Anesthesia Management: Pediatric Septic Shock: Improving Adherence to PALS Guidelines

Authors: Paul R et al., Pediatrics 2014 May 1; 133:e1358

A quality improvement initiative resulted in sustained near-perfect adherence to guidelines.

In a prospective cohort study, investigators compared adherence to Pediatric Advance Life Support (PALS) sepsis guidelines before and during a quality improvement intervention at a Boston pediatric hospital. The intervention included education, use of intravenous (IV) fluid pressure bags rather than IV pumps for more rapid fluid administration, regular feedback, surveys to identify barriers to timely care, distribution of the PALS algorithm and pocket cards, electronic standardized order sets with a visual alert system, and bedside “shock clocks” to track time from diagnosis.

A total of 126 children (median age, 9 years) with severe sepsis or septic shock were identified during the 16-month preintervention period and 116 children (median age, 12 years) during the 19-month intervention period. Adherence to all five PALS process measures increased significantly from the preintervention to the intervention period:

·Recognition of septic shock within 5 minutes (79% vs. 97%)

·Vascular access within 5 minutes (67% vs. 90%)

·Antibiotics within 60 minutes (70% vs. 86%)

·Vasoactive agent within 60 minutes (35% vs. 68%)

·60 mL/kg of IV fluids within 60 minutes (37 vs. 73%)

Adherence to all measures reached 100% midway through the intervention period and remained near that level during the remainder of the period. The number of deaths per case of septic shock decreased over the intervention period.

Comment

Yes, we can! A systematic approach to ensure early identification of patients with sepsis and to break down barriers to care can lead to sustained improvement in treatment of pediatric septic shock.