Senior Project Proposal Abby Conn October 23, 2018 I. Title of Project: Designing an Early Warning System for Pediatric Sepsis Detection at Northern Arizona Healthcare (NAH) II. Statement of Purpose: Sepsis is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight infections. Sepsis occurs when the body's response to these chemicals triggers an immune response that can damage multiple organ systems (Mayo Clinic, 2018.) Sepsis is the leading cause of death in hospitals. (Mayo Clinic, 2018) While there are internationally agreed upon guidelines for detection of sepsis in adults, there are no consensus guidelines for detection of sepsis in pediatric patients. What are appropriate age breaks and guidelines to use in pediatric sepsis detection? Are abnormal heart rate, abnormal blood pressure, and high body temperature the best guidelines to use in a patient with a suspected infection? Or is there a better indicator to use? The main goal is determining what vital signs to use for children of different ages. A heart rate of 140 is normal for a 6-week old but very abnormal for a 5 year old (PALS, 2018). Creating a system that will flag a 5 year old with a heart rate that high but not on the 6-week old with a heart rate normal for their age will speed treatment. While this is a complex issue, the system must be simple enough to implement in a triage situation. III. Background: I am interested in going into medicine or medical research. I wanted to do a project that would be beneficial and on a topic where the research would make a difference. I approached the NAH Quality Department and asked if there were any research projects I could complete with their office or if there were any ongoing projects that I could participate in. They asked me if I would help on a project on sepsis in pediatric patients. I have very little experience with sepsis and have not done any past research on the topic. I had heard it briefly mentioned before deciding on this project but all I knew was that it was caused by infections and can be life threatening. I have begun reading about sepsis to have a better fundamental understanding of the science behind the research I will be conducting. I am excited to learn more about this issue and the design and implementation of hospital protocols. IV. Prior Research:
Sepsis is an inflammatory condition caused by infection. Sepsis can be caused by many forms of infections including but not limited to: pneumonia, influenza, infected wounds and abrasions and even untreated appendicitis. Initial symptoms of sepsis include: elevated heart rate and respiratory rate, fever, nausea and malaise. Severe sepsis develops rapidly from the onset of sepsis. It can include altered mental status, difficulty breathing, decreased platelet count, abnormal heart function and Multiple Organ Dysfunction Syndrome (MODS). (Mayo Clinic, 2018) (Nachimuthu and Haug, November 2012). There are wellestablished guidelines for sepsis detection in adults but relatively few for pediatric patients. In fact, it is estimated that 59% of hospitals have no warning systems in place for pediatrics (AAP Publications, Pediatrics. 2018.) Additionally in 2016 Bacterial Sepsis and Septicemia, which are the infections that cause sepsis, were in the top ten leading causes of death for the >1 age group and 5-9 age group (CDC, 2016.) V. Significance: Sepsis is a crucial issue in health care right now. It is the cause of 10% of all admissions to the Intensive Care Unit (ICU), which amounts to more than 1 million cases in the US annually. Sepsis worsens rapidly and can be significantly worse just hours later. Sepsis that is not detected quickly can develop into Severe Sepsis, which can include septic shock and Multiple Organ Dysfunction Syndrome (MODS) (Nachimuthu and Haug, November 2012). Early detection is essential for effective treatment. (Rivers, November 2001.) Pediatric patients are one of the groups with the highest risk because they have underdeveloped immune systems, especially those who have not been fully vaccinated. Large hospital systems already have protocols in place for sepsis detection in pediatric patients but there is no standard or widely used system. Northern Arizona Healthcare plans to develop and implement a system and I will be assisting in designing a system to detect Sepsis in pediatric patients. This project will benefit NAH and our community and I hope to learn more about medical research and policy development. Because I am not a trained medical professional, I will bring a different perspective to this project. The warning system I help develop will be easy to use and interpret because I m a medical layperson. All of my findings will be shared with Northern Arizona Healthcare for implementation in the emergency department and/or for future research. VI. Description: This project will mainly be a literature review. I will review current research from relevant sources including but not limited to: American Pediatric Society, American Academy of Pediatrics, American Academy of Pediatrics Society of Critical Care Medicine, European Society of Paediatric and Neonatal Intensive Care, and American College of Emergency Physician policy statements, literature
and research regarding pediatric sepsis detection utilizing the Northern Arizona Healthcare library. The final project I intend to produce is a set of parameters, that when the patient s vital signs are inputted in the computer, will flag those with abnormal vitals within the range that would indicate sepsis.
VII. Methodology: The first thing I will do is to educate myself on sepsis epidemiology, definitions, pathophysiology, clinical presentation, diagnosis and management. This will include international guidelines on sepsis management in adults as well as existing sepsis early warning systems using sources including but not limited to: American Pediatric Society, American Academy of Pediatrics, American Academy of Pediatrics Society of Critical Care Medicine, European Society of Paediatric and Neonatal Intensive Care, and American College of Emergency Physician policy statements, literature and research regarding pediatric sepsis detection utilizing the Northern Arizona Healthcare library. Then I will work on characterizing the problem and determining how big of an issue pediatric sepsis is at Northern Arizona Healthcare by using internal and external data. For example, how long does it take to get blood cultures and lab results on patients with suspected pediatric sepsis? Then I will research the existence of current pediatric sepsis detection protocols in use in the United States and Arizona looking at hospitals that specialize in pediatrics such as Cardon Children s Hospital and Phoenix Children s Hospital and hospitals that take care of pediatric patients but are not exclusively children s hospitals. It will be very helpful in the development of the Northern Arizona Healthcare pediatric sepsis protocol to see what pediatric sepsis protocols other hospitals use- if they have implemented pediatric sepsis detection guidelines- and their process/screen. After the compilation of this data, I will observe current workflow and speak with doctors and nurses in the Emergency Department, Pediatric Department and Pediatric ICU, as well as nurse educators to see how sepsis is currently identified. The next step will be to create the screen for pediatric sepsis. After the screen has been designed we will trial it on a small scale (not hospital wide yet) to see how it works and get feedback from medical professionals to make improvements to ease of use and accuracy. Protocol drafts will be created in conjunction with my advisor and reviewed by medical and nursing directors in the Emergency Department, Pediatric Department and Pediatric ICU, as well as nurse educators prior to implementation. VIII. Problems: There is a plethora of research on this topic and numerous different protocols adopted by different hospitals. Narrowing down the amount of protocols and literature to use when developing an early warning system will be challenging. Finalizing a system requires not only research on what questions to ask and what results should trigger a warning but limitations of the computer system might pose additional challenges. The system might not be completely implemented at the end of my project due to computer programming needs.
IX. Budget: I don t foresee any expenses being incurred for this project. There is a chance that I will have to travel to Phoenix to see implementation of sepsis early warning systems in other hospitals. Should this happen I will pay for the necessary fees (gas, food, etc.) myself. X. Annotated Bibliography: Mayo Clinic, Sepsis, https://www.mayoclinic.org/diseases-conditions/sepsis/symptomscauses/syc-20351214 (accessed October 17, 2017) This source provides a brief overview about the causes of sepsis and septic shock as well as the symptoms. It identifies early treatment of Sepsis with antibiotics and intravenous fluids as a way to increase chances of survival. The source also identifies groups at higher risk of developing sepsis such as children under the age of one. I will be using this source as background information. Nachimuthu and Haug. US National Library of Medicine National Institutes of Health, https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3540576/ (accessed October 17, 2017) This source discuses the causes and effects of Sepsis briefly. It took sample from 3,100 patients in two Salt Lake City Hospitals- 20% with sepsis, 80% healthy. The goal of this study was to create a model to detect impending or existing sepsis in adults. The model attempted to find a way to detect sepsis level blood pressures in patients without abnormally high or low blood pressure. As well, the source estimates the number of timeslices -times the vitals were entered into the system- needed for accuracy to be three. A three-time slice model includes data collected at approximately 0, 1 and 2 hours after admission in the emergency department. I plan to use this source for background and preliminary development a pediatric screen. Ten Leading Causes of Death and Injury-2016. CDC, https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_20 16-508.pdf (accessed October 18, 2017) This chart lists the leading causes of death by age group in 2016. Sepsis related deaths were in the top ten leading causes of death in 8/10 of the age groups
identified. Sepsis was the 7 th leading cause of death in the age groups >1 year of age, and 1-4 years of age. Sepsis was the 8 th and 10 th leading cause of death in the age groups 5-9 years of age and 10-14 years of age respectively. I will be using this source as background and to demonstrate the necessity of this project. Rivers, Emmanuel. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. https://www.nejm.org/doi/full/10.1056/nejmoa010307 (accessed October 18, 2017) This source pioneered the term Early Goal-Directed Therapy which changed the way sepsis is treated today. They found that starting administration of fluids and medications, like dobutamine, sooner decreased the time patients spent in the hospital, shortened recovery times and decreased fatality. I plan to use this source for background and to provide context. Pediatric Advanced Life Support (PALS) Algorithms 2018. United Medical Education. https://www.acls-pals-bls.com/algorithms/pals/ (accessed October 20, 2018) This chart shows the normal ranges of heart rate (beats/min), blood pressure (mmhg), and respiratory rate (breaths/min) for the age groups: Premature, 0-3 months, 3-6 months, 6-12 months, 1-3 years, 3-6 years, 6-12 years, and >12 years. This source also covers the general treatment guidelines for other life threatening injuries such as obstructed airways, hypoglycemia, toxicosis and trauma. I will only be using the normal vitals per age groups from this document to develop a baseline for a healthy patient. Odetola, Folafoluwa. In-Hospital Quality-of-Care Measure for Pediatric Sepsis Syndrome.http://pediatrics.aappublications.org/content/early/2017/07/19/peds.2017-0350#ref-1 (accessed October 21, 2018) This source identifies Sepsis syndrome, encompassing sepsis, severe sepsis, and septic shock, as leading cause of death in children with more than 75,000 cases of severe sepsis in the US pediatric population occurring annually, with an associated annual cost burden of about 5,000,000,000 US dollars. This source also addresses the prevalence of pediatric sepsis early detection measures. In 27 of the hospitals surveyed in the study, 59% had no protocol for the identification and treatment of pediatric sepsis syndrome. As well treatment of children aged 0-18 who were hospitalized
between January 1, 2012 and June 30, 2013 and later found to have sepsis was analyzed. Blood culture was performed in only 70% of patients with pediatric sepsis syndrome and timely fluid resuscitation was performed in only 50% of patients. Antibiotics were administered within 1 hour of diagnosis in 70% of patients with pediatric severe sepsis or septic shock. This indicates that a better early warning system to identify pediatric sepsis is needed. Prusakowski and Chen. Pediatric Sepsis. https://www.emed.theclinics.com/article/s0733-8627(16)30069-4/fulltext (accessed January 5, 2019) This source identifies differences in management and detection of sepsis in adult and pediatric patients. This source identifies laboratory values for sepsis in patients under the age of 18. As well, it identifies similarities and differences between adult and pediatric sepsis including lower mortality in pediatric cases and infants and children are at greater risk of respiratory collapse in critical illness. It also identifies at risk populations such as burn victims, neonates, immunodeficiencies, medical catheters and hardware and organ/bone marrow transplantation. I plan to use this source as a foundation for the detection protocol. Randolph and McCulloh. Pediatric Sepsis: Important considerations for diagnosing and managing severe infections in infants, children, and adolescents. www.landesbioscience.com (accessed January 5, 2019) This source identifies that management of pediatric sepsis must be tailored to the child s age and immune capacity, and to the site, severity, and source of the infection. Primary prevention-preventing the infection, Secondary Prevention- preventing the progression of the infection into septic shock, and Tertiary Prevention- prevention of disability and death, are used. As well, criteria for the progression of infection to severe sepsis are defined. I plan to use this source as a foundation for the detection protocol. Bradshaw and Rosenberg. Implementation of an Inpatient Pediatric Sepsis Identification Pathway. Pediatrics. 2016;137(3):e20144082 (accessed December 20, 2018) This source describes an implementation of a pediatric sepsis screen in a hospital and its effects over a six-month period. Charts of patients with positive screens
were reviewed on a monthly basis to assess for nursing recognition and physician notification, physician evaluation for sepsis, and subsequent physician diagnosis of sepsis and severe sepsis/septic shock. Over a one-year period, the screen was monitored for accuracy and physician and nursing compliance. I plan to use this source as background and to better understand the pathway of treatment for sepsis patients once in the hospital. Workman. Ames. Reeder. Korgenski. Massotti. Bratton, Larsen. Treatment of Pediatric Septic Shock With the Surviving Sepsis Campaign Guidelines and PICU Patient Outcomes. Pediatric Critical Care Medicine. October 2016. Volume 17. Number 10 This source reinforces the importance of early recognition and rapid treatment of pediatric septic shock. Although, it places some doubt on the commonly accepted one hour to treatment plan created by Surviving Sepsis Campaign. This source found there was very little change in survival rates when treatment was started a t=1 hour or t=3 hours, however both groups had higher survival rates than those who started treatment days later. I plan to use this source as background and to better understand the pathway of treatment for sepsis patients once in the hospital.