1. Adherence to Sepsis Guidelines and Hospital Stay Elspeth Ferguson SCH Journal Club 6 th November 2012

2. Aims To determine if adherence to resuscitation guidelines in paediatrics improves the clinical outcome for septic children and infants

3. Objectives Select an appropriate paper from the literature Discuss the paper’s methodology and findings Look at what this paper adds to our knowledge Should we change our practice?

4. Case 3yr girl presents to A&E Febrile, tachycardic, spreading non-blanching rash She requires 60ml/kg fluid resuscitation along with broad spectrum antibiotics before transfer to PICU 2hr after presentation Would more timely resuscitation improve her outcome?

5. The Clinical Question PopulationSeptic Children Intervention60ml/kg Fluid resuscitation within 60min ComparisonSlower fluid resuscitation OutcomeSurvival/Morbidity/Hospital Stay DesignCohort study

6. Literature Search Fluid resuscitation Outcome (treatment) Sepsis Limited to all children (0-18yr), English language Searched Medline

7. Search Results and Article Selection 4 articles found 2 appropriate Article selected as: –Most recent –From presentation –Considered reasons where following guidelines became a problem

8. Adherence to PALS Sepsis Guidelines and Hospital Length of Stay Paul, R., Neuman, MI., Monuteaux, M.C. and Melendez, E. Pediatrics 2012 130:2 e273-e280

9. Current Practice APLS guidelines APLS vs PALS

10. Methodology Cohort Study Retrospective identification via critical care area admissions November 2009 – March 2011 Diagnosis of severe sepsis/septic shock

11. Methodology Continued Review of medical records Exclusions: –Congenital heart disease –Renal failure –DKA –Sickle cell –Severe anaemia –DNAR

12. PALS Sepsis Guideline

13. Outcomes Overall adherence to algorithm –4/5 steps dependent on need for inotropes Adherence to each part of algorithm –Time to recognition –Time to IV access –Time to 60ml/kg fluids –Time to antibiotics –Time to inotropes

14. Outcomes continued Length of PICU admission Length of hospital stay

15. Basic Demographics  126 patients  14% severe sepsis, 86% septic shock  54 met criteria at presentation, 72 progressed to SS in ED  Median age 9yr, 15% <1yr  60% had co-morbidities  5% died

16. Are the results of the study valid? 1.Did the study address a clearly focused issue? Yes Cleary defined population Outcomes clear 2.Did the authors use an appropriate method to answer their question? Yes Cohort study was an appropriate study

17. Detailed Questions 3.Was the cohort recruited in an acceptable way? Yes But: critical care areas ?likelihood of admission elsewhere Actual definition vs clinical definition Use of lab parameters for definitions 4.Was the exposure accurately measured to minimise bias? Unclear How accurate is documentation in this situation? Do we document fluid finish time Was only IV access considered?

18. Detailed questions continued 5.Was the outcome accurately measured to minimise bias? Probably But need to consider timings What else affects discharge? Bed pressures/co- morbidities/Social factors 6.A. Have the authors identified all important confounding factors? 5.B. Have they taken account of the confounding factors in the design and/or analysis? Yes Comorbidity and illness severity considered, age/gender/time of presentation not found to influence outcome

19. Detailed questions continued 7.A. Was the follow up of subjects complete enough? 6.B. Was the follow up of subjects long enough? Yes To answer their outcomes follow-up adequate Longer term morbidity not considered

20. 8. What are the Results?

21. Percentage adhering to the recognition, vascular access, and IVF administration goal times, as dependent on the preceding algorithm step. Paul R et al. Pediatrics 2012;130:e273-e280 ©2012 by American Academy of Pediatrics

22. What are the results continued LOSFluid adherence Fluid non- adherence DecreaseP Value Hospital8 days11.2 days57%0.039 PICU5.5 days7.2 days42%0.024 LOSBundle adherence Bundle non- adherence DecreaseP Value Hospital6.8 days10.9 days57%0.009 PICU5.5 days6.8 days59%0.035

23. Results questions 9.How precise are the results? Generally precise, but large IQ ranges for fluid adherence and inotropes 10.Do you believe the results? Yes

24. Will the results help us at SCH? 11. Can the results be applied to the local population? Yes – tertiary centre, minor differences in resus protocols Things to consider – team sizes, access choice 12. Do the results of this study fit with other available evidence? Yes

25. Summary and Conclusions Adherence to resuscitation guidelines particularly speed of IV fluid resuscitation is poor Timely management of septic children improves outcome Would it be worth looking at our resuscitation of septic children?