How to use the sepsis management plan

Transcript

Welcome to the education video on how to use the paediatric sepsis pathway and management plan.

The paediatric sepsis pathway is a six page document that includes an additional six pages that are resources to assist in things such as antibiotic preparation and administration, and information for parents or carers, including fact sheets and checklists.

The first page of the paediatric sepsis pathway looks like this. Now, this is a tool that is important to use when you are suspecting sepsis or you're not sure if your child may have sepsis or if your child does in fact have sepsis. The screening and recognition component of the pathway, a prompted when you suspect a sign of infection is present, and then any of the following criteria such as look sick or toxic, parental care, or healthcare or care clinician concern, a re presentation with the same illness, et cetera.

Once one of those boxes is ticked and you've got a sign of infection, it prompts you to do a full set of observations in the acute tool, including a blood pressure and an A V P U. You'll then go on to complete any, your acute assessment and include any of the check boxes that are relevant for your patient here.

If indeed they don't have any of these, components of features of severe illness and you don't still suspect in sepsis, it prompts you to then go on to give the parent or family member a pediatric sepsis checklist. It looks like this.

When you give this information to the parents, it's important to actually explain to them why you're giving it to them and what sepsis actually is. Not just hand it out and tick the box and say you've given it to them, but this is a prime time to actually take the time to explain and educate to our family members.

We also acknowledge for paediatrics that the parental role in ongoing assessment is incredibly important and sharing information so parents are informed and can continue to monitor their child and bring them back to the hospital if they need is absolutely paramount.

If the parent does indeed bring their child back into the emergency department, or they've been discharged to the ward and they come to the emergency department, wherever they may be in their journey, they might select some boxes like this, so you as the triage nurse can see what the parent is concerned about and what factors may have changed since they have left the hospital.

If we move back to the screening and recognition component of the pathway. Another example would be here if the child actually does have features of severe illness, we can see that it operates well in parallel with our acute tool. For this child in particular, we can see that they're executing a score of eight.

On the sepsis pathway, we can see that they've got an alter A V P U and they've got poor skin perfusion. So do they have any features of severe illness? The answer is yes, which then goes on to prompt, a senior medical review. Now the senior medical review will then decide if they are indeed treating sepsis with shock, sepsis without shock, or that they believe that sepsis is unlikely.

In this case, in example, we're saying that the child has sepsis with shock, which prompts this treatment bundle to commence. As you can see, it's around notifying senior medical officers ensuring oxygen saturations are appropriate , obtaining IV or interosseous access, giving appropriate antibiotics, selecting the suspected source of infection, commencing a fluid bolus, and considering the use of inotrope support and preparing that early.

It's important to note as well that these children are children that have sepsis. These children are sick. We are treating them with IV antibiotics and, and as per our bundle recommendations, and as per the surviving sepsis campaign guidelines, which is an international really recognized document.

For septic shock, we want all these elements delivered now and within one hour recognition for those children there where we think there's less likelihood of organ dysfunction and sepsis. We're saying to prioritize timely collection of all relevant microbiological samples according to the suspected source, and then you have three hours to do so. However, it's really important to note that if the child is hemodynamically unstable at any point in time, then you need to revert to giving these components quickly and within the one hour. If the child then reverts to having septic shock, we know with children that change can happen incredibly quickly.

The next part of the pathway I wanna talk to you about is the antibiotic component. So we can see here this is a little example of antibiotic choice that the doctor can prescribe some key things to consider as a child's age, a suspected source, and do they have any penicillin or cephalosporin sensitivity.

And when we're doing dosing, it's important to consider the age of your patient when you're selecting your doses. Also to note with Acyclovir that there is a meter squared body surface area calculation here for children that are older than three months and less than 12 years of age. We can see here the rest go to milligrams per kilo. But again, really important to read the document carefully when we're prescribing antibiotics and appropriate dosing regimes.

If I draw your attention back to our management and treatment resuscitation bundle, we can see that there's a section here on bereavement. Now, if the unfortunate event of death occurs, it's important to give the family appropriate levels of support. The bereavement section is front and center on page two to guide you and to make sure that these things are actually thought about and provided to our families.

If we move down to the reassess component, here's an example of our child now. So they have significantly improved acute score is a total of four now, but we can see their respiratory rates come down. They've got less respiratory distress. They're scoring zero for some of these elements. Their tachycardia has come down. It's still scoring a one, but it has decreased. In the case of here, when we reassessed, does our patient have any persistent signs of sepsis within 15 minutes following the treatment bundle? In our case, we're saying no. If the answer is yes, the patient would fall down into the purple section, which is a deteriorating or persistent signs of sepsis. But in this case here, they've got resolving signs of sepsis. So we move on to our orange section.

This is what the sepsis management plan looks like. We're now on page three and four of the pathway, and this is a back to back document.

When we look closely at the sepsis management plan, we can see we flowed down the orange section for our child. However, the purple section is also here as well. It's important to note that sepsis has a trajectory of rapid deterioration and children compensate incredibly well until suddenly they don't.

So initially children can respond to treatment, but then deteriorate hours later. So it's really important to continue monitoring and reassessing these patients as they're treated for sepsis and they're not out of the boards just because they've received IV antibiotics and initial treatment elements.

Also important to note here that children can move between streams, so they may improve and move into the orange stream, or they may actually deteriorate again and move back into the purple section. This is why it's really important to monitor, reassess, escalate as clinically required and manage them.

If the patient's in the resolving stream, we can see that we want continuous monitoring of these elements. Every 60 minutes, we want these elements done, and every four hours we want these done. Every time that we do an intervention, we can see down here, or there's a change in any monitored vital sign. We need to perform a clinical reassessment, and we want that done at every 60 minutes at a minimum.

If there's no intervention, the 60 minute mark is the absolute minimum, but if there is an intervention, you'll do it every time after an intervention. This is how fragile these patients are. And when we're reassessing these patients, we are looking at the comprehensive picture, knowing that sepsis is systems condition. We cannot look at signs in isolation, so review the trends and we wanna assess response to therapy. And if things are not improving, we need to really escalate early. We wanna do this for as long as clinically indicated, and as long as the patient has signs of sepsis. Things change. Do it more often, escalate frequently. If we do notice a change in that monitoring, which really should prompt a reassessment.

When we move on to the investigate section, we wanna collect as many of these as possible prior to IV antibiotic collection. However, we know that this will be clinical status dependent. We wanna ensure that the boxes are checked if they're done, and if they're not done, a rationale why. Just so that the next team that's looking after the patient understands the rationale and the picture is a little bit clearer for them.

We move on to the communicate section. This is a moment where we can breathe and it's really important. Well hopefully brief, but it's very important to discuss these things with the family and share key important information.

We know family questions may come up hours later. They may come up in the beginning of the treatment, so we've got to be flexible in how we respond to that. But really important that parents do feel a part of the team and that they may not wanna be involved in the resuscitation, which is completely reasonable, but they may come back hours earlier and then your opportunity to communicate with them and explain what is actually going on. Note that there are some different elements between the orange and the purple stream. Therefore, if the patient moves from one stream to the other, for example, from the orange, perhaps back to the purple or to the purple, the things such as goals of care are actually discussed because that may not appear in the orange section.

This is one of the resources I was speaking about, so to support your patient and their family with the understanding of what's happening for their child. This is the information sheet that we've developed in consultations with families and children. Families find things all very overwhelming when their child's acutely unwell, and is newly diagnosed as sepsis.

So the information sheet's designed to be given to them to have conversations about their diagnosis and treatment plan. It provides key information as you, for you as a clinician to support your discussion, including what is sepsis, what they can expect for their childcare, and also some questions that they can ask for their healthcare team.

It also is very important at this early stage that the information sheet provides information about what supports for the family are required, such as social work, welfare, and cultural supports available within the hospital. There's also online resources and supports developed by the Queensland Paediatric sepsis program that can be accessed.

If we re-orientate back to the sepsis management plan, we're now moving on to the antibiotic optimization section. This really just ensures and prompts you to that you've reconsidered the source, you've reviewed the results, and making sure you're doing handing over from the ED to the ward or the I C U to the ward, wherever the child may be going to make sure that important information is not missed or, and it's communicated early.

If you're ever unsure and concerned, child, not improving phone, your infectious disease team, wherever that may be, wherever your hospital is. And it's really important to ensure that there's an IV to oral step down and a de-escalation process occurs when clinically appropriate. If we think about documentation, we've always been told if it isn't documented and didn't happen, and documentation is key for sepsis management and helps inform the next team member of the multidisciplinary team to appropriately manage the patient.

Also, we wanna make sure that we're documenting a diagnosis of sepsis and ensure that the parent has the information sheet and knows that the child actually has sepsis. This is really important for post sepsis care so parents can access care and have information about sepsis. And from a medical records perspective, I sepsis is not documented or recorded. This results in a significant underrepresentation and burden of disease. And can significantly impact on future quality research and service delivery for our patients in the future.

In this example, we're gonna say that the patient was discharged to the ward after 36 hours. And then in this case, we wanna really make sure that we're handing over what's happened. We're handing over to make sure that we're giving the appropriate psychological support, it's documented in the health record and what's happened we're documented clinicians are involved in care, and again, we're involving all the parents and carers in that, in that process.

If we're talking about discharging, if they've moved into the orange section. We are preparing for discharge and it's important to follow standard discharge planning procedures, but also ensure that this includes readily available sepsis specific resources and informing the families about these available resources. If they're not informed, they'll likely won't be able to find it or know it exists. Again, there are many resources and support programs for families, and they're accessible through their sepsis in Children website.

Given the complexities of a sepsis diagnosis and the likelihood of ongoing impacts for children and their families, we wanna ensure that there's a GP is identified and consider referral to a nurse navigator for ongoing assessment.