with sepsis,
• a sepsis checklist for families to follow.

Specifically, the pathway was created after reviewing the UK National Institute for Health and Care Excellent guidelines, the UK Sepsis six, the Children's Hospital Association, the Improving Paediatric Sepsis Outcomes Collaborative, the Children's Hospital of Philadelphia and New South Wales CEC sepsis kills.

Sepsis screening can be initiated by any doctor or nurse at any point in time during the patient's journey within the hospital or unit. The purpose of the tool is to empower doctors and nurses to consider sepsis early, initiate action if required and escalate to a senior medical officer in order to get the patient reviewed. Now, not everyone who has screened for sepsis actually has sepsis. That decision lies with the senior medical officer. It's important to note the pathway has been designed to be used in conjunction with clinical judgment. Be empowered to assess your patient and say, this is not sepsis or this is sepsis. It's about continually observing and reassessing your patient throughout their journey. Once again, the purpose of the tool is to consider sepsis and rule it out early or rule it in and start your investigations and your management.

When screening is initiated, place the date and time and the respective box as shown you must tick. Could this be sepsis as well as one of the following criteria consisting of the patient looks sick or toxic? There may be parental or clinician concern and then continued down the page, ticking the boxes as clinically in indicated and what is relevant for that patient.

If you are considering to screen your patient or not for sepsis, remember there are some risk factors which can increase the patient's risk of having sepsis, such as being an Aboriginal Torres Strait Islander child or perhaps the age of the patient. Just to list a few examples. Risk factors such as these should lower your threshold to screen the patient. If you are considering screening your patient, the advice is Nike, just do it. If the thoughts even crossed your mind, trust that gut, it's floated across your mind for a reason. Screen the patient.

There is no harm in screening them and asking yourself and the team, could this be sepsis? In fact, upon reviewing fatalities from sepsis, the question is raised, was sepsis considered early? Was it ruled out earlier in the patient journey? If not, could this have changed the outcome? Rule it out instead of ruling it in an hour later when the child has deteriorated.

Once you have ticked the appropriate boxes, move down to documenting a full set of vital signs in the acute tool, including a blood pressure and an A V P U. Record the blood glucose level and make sure you have recorded the patient's weight.

Once you have obtained a full acute score, move on to the recognized section. Does your patient have any features of severe illness? It's important to note the sepsis pathway severity of illness features directly correlate with the acute parameters. Please note the colour coding for the acute metrics are different if using IMR versus a paper version of the queue.

As you review your acute score for each parameter and any additional assessment you've done, tick the corresponding boxes on the sepsis pathway. If any one of these boxes are ticked, the patient has sepsis or septic shock until proven otherwise, obtain an immediate senior medical review and expedite transfer to a resuscitation area. Ensure you notify a senior medical officer and a team leader when the senior medical review has occurred and what action is to occur in that resuscitation area.

Fill in the time in the corresponding box when the senior medical review has been conducted. If your patient does not meet any of the features listed for severe illness, but you still suspect the patient may have sepsis, select yes and continue your assessment for sepsis by conducting a targeted history and examination. Obtain a medical review in line with the departmental guidelines or phone RSQ.

If the senior medical iCal officer decides that sepsis is unlikely, tick unlikely sepsis, but ensure the parental carer has been provided with the education of the signs of sepsis and advise them to monitor their child for any changes or deterioration. It is really important to take the time to thoroughly educate patients on the early signs of sepsis just as we would when discharging children with a head injury as an example. It's really important to safety net to ensure that they understand what sepsis is and that their child may not have it now, but things may change in the future, and it's important for them to come back and understand that these things can happen. Timely review is is of the essence. This may be the one opportunity for them to hear about sepsis, which may in fact save their child's life in the imminent or distant future. Knowledge is power. Empower them to return to the health service should their child's condition change. Ensure they receive the tariff information leaflet attached to the pathway. Reevaluate your patient and escalate concerns as indicated throughout their patient's day.

If the senior medical officer diagnoses the patient with sepsis, activate the resuscitation bundle immediately. On the next page, tick if the patient has sepsis with or without shock.

Once the resuscitation bundle has been activated, complete actions one to six as soon as possible and within one hour for septic shock. Ensure the senior medical officer is aware that the patient has sepsis in that corresponding area you're working and consider early paediatrician referral. Monitor and maintain oxygen saturations equal to or greater than 94%. Secure intravenous or intraosseous access and collect blood cultures, a blood gas, a blood glucose level, and a lactate. An increased lactate is a red flag in sepsis and a warning sign indicating a critically unwell patient. Take a full blood count, a C R P chem 20 and co coag studies and when possible, all appropriate cultures. Commence appropriate intravenous and intraosseous antibiotics as soon as possible. Prepare and administer intravenous or intraosseous fluid.

Reassess your patient after each fluid bolus and if no, or limited improvement in hemodynamic status, consider inotrope support. Please remember to continually reassess and monitor the response of the interventions above and check your patient. Reassessment of a patient with sepsis is a key component of their care and is absolutely vital to ensure that second deterioration has not occurred and at or been missed. Continually reassess your patient, their status can change very quickly. Reassess if your patient has any persistent signs of sepsis within 15 minutes following the treatment bundle and follow the next steps according to if your patient is deteriorating or has persistent signs of sepsis or if they have resolving signs of sepsis. This will guide you for the most appropriate next steps for your patient.

The Sepsis Management Plan provides structure and guidance around monitoring and reassessment and escalation of your patient. It is important to note should bereavement services be required, a guide is available to navigate this challenging time for the family and the clinicians involved.

Ongoing patient care must be conducted and ensure that the appropriate staff and unit are aware the patient has sepsis upon transfer. The prescription guidelines have been developed by pharmaceutical and infectious disease experts. They're related to doses of sepsis and it's imperative to find the appropriate source and prescribe the antibiotics accordingly. Nursing staff, the administration guidelines are there to provide you with a central easy access point to administer antibiotics in a time critical environment.

To obtain further education on how to apply the sepsis management plan in clinical practice, please review the video named How to Use the Sepsis Management Plan.

Just ask, could this be sepsis.