Paediatric Sepsis Series — Antimicrobial Optimisation

Transcript

I'd like to welcome you here again, um,

to another of the pediatric Sepsis Seminar series. Um,

and before we start, I'd really just like to acknowledge Sarah,

who you might hear me refer to. Um, as an aside, uh,

Sarah Somerville's been a part of the team for a year or two now and has really

driven the development of this pediatric seminar series, and

it's been incredibly encouraging to see, uh,

the reach that the seminar series has had and the enthusiasm for the seminar

series. Um,

and so I'd just really like to thank Sarah for the work that she's been doing

and,

and for playing such an important part in the work of the Queensland Pediatric

Sepsis Program. My name's Adam, Adam Mein, and I'm a,

a conjoint senior lecturer in pediatric infectious diseases,

and I work across the University of Queensland and Queensland Children's

Hospital.

And I'm the medical co-lead of the Queensland Pediatric SEP Sepsis Program.

And with my infectious diseases background, I have a particular interest in, um,

the antimicrobial use, uh, that relates to the sepsis, uh,

pathway in pediatric sepsis care.

And so I'm going to talk today about how we optimize antimicrobial use in

pediatric sepsis.

I'd like to start by acknowledging the traditional custodians of these unseeded

lands on which we all live and work, uh,

for me here in Southeast Queensland, those are the turbo and Yra people,

and I'd like to pay my respects to the, uh,

elders and the descendants of the Turbo,

turbo and Yra peoples who continue important cultural, uh,

and spiritual connections to country.

And I'd like to extend that respect to First Nations peoples who have joined us

on the seminar today.

This is broadly what I'm going to talk about, uh, this afternoon,

in the next 40 minutes or so. Um, and you,

it's only the final bullet point that actually talked about antimicrobial

optimization and stewardship, but I,

I hope that that recognition of the importance of antimicrobial use

and optimal antimicrobial use in sepsis will be woven throughout the, the talk.

But let me start as usual,

by setting, uh,

the context and reminding us why sepsis in children is so important.

There were an estimated 50 million cases of sepsis worldwide each year,

of which 20 million or thereabouts occurring children under five,

leading to nearly 3 million sepsis deaths in children under five each year

globally. And of course,

the large burden of that mortality, uh,

is felt in low and middle income countries,

but this is not exclusively a problem of low and middle income countries,

and here in Australia and New Zealand and sepsis also has a,

a significant contribution to childhood morbidity and mortality.

These data now are, uh, slightly old. They're probably 10 years old or more,

but in these data from the Australia New Zealand Incentive Care Society,

all of the, um, uh, pediatric ICUs throughout Australia and, uh,

New Zealand,

there were around about a hundred thousand children admitted to ICUs,

of which 12% had serious infections. And, um,

the, the, uh, the rate,

the incidence of serious infections increased over the course of this, uh,

decade to 2013. Um,

and nearly a quarter of all I C U mortality, um,

was caused by sepsis

in the penultimate pediatric Patient Patient Safety Review undertaken in

Queensland, um, a failure to recognize, uh,

sepsis in children was the most common cause of serious preventable harm, uh,

and was associated with eight of the 12 swan, uh,

events reported in children.

And so early recognition of sepsis we know is good,

and early intervention with antibiotics is good. Now,

most of the data that support that statement come from adults,

and most of those, um,

most of the data come from the most unwell adults in septic shock.

But we can certainly say that in adults with septic shock,

early antibiotics and antibiotics within the first hour of onset of,

of shock reduces mortality. So,

early intervention in the sickest patients, um,

improves outcomes.

And we do now have some data specifically from children, um,

about the value of early intervention in sepsis. Um,

in this large study from New York State,

which looked at 50 odd hospitals, uh,

children, uh, who were evaluated with sepsis, um, the,

uh, uh,

the delivery of a three elements bundle

of care within one hour of sepsis diagnosis reduced in hospital mortality

by 40%. So, um, we do have data to, to,

to demonstrate that the delivery of a bundle of care, um,

in a timely way in children with sepsis improves outcomes.

And so these are the kinds of data that underpinned the development and delivery

of the Queensland Pediatric sepsis pathway.

And you'll note many of you'll already be aware that, uh,

the images that I'm showing you,

there are the original Mark one Queensland pediatric sepsis pathway,

which combined a screening and recognition tool to facilitate,

uh, the early recognition of children with sepsis, with a treatment bundle,

a bundle of care, um, for, for, uh,

immediate delivery and antimicrobial recommendations

along with the patient information leaflets and all, uh, and,

and that pediatric sepsis pathway has been available through, uh, wink,

including, as we'll talk about later the, the revised sepsis pathway.

Uh, and you can reach all of those resources also through our sepsis

website with the link there.

So in the lead up to this seminar, we, um,

we did ask the, the, uh, submitted questions. And, uh,

throughout the talk I'll introduce a number of these, uh,

a number of these questions, uh, as a, as a segue into, uh,

into different elements of the talk, different components of the talk.

And one of the first questions, uh, that we received was, uh,

whether or not there were any data to show that the implementation of the sepsis

pathway had been effective. And we, we do broadly speaking,

have now evidence to support early intervention in in pediatric sepsis.

But this question seems to say, do we have any data that our sepsis pathway, um,

has been effective? Because, um,

you will know that we introduced the pediatric sepsis pathway in Queensland in,

uh, 20 19, 20 18, 20 19. Um,

and as we implement, as we implemented that pathway, we did quite a, um,

a hands on labor intensive implementation.

And these are the results of that evaluation of the implementation.

So, um, for children with sepsis,

we observed that even the sickest patients, uh,

those with septic shock only received the three elements of the

sepsis bundle. Um, and that was, uh, a blood, uh, a lactate,

a, um, uh, administration of antibiotics and a fluid bolus.

Only a third received the three elements of the bundle within an hour as per the

recommendation. Um,

and for children who were thought to have sepsis with no evidence of shock and

so sepsis with organ dysfunction, but no shock,

approaching one half receive the three elements of the bundle within three

hours. And the recommendation is that, um,

those with sepsis shock receive intervention within an hour.

And for those with sepsis without shock, it, it may be, uh, appropriate, um,

to, to deliver those elements of the bundle within three hours.

But you can see that the delivery of these elements, uh,

an uptake of the pathway would appear to be somewhat disappointing.

The comparison on, for context, it's worth, it's worth pointing out that, um,

in the New York state, uh, sepsis program that I just reported earlier,

which showed such a significant impact on mortality in sepsis, the delivery,

um, of the three element bundle only occurred in just over a quarter of cases.

So, um, though we're a little disappointed by, uh, our,

um, uptake of the delivery of these elements,

it's more than comparable with international data.

So only 47% received their antibiotics within, um,

within an hour of septic shock.

And 90% of those with septic sepsis without shock received antibiotics.

So there was only limited adherence.

It should be said to the pathway,

but there was an improvement between a baseline population, uh, of,

of I C U patients, uh, that were evaluated. Uh,

between 2015 and 2018,

only 59% of whom received the three elements of the bundle, uh,

within three hours. Um,

and the I C U population in the,

so the comparable I C U population, uh, in the,

the period of the pathway implementation,

92% of whom received the three elements of the bundle within three hours.

And you can also see there, um, that the, um,

uh,

the proportion who received three elements of the bundle within one hour,

uh, went increased from 32% to 62%.

So although we were somewhat disappointed by adherence to the pathway,

we could show that in the sickest patients in I C U delivery of the three

elements of the, the treatment bundle did improve.

Now,

one aspect that I am interested in is how we, um,

uh, how we deliver appropriate antibiotics.

So antibiotics in the early treatment of sepsis are

empirical. Of course,

we don't know exactly what the cause of the sepsis might be.

And so we deliver antibiotics according to mo, to the most likely organism.

And according to the suspected source,

this is prior to getting any microbiological confirmation of, of the, uh,

etiology of the sepsis. And so, uh,

I was interested to know whether the instruction of the pathway improved the

appropriate choice and the appropriate dosing of antibiotics according to the

suspected source. And you can see here that, um,

compared with a pre pathway population in 2017, um,

the a a greater proportion of children, uh,

who were treated on the pathway,

received an appropriate antibiotic choice according to the suspected source, um,

uh, and a greater proportion received effective empirical

antibiotic dosing. So the pathway appeared not only to improve adherence,

uh, to the, um, and, and delivery of the, um,

three elements of the treatment bundle in the sickest patients, but they also,

the pathway also seemed to lead to an, in an increase in the appropriate choice,

in appropriate dosing of antibiotics.

But there is another consideration here, of course,

because many of the children evaluated on the pathway don't in fact have

sepsis, uh, and in our, um,

in our desire to, uh,

intervene early and treat children with sepsis early,

it may of course be the case that we treat lots of children who don't have

sepsis unnecessarily with antibiotics.

So one component of the evaluation that we also undertook was

a,

an analysis of whether there was an increase in the use of one

of the most commonly prescribed antibiotics,

axium or ceftriaxone at what we call third generation Keli Sporin.

Whether it was an increase in the use of these antibiotics following the

implementation of the pathway,

and indeed using these d data from the Queensland Children's Hospital

Emergency Department, we modeled that the, uh, consumption of,

um, uh,

third generation catalyst scorings in the emergency department increased with

the introduction of the pathway in mid 2019,

um, from 13, um, doses, days on therapy, uh,

per thousand DD attendance, uh, attendances to 17 days on therapy,

um, following the introduction of the pathway.

So our summary of the evaluation was, um,

that its implementation was associated with improved process measures over time.

Im improved process measures in the sickest patients. That is,

we managed to deliver, um, the three elements of the treatment bundle, uh,

in a timely way in those on I C u more commonly with the instruction of the

pathway and improved empirical antibiotic choice and dosing.

But we also observed an increase, um,

in antibiotic consumption, um,

with the implications that that has for an, uh, antibiotic stewardship.

And the process of capturing these data was incredibly labor intensive.

This was not a simple undertaking. And so, um,

to go back then to the original question,

are there data to show that the sepsis pathway has been effective?

I think we can be confident that the sepsis pathway had, uh,

a positive impact on, uh, the delivery of care in chi, uh,

in children in Queensland, um,

with the important caveat that it probably increased, um,

Keli Sporin use in in emergency departments. Um,

but there was another specific element to this question, which said,

particularly did those data show that the sepsis pathway was effective in rural

and remote facilities? And the honest answer is that we don't know. Um,

we weren't able to capture those data, uh, and, um, and,

and so we,

we would have to extrapolate our findings from the evaluation that was

undertaken in the secondary and tertiary hospitals to those rural and

remote facilities. And of course, we can't take that for granted.

We can't assume that that would be true. Now,

this brings me to then, um, uh,

an important document that was published just last year,

which was the new national sepsis Clinical Care standard. Um,

and, uh,

the reason I think it's appropriate to introduce this here is that one aspect of

the clinical care standard is that we, um,

we want to be able to monitor our progress against, um,

the care standards. So the objective of the clinical care standard was,

is to ensure that patients presenting with signs and symptoms of sepsis

are recognized early and receive coordinated best practice care,

um, and sepsis clinical, uh, the sepsis clinical care standard,

like other clinical care standards, uh, made up of quality statements, um,

which represent priority areas for quality improvement.

And against those quality statements, there are indicators, um, uh,

that will support health services monitor how well they've implemented the care

described. So in the evaluation,

the evaluation I've just described was exceedingly, uh, labor intensive.

We did it on a, uh, a multi-center basis with a dedicated research team. Um,

but we need, uh, as, as part of the delivery of the clinical care standard,

we need to find ways that we can monitor our performance against these

important clinical care standards,

the clinical care standard.

I just focused on early recognition and rapid treatment, which was of course,

the focus of the, uh, ed evaluation,

the results of the ED evaluation I just presented to you. But in fact,

the clinical care standard also hopes to standardize a much more holistic

approach, uh, to, to sepsis, um,

and highlight the sepsis journey throughout the inpatient, uh,

stay and beyond. Um, and I, I'm not gonna talk too much about,

uh, the, the broader approach to sepsis and the,

the holistic approach to sepsis and post sepsis care. Um,

but it's this holistic approach that guided, um,

our queenland pediatric sepsis, um, program,

and helped us to compose our five-year, uh, roadmap and, and,

uh, set our goals, um, for the Queensland pediatric sepsis, uh, program,

and also to revise and deliver our, um, new sepsis pathway,

which I'll talk about later.

So the next question that was submitted was whether there are specific symptoms

that recognize, um, that antibiotics might be required. Um,

and so, I mean, that's a really good question, isn't it? How do we, we see,

um,

you will all see many children who look a bit like this in your emergency

departments and clinics, and how do we differentiate, um,

that child who most likely has a respiratory viral infection from

this, uh, two year old child with fairly subtle non blanching,

a fairly subtle non blanch blanching rash on the, uh,

on the second toe. And, um,

I'll just tell a story about this case.

This was the easiest diagnosis of meningococcal sepsis I've ever made.

Um, so this was a two-year-old child,

healthy immunized with a fever and tachycardia with these

fairly subtle signs, um, of that,

that are recognized in association in a,

in association with meningococcal disease. Um,

but in the meningococcal vaccine era era, um,

meningococcal disease is quite rare now. Um,

but when I discussed when, when, when I took a history from, uh,

this child's parents, first of all, it became clear that, um,

they were academics. One was a professor of archeology, I think, at at U C L,

that is always a risk factor for serious outcomes. Um,

and, but more than that, the, uh,

the brother of the father was also a professor and was a,

was a professor of pediatric infection and was, um,

one of the European leads of a large study looking at genetic predisposition

to invasive infection.

And they told a beautiful story about how a whole generation of this family

in the seventies had all, uh, had invasive meningococcal disease.

And it seems as though this, uh, apparent family predisposition had prompted,

uh, and driven, um, this little girl's uncle to, um,

to his clinical and research career in infectious diseases.

So what are the clinical features that we

use to try to diagnose sepsis? Well,

they clearly overlap with self-limiting, uh,

febrile illnesses, respiratory viruses,

like the snotty child in the slide before. And we,

but we try in our screening and, and, and recognition,

guidance on the sepsis pathway,

we try to highlight those red flags that increase the risk of serious

in infection, um, in children. The question, if you remember,

was are there specific clinical features that, um,

guide the use of antibiotics? And the answer is that these are not specific, uh,

uh, certainly not to sepsis. What we're trying to do is, um,

present clinicians with fairly sensitive, um, uh,

indicators that the child in front of them may have a serious infection and

prompt a closer evaluation and review. And if there are any suggestions,

if there are any red flags of the sepsis at that stage,

the pathway directs the clinician, uh,

to get the most senior clinician available to perform an immediate review

and make a clinical decision as to the most, uh, as to the likelihood,

the probability of sepsis.

So there are features to look out for,

but they're not specific clinical signs of sepsis.

There's been a great deal of work done over the last decade or more that, um,

seek to improve, uh, the diagnosis of sepsis using either, um,

particular physiological variables like heart rates or respir rates,

or blood tests like c r P and procalcitonin,

and possibly even in a more sophisticated way, um,

combines these, uh, variables into risk models.

And there have been 160, uh,

last decade,

very few of which have had any impacts on the management of children with

sepsis. The best risk model, the best known risk model,

which was published now a decade ago, which was, um, discriminatory,

uh, and, um, uh,

helped clinicians understand the probability of serious infection.

When this model was, uh, tested in the context of a randomized control trial,

um, the,

the introduction of this risk model had absolutely no effect on the,

um, on the, uh,

decision to admit to hospital or to use antibiotics.

So no impact on antibiotic use or admission to hospital.

So we still really are left with, um,

a screening and recognition tool, which highlights the clinicians,

uh, clinical signs that, that increase the risk, uh,

of serious infection and sepsis and prompt the clinician to get the most senior,

uh, uh, clinician available to review the patient and make a treatment decision.

Um, so this then is the revised pediatric sepsis pathway,

which like the clinical care standard, takes a more holistic, uh,

approach to care and extends the management plan beyond the initial

treatment bundle, um, and guides clinicians through the process of,

uh, ongoing care monitoring, communication and coordination,

including post sepsis, post sepsis care.

So, um,

I am now going to move on to this element of the, uh, uh,

of the sepsis clinical care standard.

I've talked mostly about early recognition, time, critical management, and now,

um, we'll talk about antimicrobial, uh, therapy,

or what I like to determine as I called, uh, as,

as I coined in the title of the talk, uh, antimicrobial optimization.

So, of course, the,

the ensuring that children get optimal antimicrobial therapy, uh,

requires that they get early treatment, but that they get early, um,

and appropriate empirical treatment. That is before we know what the,

the, the organism causing the sepsis is. Um,

and so there was another question that was submitted to us before the, the talk,

um, that, that asked is sepsis different at different ages.

And the answer is emphatically yes. I mean, first of all,

a reminder that the risk of sepsis is much higher in young children.

Neonates are at highest risk of sepsis and serious infection.

Uh, and that risk declines in infancy though is still fairly substantial in the

first year of life.

And then beyond the first year of life in healthy immunized children, um,

the risk of serious infection and sepsis, uh, declined substantially.

And not only is the risk of sepsis different by age,

the type of sepsis, uh, and the,

the source of sepsis is different according to age and according

to the presence or absence of comorbidities.

So what I'm showing you here on the left hand side,

left hand panel panel A,

is the breakdown of the source of sepsis, um,

in previously healthy children.

And you can see that that first column on the left hand side is a fairly even

distribution of infections like, uh, intraabdominal infections,

bone and joint infections, um, brain infections,

uh, respiratory infections, primary bloodstream infections,

and urinary tract infections, fairly evenly distributed.

If you compare that with the right hand column of panel a

children with comorbidities, then you can see there, um,

that the most common source of sepsis in that group, uh,

are central line associated infections, completely different distribution.

In the same way in the middle, you've got neonates who have, um, a,

a much higher proportion of what we term primary bloodstream infection,

along with, um, central nervous system infections.

And then that breakdown is just, um, uh, and,

and then those data are just broken down in panels B n C, uh,

for children without co uh, comorbidities, that's column B. And for children,

uh, with comorbidity, comorbidities in column C.

So in column B, healthy children,

lots of urinary tract infections in infancy.

And by the time you get to 10 years of age,

a much greater proportion of bone and joint infections, um,

most likely caused by staph aureus,

which is the most important pathogen in that age group. Um,

if then I move onto the type of sepsis according to

likely organism, then again, you've got a similar, um, uh, uh,

a similar distribution panel, a previously healthy children, um,

you've got a fairly even split of organisms like strep pneumonia,

staphylococcus aureus, um, e coli,

and group A strep. Um, and, uh,

and that changes according to whether or not you have, um,

comorbidities. So in neonates,

you have a much greater proportion of what we term, um, uh, um,

opportunistic infections with things like coagulase, negative staphylococci, um,

in healthy children. Uh, you've got this great, uh,

burden of staphylococcus aureus that, um,

increases in frequency as you get older.

So this sepsis, um,

does sepsis vary by age? The the answer is emphatically yes,

and it's exactly that, that we take into account as we make our antibiotic,

um, recommendations.

And so the pediatric sepsis pathway still includes really quite

detailed empiric prescribing recommendations according to the su

suspected source of sepsis. And so I'll just bring out, for example,

in detail, um, the recommendations for sepsis.

'cause this is the sepsis pathway with a presumed respiratory source,

presumed bacterial pneumonia and sepsis,

and compare that with, for example, um, the recommendations for, uh,

skin and soft tissue or skeletal infection. Um,

we also received a question about which is the most appropriate source for

antimicrobial recommendations. Where, where should you go to get this, uh,

guidance? Um, and I would say that, um,

these statewide Queensland pediatric sepsis program recommendations were derived

by an expert stakeholder group, um, including pediatric id,

uh, specialists and anti micro wheel stewardship pharmacists,

and we're endorsed by the clinical advisory group of the sepsis program and the

Medicines Advisory Committee at C H Q.

So I think these are really carefully constructed,

um, uh, resource that's been specifically tailored, uh,

to children in Queensland. And so I would, I would strongly recommend,

um, using the,

the recommendations within the Queensland pediatric sepsis pathway for your

empirical, uh, recommendations.

There are sepsis recommendations within the therapeutic guidelines,

which was, which was one, um, possible source. Uh,

but for the most part,

they don't break down recommendations as far as I can tell for children by

suspected source. Um, so they make recommendations about sepsis without,

uh, without a source, but not, uh, by suspected source.

And then the other question was whether cred was a suitable resource for

antibiotics.

And though we've been in discussion with cred for some time about how we can

support them to make, uh, appropriate antibiotic recommendations,

but to my knowledge, they have, we haven't yet, um, solved, uh,

the issue of, uh,

including antibiotics within the cred resource. Um,

creds obviously a really fantastic resource for, um, the urgent,

uh, for supporting the administration of drugs in, in, um,

in urgent care and, and resuscitation, and we would support their inclusion.

But so far, that hasn't happened. So again,

the recommendations that have been made have been made according to, uh,

our Queensland population, uh,

based on the most likely organisms that cause, uh,

individual sources of, of infection. But not only do,

not only does sepsis change according to age and the presence, uh,

or absence of comorbidities, it also changes according to geography, doesn't it?

And in a state the size of Queensland,

we acknowledge that there are differences in the most appropriate,

um, empiric empirical therapy.

So if we think about particularly staphylococcus aureus, this, um,

really important bacteria, um, that that's the most common cause of,

of sepsis in older children. Um,

we know that rates of MRM R ss a vary between, um,

Southeast Queensland and parts of, um, uh,

and parts of remote Queensland. Um, and so in,

in, in remote Queensland, uh,

we can see that the rate of MRM R S A is is more than, uh,

is approaching 35%, 35 or 40%, whereas, uh, statewide,

uh, the estimate is more like 15%, uh, in children. Um,

and so our antibiotic recommendations take account of,

of, um,

the need to apply this locally according to local epidemiology and allow

for the inclusion of MRM R S A cover where there are sufficiently high rates

of MRM R S A occurring locally,

or there are particular risk factors for mrm R s A. So if I draw out,

for example, the antibiogram for staphylococcus from the Cairns,

h h Ss, we can see again that, um, more than 30%, uh,

of their invasive staph aureus, uh, are M R S A.

What I would just say is that most of these antibiotic, uh,

antibiograms are derived from really quite small numbers of

isolates, um, in children. Um, and, um,

so what I've had to do here is combine three years of data to come up with a,

a number of, of isolates that's sufficiently large for the,

uh, for the antibiogram to be generated. Um,

but you would interpret an antibiogram like this and say, well,

for a child presenting, uh, in Cairns, it may entirely be,

be entirely appropriate,

the empirical management of a skeletal infection or a severe skin and soft

tissue infection associated with sepsis to include both flucloxacillin

and, uh, clindamycin,

or more likely in Queensland Vancomycin linco ide.

We did also receive a,

a submitted question about whether or not there's been an increase in septic

arthritis, uh, recently in Queensland.

And it's a really interesting question to us in infectious diseases.

There's certainly a, a feeling, um, uh,

a sentiment amongst, uh,

infectious disease specialists in Queensland that we've seen, uh,

a greater number of inva invasive infections, um,

laterally in recent months, uh, but of a range of invasive infections,

um, certainly, uh,

invasive and complicated respiratory infections and EMAs complicated brain

infections, um, and, and possibly, uh,

complicated bone and joint infections. But septic arthritis, of course,

isn't a notifiable, uh, condition. And so we don't really know, um, if,

if, if that's a, a, a true, uh, observation or not.

Um,

I suppose what we are aware of and what we've been discussing in Queensland, um,

like many others around the world, um, is, uh,

an apparent increase in, uh, invasive infections caused by a particular,

uh,

pathogen called group A streptococcus or streptococcus a And here in Queensland,

uh, well indigenous Australians throughout the country have some of the highest

rates, uh, of, um,

infectious complications from streptococcus A.

So we take very seriously the possibility that strep a, uh,

is causing an increase in the, the, um,

number of infections because of the potential impact on our indigenous

communities, um, and around the world. There has been,

uh, uh,

there have been reports of both an increase in the number and unusual

presentations, uh, of, uh,

streptococcus A that we've also observed here in Queensland. Um,

it's not clear why that might be. Um,

there's the possibility that this to some extent reflects changes in

the host population,

and that might be because of reduced social mixing during a covid, uh, pandemic.

But it may also have something to do with the emergence of this, um,

highly pathogenic strain of, of streptococcus a called M one uk,

which has the potential, uh, to drive, um, really high levels of,

uh, toxin production, um,

and appears to be associated with increased virulence and worse outcomes.

Uh, and so we're keeping a really close eye on, uh, the, the possible, uh,

on the epidemiology of streptococcus a, uh,

and the possibility that this, uh,

highly virulent strain of strep strep A is driving, um, uh,

an increase in the number of invasive infections.

So, um, we've talked about the appropriateness of empirical therapy. Um, we,

another component of antimicrobial optimization is, um,

is the importance of diagnostic sampling, uh, to guide therapy.

It's only if we can get those samples sent to the lab, um,

that we might be able to know which organism,

which pathogen is causing the sepsis and target our, our therapy accordingly.

So again, we received a, a question, um, before the seminar, which said,

which cultures should be taken before empirical antibiotics? Well,

one of the indicators in the antimicrobial management quality

statement is, uh,

the proportion of patients who had a blood culture taken prior to antibiotics.

That's a good measure of, uh, uh, of good antibiotic stewardship practice.

Um,

and so when we evaluated the sepsis pathway in 2019,

we found that around about three quarters of the children, uh, with sepsis,

uh, with suspected sepsis had a blood culture taken prior to, um,

uh, antibiotic delivery. Um, and,

and that in the pre pathway era,

that proportion was around about 82%. Um,

now that difference wasn't statistically significant, um,

but it is an important observation. And of course,

it may be that in, uh,

in our drive to reduce the time to antibiotics, it sometimes means, uh,

the cultures are not being taken promptly. So,

which cultures should be, uh, taken prior to antibiotics? Well,

we'd strongly support, um, uh,

taking blood cultures before antibiotics are being delivered, but we'd actually,

we actually, um, recommend that, uh,

all relevant microbiological samples are taken prior to therapy, um,

or we recommend the timely collection of all relevant microbiological samples

in a stable patient with suspected sepsis. In the absence of shock,

it would be entirely appropriate to collect samples such as urine and blood,

maybe even C S F from lumbar puncture, um, before giving antibiotics. Now,

this is obviously completely inappropriate in the context of shock,

where the urgency to deliver antibiotics and fluids and resuscitation takes

precedence even in that setting. We would say that, uh, in the process of it,

of securing IV access, we should be, um,

making sure that we take blood cultures prior to antibiotics.

So we'd like to encourage all, um,

relevant microbiological samples to be taken in stable patients, uh,

before antibiotics.

So the next component of, um,

antimicrobial optimization would be antimicrobial, uh, review. And of course,

we do that to some extent with the results of our diagnostic samples in

mind. Again, I just highlight to you the data that I presented earlier, um,

which showed an increase in the use of third generation Keli Sporin in ED at

Queensland Children's, um, uh, uh,

with the introduction of the sepsis pathway in in 2019.

What we also find found, though,

was that there was no increase in inpatient prescribing.

So it would seem that even though, uh,

there seemed to be an increase in the delivery of those doses of, uh,

kelo sporin in the ED that wasn't being translated into the inpatient

setting, which one might infer, uh,

is a result of patients who didn't need antibiotics. And on reflection,

patients who didn't need antibiotics being reviewed appropriately and their

antibiotics being deescalated or stopped as soon as they,

as soon as it became clear that sepsis was no longer the problem,

and that anti antimicrobial review is a core stewardship intervention.

Um, and so then, uh,

this brings me to the other relevant clinical care standard to this talk,

which is the antimicrobial stewardship clinical care standard for which there is

a, um,

an auditing tool made available on the commission website, um,

that you can use to, uh, review, um,

the proportion of, uh, antimicrobial prescriptions that are,

uh, in accordance with local recommendations like the sepsis pathway.

So in fact, this antimicrobial stewardship clinical care standard,

um, and data tool could be a valuable way of evaluating,

um, and monitoring antimicrobial management in sepsis and thereby,

uh, monitoring your, your, uh,

performance against the sepsis clinical care standard two.

So I'm just gonna move finally onto, uh, dose optimization. Um,

so not only is it important to choose the most appropriate choice of

antibiotics, um, to make the most appropriate choice of antibiotics,

but it's also, uh,

important to ensure that antimicrobial dosing is effective. And so,

along with our antimicrobial recommendations,

there are also dose recommendations.

And it did seem again that, uh, with the introduction of the sepsis pathway, uh,

the proportion of children evaluated for sepsis who received an

appropriate dose increased, uh, and we've had lots of positive feedback,

particularly from nursing staff around the state,

about the value of these dosing recommendations, um,

on the sepsis pathway. So, um, we provide,

uh, empirical dosing recommendations. And then of course,

there are some antibiotics for which there are well established, uh,

requirements for therapeutic drug monitoring,

particularly for vancomycin in the context of, um,

staph aureus, sepsis and gentamicin most commonly, uh, for a, from,

from a toxicity perspective, but increasingly, um,

in critical illness in I C U. Um,

and this is still a research question at this time,

there is interest as to whether, um, all antimicrobials or, or,

or a large group of antimicrobials that we call beta lactam antimicrobials, um,

ought to be optimized using the same therapeutic drug monitoring or

personalized, uh, dosing. We've been doing a, a study,

um, of sepsis in children and adults on I C U over the last few years

that integrated a novel pathogen diagnostic where we sought to,

uh, identify the pathogen, the bacteria causing sepsis, um,

using a, uh, metagenomic sequencing approach.

And we integrated that diagnostic with a, uh,

dosing intervention to try to optimize antimicrobial exposure

antibiotic levels in patients with sepsis. Um, uh,

first of all, what I'd say is, um,

our metagenomic sequencing,

which was highly novel and also really quite challenging,

we did manage to have some success in taking positive blood cultures.

Those are the bottles that go on the incubator and flag after a few hours that

there is a bacteria growing, um,

and shorten the time to pathogen identification.

So that can help then in targeting your antibiotic therapy and also antibiotic

resistance prediction, um, which again, might be useful for optimizing, um,

and rational or rationalizing your antibiotics. Um, and so, uh,

this diagnostic approach is, um, still quite highly novel,

but has the potential to reduce the time, uh,

to recognize the causative pathogen and, uh,

identify the presence of antimicrobial resistance,

which might allow you to optimize your antibiotics sooner.

The second component of the study, as I say, was, um, was the use of, um,

therapeutic drug monitoring and dosing software to personalize, uh,

antibiotic dosing.

And what we found there in the figure on the right was that in patients who

failed to achieve and, um,

therapeutic antibiotic levels in the first 24 hours,

so those that fail to achieve therapeutic levels with empirical dosing,

um, we, uh,

significantly reduced the time to achieve therapeutic levels with,

uh, drug monitoring and dosing software.

So this may be an intervention to improve the antibiotic levels,

uh, in the sickest patients with sepsis on I C U.

That's still just a research tool at this stage. Um, what,

what else would I like to show you? Well, I suppose the other way that we, um,

might evaluate our, uh, sepsis pathway, um,

is by, uh, capturing data, uh, routinely and electronically.

And we've been trying to do that with the introduction of a sepsis dashboard.

And this is a, uh, a mockup of the dashboard developed by, uh, Bruce Keo and,

um, the, the BI team at Queensland Children's Hospital, um,

but with a hope to roll this out, uh, across the state in time through C B I.

Um, and, um,

one aspect that we included in this sepsis dashboard is, uh,

the ability to monitor our antibiotic, uh,

use in patients and patients with suspected sepsis. So again, this is another,

uh, uh, important element of antimicrobial optimization, uh,

and stewardship that we hope to be able to roll out to states with, um,

the E M R at least. Um,

I guess while we're on sort of future, um, uh, the,

the future of sepsis management, this is, uh,

an area that here in Queensland we are quite interested in.

We're interested in refining our approach to sepsis so that we might be able to

move away from these fairly simple and crude, uh,

tools that we have for sepsis recognition, using red flag clinical signs,

uh, to a slightly more sophisticated, uh,

data-driven AI or machine learning approach to the prediction of sepsis in

children. Um, this is of course, work that's going on all over the world,

and this is, um, one of the most established groups, um, that have been, uh,

that have implemented a, an AI tool. Um,

I forget what the, the trues, uh,

acronym stands for early warning score of some kind. Uh,

and in five hospitals, adults, of course, um, uh,

that implemented the TRU system, uh, those whose,

um,

who were flagged by the TRU system who received antibiotics within three hours

of the alert had a reduced in hospital mortality than those who were flagged by

the system and didn't receive antibiotics. Um, that's not quite the same, uh,

as a randomized control trial to say what the impact of the implementation is,

but it was encouraging, um, evidence that, um,

an AI-based system may have important clinical outcomes, um,

for adults with sepsis, and we'd be keen to replicate, uh,

and develop something similar in children.

And what was nice about this was that they also looked at how that AI

system might best be implemented and termed, uh, um,

and came up with this term human machine teaming, uh, where, uh,

clinicians and machines work together to evaluate,

uh, the risk of, of serious infection and, and sepsis. And that's certainly, um,

a that that sort of, that human machine collaboration is, uh, a,

an important phenomenon that people recognize in Queensland.

Um, we're some way towards, uh, some, some way down that route. Um,

Paul Lane, Rudy Schnat, Vic Kalki,

and others up at Townsville derived an adult based AI sepsis tool,

which is now moving into a prospective evaluation with a broader group.

And we, in the Queensland Pediatric Sepsis program have been developing, uh, a,

a partnership with the Center for Information Resilience,

where we are looking to, uh, do some of this same work across Queensland,

um, to, to derive our own AI driven, um,

risk prediction for sepsis. But also what,

what I'd like to say in relation to this talk is that that tool might be able

to, uh, also inform the most appropriate antibiotics empirically, uh,

and the probability, the likelihood, uh, of antibiotic resistance and,

and thereby guide early antimicrobial optimization.

So finally then, um, sepsis of course, as you know, uh,

is a leading cause of preventable harm, um,

and early recognition of management improves outcomes. Um, our management plan,

the revised sepsis management plan in, uh,

combines now locally relevant sort of bespoke Queensland empirical

a**l recommendations along with dosing guidance and, um,

antimicrobial optimization and stewardship, uh, interventions down the track,

uh, personalized dosing, particularly in I C U may become, uh, the, the,

the expectation and the norm. And in time we hope that, um,

our will make some significant advances in our use of data to improve

reporting via dashboards and also to,

to start to perform data-driven clinical guidance.

Here are, uh,

many of the links that are available to you from the program regarding the

sepsis pathway, uh, various educational tools. Um,

I'll just flag world sepsis day again in September, 9th of September,

I think this year. I might have got that wrong, actually,

I don't think it is the 9th of September 13th. Thank you.

I'm confusing it with, um,

a music festival I'm organizing on the 9th of September.

Feel free to feel free to come. Um,

and I'd just like to acknowledge this brilliant team. Uh, Sarah's already had a,

had a shout today. She's done a brilliant job, uh, of the pediatric, um,

sepsis seminar series.

You can carry out the evaluation survey using the QR code in the corner.

Um, and finally, really important to, uh, reflect on these brilliant,

uh,

consumers that have been an important part of our pediatric sepsis story here in

Queensland. Are there any questions? I think we've got a few minutes.

Jeanette has a question.

Is there more line related sepsis due to the greater risk or greater numbers of

lines and immunocompromised kids? Jeanette? I think, yes, that, that in fact is,

um, a trend that we've observed now for 10 or 20 years in high income settings,

that sepsis is increasingly healthcare associated, um,

more commonly with things like line, not exclusively with lines, um,

but unusual organisms often, um,

associated with healthcare interventions like line. So, um,

we published some similar data from the uk uh, from Liverpool in, uh,

about 10 years ago. Uh,

and I think it's safe to say that that's an observation that we've seen, um, in,

in Queensland too.

Okay. If there are no more questions,

I'd just like to thank everybody for joining us again.

It's been a really fantastic turnout.

Thanks for all the questions that were submitted too.

I hope I did a reasonable job of answering some of them. Um,

please reach out if, if you feel like there's anything that didn't get answered,

um, and I'll try to do that.

Excellent. Thanks so much Adam, and thanks everyone for attending.

we used to get a number of patients down from Papua New Guinea with severe, um,

gastrointestinal or a third world type of presentations of sepsis. Um,

and then adults are seeing more and more, um,

infections related to living near the sea,

cuts in your legs becoming severe sepsis with multiorgan, uh,

dysfunction and, um, sort of breakdown of tissue or,

or cellulitis, um, and with nasty infections.

And, and I guess on these occasions, um,

my approach would be to use the guideline to add in

what we've already spoken about, um,

meropenum being the most important and seek i d advice.

And I think there will show where that fits into the guideline in a moment.

Thanks, Paula. And I,

I guess this slide really just shows that, um,

in media doses as a specific type of infection case, um,

if you get it as a child or less than 18 year old,

your risk of dying is really high.

And it's not that you've got lots of comorbidities.

Most of these children don't have much in the way of comorbidities,

but potentially unrecognized, potentially unavailable, um,

appropriate medications and, uh, uh,

we are not quite sure why, but they usually present, um,

if they're gonna present with sepsis, with a very severe sepsis,

needing significant, significant, um,

intervention and, and the risk of of dying is reasonably high.

So thinking about it early, getting the antibiotics in early,

and then starting to think about what else could it be. And in this case, um,

specific infections to seasonal changes is important. Thanks Paula.

And if we relate that to our sepsis guideline,

just to highlight the success suspected source of infections at the bottom

gray area, trying to create a picture to the PMC or,

or the coordinator of what,

what you're seeing might be helpful in trying to decide what we are gonna give.

And if you can get the next, um,

slide and just to highlight that in, um,

north Queensland and beyond defo North Queensland media doses, um,

should be added and it's specifically on the guideline, um, in that area.

Thanks. Next one, Paula.

Out west. Um, I think it's important to think of two things that, you know,

depending on presentation is really, uh, critical. Um,

the first is that there's a clone of M R S A, um,

non-hospital acquired M R S A, um, non, sorry,

non multi-resistant M R S A,

which is around about 50% of all staff presentations in that

area now.

So although Vancomycin is for severely ill

patients, it is important to think about children with multifocal or severe

illness to very early start and think about vancomycin

as a, a specific, um,

antibiotic for these children and very rare but to

highlight that, um,

not all things will be at all treated by the um, um,

guideline.

And we need to think about who else do we call along the way is children

presenting from, uh, rural properties, um,

who don't have town water and chlorinated water or have been camping out in the

bush, um, jumping into billabongs and things like that where, um,

some of these kids should be moved very quickly towards, um, uh,

an I C U and neurosurgical capabilities for, um, aic,

mening Meningoencephalitis. Thanks Paula. The next one.

So I think in the guideline there's an area where we can,

in the purple box,

we can think about are we really giving what we think we should be giving and

is there anything we can do to optimize our antibiotics?

And so consider getting a local or um, a d uh,

expert guidance as to what's going around,

what should we thinking about in this area? And there's a number there to call,

um, if you should need to thanks Paula

and really out of the funny areas,

but we can use this guideline beautifully here. Uh, most of the time is, um,

the, uh, east coast Cairns really down to Mackay where, um,

although we do have seasonal osis,

it's really rare and we need to search and think quite carefully about it.

But there is still a higher incidence of umm R s A in the

community. And um,

so moving towards and thinking about adding specific antis,

um, antibiotics early if they're not responding is, is important.

And I think what is important there is the capacity to locally escalate and, um,

in the guideline you'd have seen a number of references to locally escalating

patients and, um, the ICUs, they,

the adult ICUs are comfortable and capable of admitting and,

um, supporting children with sepsis and will would like to be, uh,

involved as early as possible in managing, um, these children.

Thanks Paula.

So I think in summary for us on the far north and Will or North Queensland

guidelines are very useful resource, please do use it. Um,

getting onto it sometimes can be tricky, um,

but recognizing that sepsis is a possibility and that, um,

the earlier we treat it, uh,

the better the outcomes is u are usually gonna be is really important.

I'd like to suggest we all consider our environment that we work in and get to

know it where, where do I find the fluid, where do I find help,

um, where do I find resources online, paper, telephonic, um,

and because a lot of the doctors and staff,

they are locums and may not be aware of that,

that should be really part of an orientation for them as well.

And then ask early how you could get help and, and how you get, um, um,

who you can get on the phone to help and specifically Id, um,

advice which is related to the, the local, where the patient came from.

And then obviously we've got, um, R S Q going through to, um,

to the pmcs and, and uh, medical coordinators.

Thanks Paula. I think that's it.

Thanks Greg. Um, and Paul, thank you both very much and just wanted to, um,

show sort of resources page.

So our sepsis website, uh,

children's Health Queensland is full of a whole lot of resources. The,

the pathway itself does, um, point towards, uh,

where you can find some of these resources.

And of course the Australian Commission, uh, sepsis standard,

there are some resources available there too.

So we've got about five minutes left, uh,

for us to, to maybe take some questions and answers. Um,

and if, I don't know if there's any in the chat, but just before I, I I leave,

well, before we go to that, I just wanted to let you know that these,

these kids have been our inspiration for developing this pathway and,

and seeing it on through. Um, so thanks to them cause they keep us going.

I'm gonna stop sharing now.

with an unplanned readmission within 30 days. So those

are the types of order that they are recommending you do.

And so from our perspective the other things that you

could do instead are looking

at the number of patients given the sepsis in children leaflet.

So this is this leaflet here, which is

available.

Both to print off from the homicide or

if you contact us at peace status, we will

send you these leaflets and important thing about these leaflets is

that they and allow the parents to then go to

our website and see our wealth of information for

them. So on our website we have this

Through the acute care no longer term recovery. We have

a family support network that they can sign up

to and that puts it in contact with our Advanced social workers. And

we also have this journey through

sepsis video series, which is actually led by

our wonderful consumers. You've lent us

their time and advocating for improved and

census care. So they have

talked us through what it was like for them to go

through the ICU but of services when

you were being transferred when you were in the world the worrying bit about

being discharged from the Ward to rehab for example or being

discharged from the Ward to home and

then having to access care from

home with things we're a little bit tricky how to do that

how to navigate all of that and we we did this because

we found out from our research that parents who

are going through sex is feel very alone feel very isolated and

as well as just not having enough

information and

They did ask you know that that and if

only they could talk to someone who lived the experience

then that that would be

invaluable to them. So part of the video series is making

sure that consumers are talking directly to Consumers and

on the back of that what we've developed is this

peer mentor program which they can access through

our family support network just by contacting us and when

you give them this leaflet and this is these the

main Tools in this program are

and parents who have lived through

having a child reception have they been undergone some

training and and they then become they

then Mentor families who are acutely going through

sexist at the time so that those families are getting

the direct and ability to talk to

somebody who's lived their experience and to get support

through that so we have an awful lot available

for for patients with sets us and that

peer mental program is virtual.

If you happen to be in Rockhampton or you happen to be in Townsville

and your parents there can still

access this Mentor program because it is all either over

the phone or and virtual other teams or

whatever.

So so those resources are

available and we also have all of our do you

know the signs of sepsis translated into any number

of languages? Which downloadable from the

from our website

The other the other bit, I thought

might that we could provide service force is if you

if the child is if a family is bereaved and through Pediatric

Services many of our children many of those families would

be referred to the chq and bereavement services

and we could follow them through that so

that's worth bearing in mind.

So what are we doing in the near future? So the

next three to six months we are going to be having a new look pediatric

sepsis Pathways. So instead of

having an ed Rural and remote and impatient pathway, which

are almost identical but not quite we're going

to make it into one. So there's only one pathway across the

whole state and it's going to go beyond that

a cute treatment bundle. So at the

moment it's sort of ends there with a little bit of monitoring and

what to do if things are aren't improving but we're

actually going to go beyond there looking at the acute treatment

to the first 24 hours and then beyond the first 24 hours and so

we're going into the resolution of sepsis the recovery

and tips and also if there is a

simp and we will be making sure

that the checkpoints that are

in there match this hipster standards so

that if you do this you will be able to order it and

show that you are meeting the quality Care

standard and the digital path.

They can and pathway then will match that

so they will be able to pull that information from IMR and

clearly the dashboard will be adjusted to follow

on from that. So and digital signs

will be able to do this digitally so that is coming and it's

not coming in paper very soon and obviously

in electronically in about a year's time,

but also we're spending quite a lot of time developing and

our post-stepsis model of care and that's

been led by Alana one

of our Advanced social workers. And this is

very much being co-designed by consumers from

all over the stage. And we we

are also involving the older

patients who have experiences who may

be able to help us teenagers and obviously

Healthcare professionals from across

the state who are delivering this okay, and then we'll come

up with a model of care that will go through and feedback sessions

with with the stakeholder group.

in the state prior to implementation and and

I think they the key the

key thing for us with this

is that we

this is what the consumers are saying that they desperately need and

we hope that it will help Healthcare

professionals to understand that we don't want to

reinvent the wheel we want to build on services that are

already existing. We just want to streamline things so

that we match what consumers need but also don't

overload our Healthcare professional. So I'm pretty sure

that we will be able to deliver something that walks

a very nice Road in the middle of that without

creating a whole lot of new work which

is which when you first read the Care standard

you think are this of our stuff we have we're not doing actually are

doing a lot of it. It's just not coordinated. And so I'm hoping

that this model of care will make

that obvious and so make your lives easier

and

In Men in coping with these patients who are who are

have lived through this and need a little bit of extra help

thereafter.

So that's what

the algorithm looks like at the end of the day lots

of stars. Lots of things. We need to collect. We don't need to

connect them all all of the time. You don't even need to connect everything and

in that in that line,

but we do need to highlight those areas where we know if

we improve the quality of care that we give

we're going to improve outcomes for our

patients and families. And these

are them these wonderful people

have been incredible Advocates they've lived they've lived

the life of Simpsons which is being very different. Some of

them have been believed and they've taken

the time out to tell us about the experience and

what was good and what was bad and they're

incredibly inspiring because all of us

want to come to work and to do good work

and these guys keep us on the straight and narrow and

I keep our feet firmly planted on the ground. So we we are

very grateful to them and their time and their

effort and lastly. I'm very grateful.

You are lovely team who are listed or

there who are award-winning and you know internationally for

the work that they're doing but our key

message here is that we are here to help. Please don't

see the sips of standard as yet. Another

thing that you have to do. It's a wonderful

tool to help us live a really

really good care most of it we're doing already and

and we can show that we're doing it already who work

together. And for those of you who haven't yet implemented the

steps to part where we can help you to do that. For those

of you having struggling to connect data, we can help you

to do that. I'm hoping that within a year to two

years for the digital side, at least that will

be seamless and we'll be able to suck it out the back of

our and then we can concentrate and what we can do for the

paper science to see how we can get that sort of data into

the Statewide system as well. So you can be you know

benchmark yourself if you want to

so I'm going to leave it there

and

I hope there's a little bit of time left.

for

for questions

Thanks, Paula. I think we've got about six

minutes. So we've got definitely a chance for some

questions if people want to put anything in the

chat, we can moderate it that way.

I've got one. Yeah, and

I just thought of as you're presenting so lots

of information and lots

lots to digest there. I think in terms of the national

casting but like you said it's a it's a really exciting piece

of work and it's been in the works for

some time. So I think it's going to just standardize and make everybody's as

you said, you know the outcomes for children and better

I suppose. My question is you

talked about

them like the key messages and stuff. But what would your call to

action be for people who are online today? So to digest

all that information, what would you say would be the next step? Where

should they go for more information or what would kind

of be the first two things that you was suggest people

do because I mean, it's everybody's responsibility

isn't it to get this standard happening it is,

so, thank you.

I think if you're thinking about and

you know, if you are more of a managerial level

or senior leadership level and I

would go to the website and actually read the standard because

It I know it's a number of pages but it's actually really easy to

to read and and particularly the

beautiful clinicians and a bit of the system and and

you're not alone. So if this will

need to be implemented, so the only

Children's Hospital is it's the one done in Brisbane. The

rest of us are all in mixed hospitals. And so this

is being done in adults as well as Pediatrics and

will be your go to are your

patient safety and team in your facility. So

I would I would go to them and say how do we

how do we how are we going to tackle this for both adults

and children? And then how do we as if

you have inpatient facilities, how do we pediatricians

uniquely contribute to that? So I think initially for

those leadership levels read the standard

and for for people who don't need

to know everything I would go to our website. There's

a lot of information on our website in

terms of what you need to know as a clinician and in

order to deliver good care and for

all our clinicians online if you

haven't

Done the video series journey through

sepsis which is our consumers experience. It's

really it's really worth it

it just

and it's you between the eyes what these families go through and I

think it's really important and and it's important

that their galvanizes you to do. Well and the

fact is that most of the time we do a really good job all of

us.

And just every now and again it becomes a

bit tricky.

A novel. Thanks Paula. Okay, cool. We've got some questions

coming through. Thanks everybody. We just

got a comment here before I read out a question, but we've

got a comment and from Celine Hill that she's a received great

feedback from the Ed nurses and we do hear

this a lot that they do love the antimicrobial Administration

guidance. And I think that's what makes Queensland unique

too. I don't think New South Wales have that in their pathway and

that's something that we've learned from them that they're a

little bit envious I think because we do here from the

staff that they do really find that useful.

we have a question from and

at this stage what percentage of children on the sepsis pathway

have sepsis have we done any analysis of that Paula and

not sure if you'll have it on the top of your head, but we could potentially get

it to end we have so it depends what you mean by

on the pathway. So if

you are screened as heading thickness,

if you are if you go through the screening program

and then they ask you

to

It's enough to trigger a review by

a senior medical officer that is about of

that presented to the Eds in Queensland.

thing of their features of severe disease,

I think I need to get a senior smile to see them and the

senior is the most they decided this could

be sepsis. There were about 350 something

like that.

So very very very few actually screened.

Seen by senior clinician and then we're

treated as sepsis now of those where the

scenic clinician said. I think this is sepsis.

How many actually in the end ended up having sepsis

44% so our senior

clinicians are pretty good at picking it.

So when by the time they see the child and

they decided is, Texas.

They're any good at wrong one into which is which is fabulous.

And because it's a really difficult

diagnosis to get right early and it doesn't

it doesn't mean that it was wrong for those other children to have

antibiotics. They may have had an invasive infection for example,

but not quite deteriorated into organ dysfunction. So maybe appropriate for

them to have antibodies Etc.

Of the patients where the tradition said.

I don't think this is sexist very few

of them. Then went on to have sex as it

was like 3% So clinicians are really good and they

have the ability to

pull in that constellation of of signs

and symptoms and digest it because they've seen

such as before.

They're able to actually make the diagnosis and that's the key.

and

Hey, alright, we might have.

Time for one more quick question. I'm just

looking here.

Does the clinical expert you

spoke about before need to be on site 24 hours

per day, so there's and so

the clinical expert.

And in the acute management

and for say for

a tertiary institution would likely be the

edsmo because they would be able to be recalled within

a reasonable time frame anyway, so

so keep you know for kids in Ed, that

would be fine for your inpatient Wards. I

think whether you decide it's your senior.

senior registrar for kids

your pediatric is the moment of them are on what we

call within 30 minutes. I think that you know, that's all within

the the it

would just need to be worked through so that if for you

in your circumstances could be worked for you through if you're

a more remote site where you don't have

that backup, that's what the pediatric medical

coordinator and Telehealth is full.

So I think what what the what the standard

is not doing is being prescriptive about what you in

your facility does what it is being prescriptive about is that

you've thought about it you've had an agree guideline and

that has gone through governments so that if it fails

you can then pull

And say oh hang on a minute, you know, somebody wasn't

on the roster for that day or somebody wasn't nominated on

that day to do it. We just need to have thought about it. So

it's done.

fantastic

All right. Thank you Paula. I think we are bang on three

o'clock. So any questions we didn't get to guys we'll definitely

Endeavor to to summarize them and send

an email or of course. Feel free to reach out by the Pediatric sepsis

account. Thanks all

so much for joining. I just want to plug our next

session as well. This is a monthly series

that we're now running is Sarah said at the start of the session. So

obviously the July Focus was on the

standard next month on August. We're running

a session on the 11th of August and on the

25th, it'll be advertised through the same channels that

you found this or you can also follow the Eventbrite

page, which I will post in the chat. Matt session

will be all about data and metrics so a

good follow-on session from this in terms of how how we

can help you collect information

and the local monitoring and the importance

of that and also talking about documentation matters and

and documenting sepsis and the ICD-10.

And that will be led by our wonderful AMS pharmacist Mel

and other medical lead Adam Irwin. So

thanks everyone for joining reach out if

you have any questions, but just to reiterate what Paula said we're here

to support you through this. So any any questions,

please reach out. Thanks everybody. Thanks everyone.

Good luck.